child labor introduction research paper

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Social Norms and Family Child Labor: A Systematic Literature Review

Alhassan abdullah.

1 Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong; kh.ukh.tcennoc@assahlaa (A.A.); kh.ukh@hnyuhi (I.H.); kh.ukh@yremec (C.R.E.)

2 Department of Sociology, Haverford College, Haverford, PA 19041, USA

Inès Huynh

Clifton r. emery, lucy p. jordan, associated data.

Not applicable.

Background. Research has established the family as the predominant context for child labor practices. Decisions to involve children in child labor within the family or by a family member (herein family child labor) is strongly motivated by cultural beliefs that normalize child labor. This systematic review sought to synthesize evidence on the social norms that support child labor practices, and the normative interpretation of international child labor legislation/standards. Methods. We followed the PRISMA procedure for systematic review by reviewing empirical articles published between 2000 to 2021 and contained within the four key databases: Scopus, ISI Web of Sciences, PubMed and Embase. Findings from 13 articles that met the inclusion criteria were analyzed thematically. Results. The review included studies from three continents: Africa, Asia and Europe. Gender norms, informal apprenticeship norm, norms on succession and sustenance as well as obedience, were key social norms that influenced child labor practices in the family. Parents’ decision to involve children in child labor was strongly influenced by the collective acceptance of some occupations (e.g., cocoa farming and fishing) as family occupations, which need to be preserved, undertaken and passed on to children. Child rights and the UNCRC principle of children’s participation were considered foreign to most non-western countries and interpreted as contravention to the cherished social norm of obedience. The findings underlie the link between social norms and the common social values of resilience, hard work, and respect. Conclusion. The results provide foundations and target to develop normative change intervention programs to re-orient the negative interpretations of common social values and provide alternative pathways that prevent child labor within the social context.

1. Introduction

Child labor remains a major issue concerning child protection, despite increased research attention on its severity, causes and the intervention measures to curb it [ 1 , 2 , 3 , 4 , 5 ]. According to estimates by the International Labor Organization (ILO), over 246 million children (between 5 and 17 years) are involved in child labor, with 48 million located in sub-Saharan Africa [ 6 ]. Over two thirds of child labor cases happen in the agricultural sector, with more than 70% happening within the family unit [ 6 ]. Agriculture and other works undertaken by children in the family are “often hazardous in [their] nature and in the circumstances in which [they are] carried out” [ 6 ]. The fact that the family unit is regarded as a suitable context for child labor, where family members influence the involvement of children in labor, makes child labor within the family (henceforth family child labor) an important area and target for research into child labor. Literature on the causes of child labor underscore two critical antecedent factors: (1) economic forces and (2) cultural norms/values that support child labor [ 1 , 3 , 7 , 8 ]. Growing evidence has shown that the impacts of economic forces on child labor is mediated by cultural norms [ 9 , 10 , 11 ], and the cultural norms influence the choice families make for their children [ 9 ]. Even families who are stable economically have been found to allow their children to engage in work, e.g., using them as headsmen [ 12 ], highlighting the instrumental role of social norms in influencing child labor decisions within the family unit. Norms are deep-rooted beliefs that influence social actions within an institutionalized group. However, no study has so far systematically analyzed the sort of cultural norms and values that influence child labor decisions within the family. Social norms are predicted to have consequences on the health of people [ 13 ], mediated through the effects on health-seeking behavior, alcohol use and other risk factors [ 14 , 15 ].

Sociologists typically study social norms and their impact on social actions/decisions under the rubric of Parsons’ statement; legitimacy of social values are unquestionable, however normative interpretation of the values differ and often matters the most [ 16 ]. Much research on the impact of cultural values and social norms follows Parsons’ [ 16 ] argument by seeking to examine the different pathways social values are interpreted to influence social actions and decisions. Primary research on the influence of cultural values on child labor has shown that parents’ decisions to involve children in child labor are influenced by their desire to ensure that children secure a better future [ 17 ], become hard working people [ 18 ], are resilient to life challenges [ 19 ] and to ensure their adequate development [ 18 ]. Inherent in these justifications of child labor are the normative interpretations of common social values, such as hard work, success, and resilience, within the culture. They show that normative interpretations matter in efforts to change values in communities. On the other hand, the value of success in other contexts may not be normatively interpreted with associated social actions that bear on involving children in family work/child labor. Instead, they may be operationalized through enrollment in education. For instance, Green [ 20 ] reports that Western perspectives on childhood highlight the need for children to be free from adult responsibilities and acquire the best formal education to ensure their success in the future. Varied normative interpretations of common social values and their influence on family child labor decisions led us to argue that social norms play a central role in an attempt to understand and address the child labor phenomenon. Weiner [ 21 ] reports cultural values among the key antecedents of children’s work. This systematic review of existing literature seeks to examine the social norms that underpin child labor within the family in order to provide systematic evidence to inform research and intervention programs.

1.1. Social Norms, Child Work and Family Child Labor

Child labor in the family is a contested concept, especially in the context of cultures that traditionally require children to perform domestic duties and support their parents as part of their childhood training [ 22 , 23 ]. Whilst some argue that child work is an essential requirement for the socialization of children [ 24 , 25 ], others have found child work as an architect to child labor, child exploitation [ 26 , 27 ], and modern slavery [ 28 ]. The International Labor Organization (ILO) defines child work as all productive activities that are carried out by children (either in a family business or common market; remunerated or not) that last for a minimum of 1 h duration within a day [ 6 , 29 ]. Duration of work, nature, intensity of work, and the age of the child are typical features that determine child work. Similar features determine the judgement of child labor [ 30 ]. The ILO Convention 138 [ 31 ] sets a minimum threshold of 15 years for a child’s admission to work, and 18 years for hazardous work [ 6 , 32 ]; but many developing countries have the flexibility to admit children aged 14 years to engage in “light work”. So far, the extant literature on child work and child labor have agreed that there is a very thin line between the two concepts (child work and child labor), which is often difficult to determine until they have happened [ 29 ]. They are difficult to differentiate in practice [ 29 ], and vary from nation to nation [ 33 ]. It is more difficult to differentiate child work and child labor in localities that have sanctioned child work as part of the socio-cultural traditions [ 6 ]. White [ 27 ] highlights the complexities involved in the two concepts.

“It is impossible to draw a clear and unambiguous line between ‘child work’ (the more acceptable forms of children’s work, which are relatively unharmful and in cases may even be beneficial) and ‘child labour’, the unacceptable, exploitative and harmful forms of children’s work, a ‘social evil’. Most attempts to draw such a line are either too general, vague and circular to be of use, or if they try to be concrete and specific, are too contradictory and illogical, and out of line with the views of children themselves.” [ 27 ] (p. 837)

Essentially, the argument suggests that promoting child work may risk promoting child labor within the family unit. This is particularly the case as recent child labor statistics identify the family unit as the main contexts where child labor thrives [ 6 ]. Nonetheless, evidence on the central role of culture in underpinning child work and child labor suggests that culture or social norms could be an important source in efforts to understand how child work and child labor can be differentiated, understood and prevented.

Similarities in the social norms and value aspirations that underpin both child work and child labor also convolute the seemingly cybernetic relationship between child work and child labor in most cultural contexts. Children are considered to work on family farms as part of their preparation for adulthood, and to acquire basic skills that are integral for their development [ 18 , 34 ]. Children’s involvement in family farms increases family income and enhances family standard of living [ 17 ]. Their participation in fishing and family cocoa farms are regarded as important means to secure better future for children [ 17 ] and to maintain family businesses [ 35 ]. Similarly, it is believed that the involvement of children in labor increases their affection for the labor market and enhances their personal development [ 19 ]. Engaging in child labor is considered an acceptable pathway to prepare children to be hardworking adults, and resilient to future work challenges [ 19 ]. Children in Turkey are found to work during their early years in order to contribute to family farm work [ 36 ]. Inherent in these justifications of child labor and child work are normative interpretations of the values of hard work, resilience, success, and achievement. Furthermore, decisions and attitudes towards child labor in Africa are also informed by the communal expectations of respect and mutual interdependence [ 37 ].

Social sanctions, including stigma against parents, compel them to conform to the norms that support child labor practices [ 38 ]. Lopez-Calva [ 39 ] theorized that there is a direct relationship between social stigma and child labor. Stigma against parents who do not support child labor norms (fail to involve their children in child labor) is found to be associated with increased child labor practices. The desire to obtain social acceptance, avoid the likely cost of stigma and social rejection, increases the utility of engaging children in child labor. The critical role of social norms in child labor practices led us to systematically examine specific social norms in the literature and unravel ways they inform family child labor practices. Such an advancement is critical to inform further research and the development of concrete normative campaigns that shift social norms in communities.

1.2. Social Norms and Legislation on Child Labor

Local social norms that support the involvement of children in work and child labor may likely be in conflict with international standards that frown on child labor practices. Communities are more likely to value their local norms that favor child labor and to to discredit international child labor legislation. Legislation and standards to regulate child work and prevent child labor have been in existence since the identification of child labor as a major social problem affecting the growth, health and wellbeing of children [ 40 , 41 ]. Led by international organizations (such as ILO and IOM), international promulgations on standards to prevent child labor have been developed and revised consistently to protect children. The United Nations Convention on the Rights of the Child (UNCRC) [ 42 ], the ILO Convention No. 182 on the Worst Forms of Child Labor (1999) [ 43 ] and the ILO Convention No. 138 on the Minimum Age of Employment (1973) [ 31 , 44 , 45 ] are the key international legal frameworks that regulate child labor practices. Article 32 and 35 of the UNCRC spell out issues related to the abolishment of child labor, forced labor and the need to protect children from all kinds of work exploitation. Principles in the UNCRC are developed based on the western conceptualization of childhood [ 46 ]. However, some of the commitments are echoed in other regional legislation such as The African Charter on the Rights and Welfare of the Child [ 47 ], and operationalized in the local laws of most countries. Overall, the UNCRC has an overriding commitment and target for member countries to ensure that children participate in decisions that affect them, are protected from harm, and enjoy the rights to life, survival and optimal wellbeing. However, the implementation of this legislation and its impact on children are largely influenced by social norms and values [ 48 ]. The rights of children in some contexts (e.g., South Africa) are seen as part of measures to undermine the authority of parents, traditional leaders [ 49 ] and elders [ 50 ]. Children in Africa are expected to act in response to the wishes and demands of their parents [ 51 , 52 , 53 , 54 ]. Children’s participation in cocoa farms is normatively interpreted as a form of agency [ 55 ]. However, the standard participation procedure spelled out in the UNCRC that allows children to exercise autonomy is considered an act that spoils children [ 55 ]. The foregoing evidence highlights the various international child labor legislation that could be interpreted within the context of local social norms, and how that influences family child labor practices. Therefore, additionally, the aim of this systematic review is to identify the various ways international child labor standards are interpreted in local contexts by seeking responses to the following key questions:

Guiding Review Questions

• What social norms precipitate child labor practices?
• How are international child labor legislation/standards normatively interpreted in the context of child labor?

Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [ 56 , 57 ] and recommendations by Rew [ 58 ], we conducted a comprehensive literature search to synthesize evidence on social norms that influence family child labor practice. The use of the PRISMA guideline provided a transparent framework to synthesize data following scientific principles that enable replication. Rew’s [ 58 ] suggestion helped to make vital decisions in the review process, including selecting relevant databases, setting important criteria for including studies and criteria for the screening and assessment of the quality of included studies.

2.1. Search Strategy

Four academic databases including: Scopus, ISI Web of Sciences, Pubmed and Embase, were searched. The literature searches were conducted from June to December in 2021. A combination of key words on child labor and social norms, together with Boolean operators were used in the search. Table 1 presents the keyword combinations and Boolean operators used in the search. York dare database, Cochrane library and PROSPERO database were searched to confirm the review has not been replicated elsewhere. Snowball search and expert recommendations supplemented the search procedure.

Boolean search strategy and word combinations.

Note: (*) is used to identify different ways the word maybe written.

2.2. Inclusion Criteria

Following the purpose of the systematic review, a clearly defined criteria was developed to guide the screening of studies. Studies that satisfied the following criteria were included:

• Articles reported qualitative or quantitative evidence (or both) on cultural norms that influence child labor practices. Additionally, (or) reported evidence on the normative interpretations of international legislation that seeks to prevent child labor practices.
• Articles reported findings from the views of any of the following groups (or a combination of any of them): community members, children, parents and social service workers.
• Articles are empirical studies published in English, between 2000 and October 2021. The benchmark of 2000 was chosen in line with the promulgation of the ILO standards on Worst Forms of Child Labor (1999), ( n .182), ensure that the findings are relevant to current legislation and guidelines on child labor.

2.3. Search Outcomes and Screening

A total of 7531 results were obtained from a general search through the four databases. Title, author names and other reference details of the studies were exported and saved into an excel spreadsheet. This allowed for duplicates to be automatically searched using the duplicate function in excel. In total, 2682 results were retained after duplicate titles were searched and removed. Articles that were published before 2000 and published in languages other than the English language ( n = 56) were removed before screening. The remaining articles were screened. Article titles that were beyond the scope and purpose of the study were removed ( n = 2044). This included book chapters and non-empirical studies. Six hundred and fourteen (614) articles were deemed as not satisfying the purpose and criteria for inclusion in the study. The remaining 24 articles were read thoroughly and 12 were removed as their discussion of social norms were not in the context of child labor. One additional study was found after a snowball search through the references of the 12 articles. The entire search and screening procedure was conducted by the third author and validated by the first author. The researchers conducted weekly meetings to discuss the search and screening process. There were no major disagreements with respect to judgements on the eligibility of studies. Minor disagreements, which mostly happened in the quality appraisal of studies, were keenly discussed with the senior authors (author 2 and 4). The screening process is presented in the PRISMA flow chart shown in Figure 1 below:

PRISMA flow diagram.

2.4. Quality Appraisal

We assessed the quality of the included articles using the quality appraisal tool by Salzmann-Erikson and Dahlén [ 59 ]. A 25-item checklist was used to assess the quality of empirical studies, mostly qualitative studies, by focusing on the methodological rigor of the articles. Key questions on the appraisal checklist included: “Are the criteria for inclusion described?”, “Does the study’s title correspond with its content?”, “Are the criteria for exclusion described?”, “Is the study’s purpose clearly answered?”, “Is the data systematically collected?”. Each item was assessed using a dichotomous response of “Yes” and “No”. Articles are rated as low quality if not more than 17 items of the quality assessment checklist are rated “Yes”. Articles with 18 to 20 points “Yes” ratings are considered to be of medium quality, whilst those with more than 20 points “Yes” ratings are considered to be of high quality. Six of the included articles were considered low, two medium and five as high quality. The ratings give a general idea of key information that were missing in the published articles, but they were not used as a basis to remove articles from the study. The appraisal was performed by the first author and validated by the third author. No significant difference was recorded in the assessment by the two authors.

2.5. Analysis Procedure

We followed Braun and Clarke’s [ 60 ] recommendation for conducting reflexive thematic analysis in analyzing evidence from the included articles. As part of the screening process, each article was read thoroughly, and notes on key ideas and findings were written in the comment section of Adobe PDF reader program. The written notes captured key findings, overall ideas of the study and key contributions of the study. Direct quotes from participants in most of the articles were linked to the notes. The quotes, key ideas and author’s written notes were organized in excel for further analysis. The written notes were again reflected upon in line with the meanings they connote and their context. The written notes were then refined and stated as codes. Examples of codes included “decisions undermine respect” “part of culture to work” “we have to contribute to family income” “children are cheap labor” and “cocoa and fishing are family work”. A list of all codes from the 13 articles were organized in word together with a short description of the meaning and nuances. This enabled the researchers to compare the codes and merge them to form themes under the rubric of social norms. The core themes included: gender norms, obedience, and informal apprenticeship norm. Codes were merged based on their similarities in terms of the interpretations of particular social norms or values. A detailed report of the themes is discussed in the results section.

3.1. Study Characteristics

Out of a total of 7531 articles and reports retrieved from the broad search, 13 articles met the inclusion criteria. Four of the included articles by Adonteng-Kissi [ 61 , 62 , 63 , 64 ] were published from two broad studies. Hence, the total included articles emerged from 11 unique studies. Broadly all 13 articles included in this review examined the social norms in child labor under the rubric of understanding the causes of child labor, particularly the social and cultural causes. All articles (except [ 65 ]) involved interviews with children and parents [ 61 , 62 , 63 , 64 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ], including children who are victims of child labor and parents who are perpetrators [ 61 , 62 , 63 , 64 ]. Six of the articles included the views of social services workers, and workers of Non-Governmental Organizations (NGOs) [ 61 , 62 , 63 , 64 , 65 , 67 ]. Most of the studies used a multi-method combination of qualitative in-depth face-to-face interviews, focus group interviews, ethnography, participatory research and/or observations [ 61 , 62 , 63 , 64 , 65 , 66 , 68 , 70 ], whilst the remaining studies used single methods: in-depth interviews [ 67 , 72 ], ethnography [ 69 ] and a combination of in-depth interviews with surveys [ 71 , 73 ]. The majority of the studies were conducted in sub-Saharan Africa ( n = 10) [ 61 , 62 , 63 , 64 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ], two in South Asian countries; Nepal and Bangladesh [ 69 , 72 ], one in Central Asia (Tajikistan) [ 67 ], and one in South Eastern Europe (Turkey) [ 68 ]. Child labor within specific occupations such as cocoa [ 65 , 70 ], carpet industry [ 69 ], fishing and farming [ 61 , 62 , 63 , 64 , 66 ] and domestic work [ 71 ] were the focus of most studies. However, 3 of the 13 articles focused on a general description of child labor and child work [ 68 , 72 , 73 ] without specifying a particular occupation. Even in such studies, participants linked their responses to child work or child labor in domestic work, farms and factories. A summary of the included studies is provided in Table 2 .

Summary of studies included in the review.

Note: GLSS = Ghana Living Standards Survey.

Themes related to social norms precipitating child labor

3.2. Informal Apprenticeship Norm

A common finding from most of the articles ( n = 8) is that children are culturally expected to receive informal apprenticeship training in the family by engaging in their parents’ primary occupations. The rationale behind the social norm of child informal apprenticeship is supported by narratives from key stakeholders, including parents [ 61 , 62 , 64 , 65 , 68 , 71 ], child victims of labor [ 67 ] and agricultural coordinators [ 65 ]. Parents in a Ghanaian study [ 61 ] argued that the informal apprenticeship for children is needed to prepare children to be tough so as to meet future life challenges. A parent described how this justification influenced her involvement in street vending during her childhood:

“In my own situation, I used to be a newspaper vendor on the streets. I had to sell newspapers on the street of Accra in the morning before going to school. My parents used to tell me that they were training me to be tough in life so that I’ll be capable of facing the challenges of life.” [ 61 ] (p. 474)

Children are believed to become hardworking when they start work early. This cultural notion underlies Turkish parents’ decisions to involve their children in work.

“I want them to start working now, so that they get used to working and not become loose.” [ 68 ] (p. 46)

The rationale for training children to be tough, and hardworking through child work and child labor is complemented by the cultural belief that engaging children in labor secures a better future for them. It is the shared normative belief that children’s participation in work at early ages imbibes in them a natural spirit of hard work and makes them resilient to work-related challenges in their adulthood [ 62 , 65 , 68 ]. A parent, who is identified to have involved her child in cocoa farming, emphasized the need to engage children in work in order to ensure they have a better future.

“Our culture teaches our children to believe that work socialization is meant to provide training which will ensure a better life in the future.” [ 61 ] (p. 472)

The early child apprenticeship training is conceived normatively to inculcate strong work ethics in children, leading them to become hard workers, resilient and ultimately to achieve success. Evidence from parents in Ghana [ 64 ], Turkey [ 68 ], and Côte D’Ivoire [ 65 ] confirmed the cultural justification that children learn better [ 65 , 68 ] and obtain strong work ethics [ 64 ] when they start work early. Narratives from some parents confirmed that these cultural justifications influenced their decision to involve their children in work, albeit arguing that such work does not constitute acts of child labor.

“Whatever work I assign to my children is not intended to harm them but to train them to have strong work ethics that will in turn help them to have a better future.” [ 64 ] (p. 59)

The narrative confirms that the interpretation of social norms does indeed matter in influencing social action [ 16 ].

Additionally, inherent within the normative justification of securing a better future for children through child labor and child work is the notion that work enhances children’s level of creativity [ 63 ]. It is also meant to increase and sustain their interest in work (confirmed by evidence from Ghana, Tajikistan, South Africa and Côte-D’Ivoire) [ 64 , 65 , 67 , 71 ]. Akilova’s [ 67 ] study among children working in Tajikistan revealed that children have normalized these interpretations and as a result they consider work as a normal part of childhood. However, it appears that the children have been conscientized to consider work as part of the training within the family. As a result, they do not consider work in or with a family member as a classic form of “work”. A twelve-year-old child who started working at age 2 narrated her experience this way:

“I actually started working at age two–not really working though. I went with my cousin on herbike to sell refreshing drinks and tea to people in the market. I just accompanied her. I started working on my own when I was 12.” [ 67 ] (p. 240)

The notion of child work as a normal part of childhood was found to be stronger in rural Tajikistan [ 67 ], similar to the evidence from Ghana [ 64 ]. The legacy of the Tajikistan community, which focuses on developing children to become productive members of society, may have enforced the norm of child labor and child work, even among children [ 67 ]. Particularly, it was found that children between the ages of 12–14 were considered matured in Tajikistan.

When quizzed on how they considered child work within the family, some Ghanaian parents justified that working in the family is a traditional form of schooling, which provides alternative sources of livelihood for children [ 64 ].

“Engaging my children in fishing is simply a traditional system of schooling which doesn’t violate the rights of my children.” [ 64 ] (p. 60)

However, parent’s view on child work and child labor as alternative sources of livelihood for children appears to be strongly influenced by the high rate of graduate unemployment. The high rate of graduate unemployment made formal education unappealing to parents, which enforced their beliefs in the norms of informal apprenticeship. A parent in a rural community in Ghana affirmed this notion in her narrative:

“Why should I enrol my children in school if they’re going to be unemployed after finishing? For me, I believe it will make more sense to engage them in my farming for them to acquire some skills that will help them in their future lives.” “Why should I enrol my children in school if they’re going to be unemployed after finishing? For me, I believe it will make more sense to engage them in my farming for them to acquire some skills that will help them in their future lives.” [ 64 ] (p. 59)

The evidence highlights the strength of the social norm of informal apprenticeship in the Ghanaian society.

3.3. Gender Norm

Diverse interpretations of gender roles and expectations appeared in most of the studies as antecedents to child labor. Societal expectations on the role of males and females influenced child labor practices, and the nature of child labor related activity children are engaged in. Men are trained to become breadwinners in the family, with women as family maintenance agents ( cf . [ 62 , 64 , 65 , 67 , 72 ]). As a result, child labor in income-generating activities, such as fishing, carpet work and cocoa, was found to be common among boys, whilst girls predominantly engaged in domestic duties [ 62 , 64 , 72 ]. Most female parents confirmed the decision to engage their young girls in domestic chores as part of their training to become good wives.

“I want to use my personal experience as an example. I was the only girl amongst seven boys, so I needed to be familiar with the demands of marriage life as is required of all girls. When I was living with my siblings, I used to wash, clean and sweep for them because I was being prepared for future life. The role of a girl in the household is to provide services to the boys.” [ 62 ] (p. 13)

The cultural belief that a good wife is one who satisfies her husband’s family’s expectations influenced parents in Tajikistan to engage their children in domestic chores at their early ages [ 67 ]. Similarly, young boys in South Africa engaged in hard labor to feed their family as part of their preparation to become breadwinners for their future families [ 71 ]. It is reported that the gendered notion on child labor is enforced by social sanctions. Boys in Bangladesh who undertake household chores are labelled as “women” and called names, and vice versa [ 72 ]. Their parents are also seen as bad parents.

“If men do these jobs [housework] everyone will call him a woman.” [ 72 ] (p. 13)

It is the cultural expectation that children carry out the culturally defined occupations/activities which prepares them adequately to assume their roles as breadwinners and family maintenance agents.

3.4. Asset Value of Children

Themes and narratives from the included studies revealed that societal standards that support the asset value of children also influence child labor in the family [ 62 , 63 , 64 , 67 , 71 ]. These social standards underlie the economic importance of children’s contribution to family work and family income. Parents are therefore encouraged to engage their children in their own occupations so as to benefit from their economic value. Children are more likely to be involved in child labor in families where parents’ occupations demand a lot of labor.

“Fishing is a very difficult task and parents need more labour to be able to carry out the task. In my view, government should allow children to support their parents and supplement household income. At the low income we get from our fishing business, how can we hire only adult labourers?” [ 62 ] (p. 10)

The narrative shows that children are cheap sources of labor, as well as alternative sources of labor. The notion of children contributing to families is endorsed by parents in South Africa [ 71 ], Ghana [ 63 , 64 , 65 ] and children in Tajikistan [ 67 ]. According to parents in Ghana and South Africa, certain kinds of family occupations, such as fishing, farming and family business, require more hands [more labor] with specific tasks assigned for children in the family [ 63 , 64 , 65 , 71 ].

“This is because there is inadequate mechanisation of artisanal fishing industry. The work is quite difficult, and fishermen need more hands.” [ 64 ] (p. 60)

The need for more hands due to the lack of mechanization of fishing (use of modern fishing methods) influenced parents to involve their children in child labor. This was confirmed by another parent:

“I think many parents are using their children to work because their work is not mechanised. The State needs to support parents to mechanise their work to help eliminate child labour.” [ 64 ] (p. 60)

A chronological analysis of the above two quotes confirm that children are indeed engaged in hard work as they are meant to work in non-mechanized family fishing practices. Promoting mechanized fishing practices may provide leeway to avoid hard work in family fishing but may not completely remove children from working in family fishing.

The social expectations for children to contribute to family income is accepted by children as part of their mandatory responsibilities to their family. Some children in Tajikistan revealed that it is their obligation to contribute to their parents’ work/business so that their parents could save money (meant for hiring other staff) [ 67 ]. Children feel enthusiastic when they judge themselves to have satisfied this societal demand [ 64 ].

3.5. Value of Formal Education

A normative interpretation of the value of formal education was found to inform parents’ decisions to involve their children in child labor. Albeit diverse, there was an argument about the relevance of formal education, which influenced parents’ decisions to engage their children in labor [ 64 , 67 , 68 , 69 ]. Parents believed that informal apprenticeship in family work provides future job security for children, compared to formal education. Due to the low job security arising from formal education, children are believed to be better off receiving an informal apprenticeship from their parents’ occupations. The relative importance of informal apprenticeship training over formal education influenced child labor practices.

“Parents tell us that they know children in the community who have successfully completed their education, yet they don’t have jobs. Some parents believe putting their children into farm work is worthwhile because their children develop their employment skills that get them ready jobs.” [ 64 ] (p. 60)

In the context of poor school quality, low job security after school and severe challenges with school access, parents may rationally prioritize informal apprenticeship through child labor over enrolling their children in school. The high rate of graduate unemployment in many developing countries was found to support the shared belief that informally training children in family work is a better option as opposed to formal education ( cf. [ 64 , 65 , 66 , 68 ]). Some parents are further encouraged by the cultural belief that “education does not fit every child”. Parents who held this belief suggested that children who are stubborn do not require formal education, instead they should work in family farms [ 64 ].

On the other hand, some parents justified their decisions to involve children in child labor as part of the measures for children to appreciate the value of formal education. They argued that education is without stress since it does not involve hard work. Therefore, children’s experiences of both hard work and formal education would enable them to assess the two occupations and appreciate the value of formal education (see [ 68 , 69 ]). The following narrations from parents in Turkey exemplify their argument:

“I swear to God, I’m not after their money…. They don’t work and they don’t care about school. I’m saying if they work, maybe they will understand the value of school and go to school.” [ 68 ] (p. 46)

“I say maybe if they work, going to school will feel sweeter [better] to them. For instance, because work will be too hard, school will be [easier].” [ 68 ] (p. 46)

Even though the overall intention for engaging the children in hard work (child labor) is to make them accept formal education, the rationale can be defeated when the children develop a liking for the work compared to school. That said, evidence from children in Nepal suggests that children who experienced the two; formal education and family child labor, found education to be the better option [ 69 ].

3.6. Sustenance and Succession of Family Occupation

A considerable number of the studies reported findings on the social norm of sustenance and succession of family occupation [ 62 , 64 , 65 , 67 , 73 ]. Works undertaken by parents, such as farming and fishing, are conceptualized as family occupations which are supposed to be assumed by their children and sustained for future generations [ 64 ]. Evidence from parents, social service workers and NGO workers in Ghana confirmed that cocoa farming and fishing are classical family occupations which children should strive to maintain. Family occupations give identity to the family. The desire to maintain family occupation enforced parents’ commitment to involve their children in cocoa farming and fishing [ 64 , 65 ].

“Most parents are farmers in these rural communities, and very often they want their children to help them on the farms because they want to socialise their children to take over from them. However, this cultural practice is sometimes abused by some parents. Some parents engage their children in work in times that those children are supposed to be school. Children support their parents on the farms to perform tasks such as weeding, planting of seedling and burning unwanted woods in the farm. Many boys work for 8 h on the average in a day.” [ 62 ] (p. 9)

Commitment to the norm of sustenance and succession of family occupation made parents opposed to the idea and efforts to eliminate child labor (see [ 62 , 64 , 65 ]). Even professionals, such as NGO workers, who are mandated to ensure the application of child labor standards and implement measures to eliminate child labor, are sometimes influenced by these social norms.

“I have been in this community long enough to know that many farmers want their children to be socialised and take over from them and therefore they won’t agree to total elimination of child labour.” [ 62 ] (p. 10)

The findings highlight ways deep rooted social norms can influence child labor and obliterate the commitment to eliminate child labor. Training children on family occupations is considered the primary responsibilities of families to ensure that the next generation of farmers are produced [ 65 ]. A cooperative director for cocoa farmers in Côte D’Ivoire explained:

“And also we have to prepare the future generation of farmers. So, when the child is in the farm, there are some activities that he can do and some other activities that they can’t. He must assist. He look at his father working. And then the child keep it in his mind. So the child, during his free time, his holidays, must go to farm and see what his father is doing.” [ 65 ] (p. 8)

Krauss’ [ 73 ] household survey among Ghanaian parents and key informants, such as the Minister of Education, showed that top level policy makers are also influenced by these social norms. An indication that social norms on child labor cut across various strata of society. A quote from the Minister of Education in Ghana showed ways the social norm of succession influences child labor:

“…I belong to the old school, where you ‘bring up the child the way he should go’ so that if you are a child in a farming family you should be able to learn about farming from your parents…” [ 73 ] (p. 551)

The desire and commitment to uphold the norm of sustenance of family occupation is enforced by the notion that family occupations will collapse if children are not trained to assume and continue with it ( cf . [ 64 , 65 , 73 ]).

“Our family businesses will collapse if we take our children out of fishing. It is part of our culture for children to get deeply involved in what we (parents) do.” [ 62 ] (p. 11)

Themes related to the normative interpretation of child labor standards

Only 2 of the 13 articles reported evidence on the normative interpretations of child labor and related legislation or standards [ 61 , 66 ]. The finding discusses parents’ interpretations of the UNCRC sections on children’s active participation in decisions, and children’s rights. Evidence on the two themes is discussed below:

3.7. Obedience

Parents opposed the UNCRC commitment for children to be given the free will to make decisions and contribute to decisions that affect their lives [ 61 , 66 ]. Children’s rights to active participation in decisions were interpreted within the normative cultural framework of obedience and respect. Children’s active participation in decisions were considered among the potential practices that deviates from the cherished norm of obedience and respect of elders [ 61 , 66 ]. Children are culturally expected to obey the decisions of elders and take instructions from persons who are older than them, especially their parents. Thus, the power to make decisions within the family rest upon elders, who also have the cultural authority to make decisions for children [ 61 , 66 ].

“Ghanaian culture gives parents more power over their children. Thus, there is virtually no children’s rights to participation in family decisions since parents’ views on matters concerning the child carries a lot of weight. It is quite difficult for children to disobey their parents in matters relating to child labour.” [ 61 ] (p. 472)

Legitimacy of parents’ decision-making power and the social expectation of obedience influenced children’s acceptance and commitment to instructions from their parents [ 66 ]. Those who obey and submit to parent’s instructions, without questioning, are considered to be good-natured [ 64 , 66 ] and respectful children [ 71 ]. The incentives associated with being considered a well-natured child further strengthened children’s commitment to the belief that adults are better positioned to make decisions for children [ 71 ]. Additionally, the cost associated with being branded as a bad parent [ 61 ], and having your children considered as “wayward” [ 64 ] influenced parents’ conformity to the norm.

3.8. Child Rights in Child Labor

Broadly, Adonteng-Kissi’s [ 61 ] study explored parents’ and stakeholders’ opinion on children’s rights within the context of child labor in the Ghanaian cultural context. Collectively, parents agreed that a child’s right is a foreign concept that contravenes the social norms in Ghana, particularly the social norms that support child rearing practices. They argued that children’s rights spoil children and make parents powerless in their efforts to guide and nurture their children towards a successful future. They believe that engaging children in the works of their parents is not wrong, as that has been the practice since the inception of traditional communities. Evidence from the narratives of parents who involved their children in child labor revealed that government officials are reluctant to implement children’s rights and child labor related legislation, because they agree that child work is an old-aged practice that is good for children. Effective child support, interventions for struggling parents and strong government enforcement [ 61 ] were identified among the key resources and structures required to ensure the effective adoption and implementation of children’s rights to end child labor in Ghana. The lack of these important requirements makes children’s rights unfit for the local Ghanaian context. It was suggested that the social norm that spells out the need for children to work and complement family income may change if there are adequate social interventions to support child rearing and family wellbeing. The lack of such interventions makes child rights meaningless in the local context. Citing western countries, the parents believe that child rights have worked in such contexts due to the existence of strong social interventions and legal structures that ensure compliance.

4. Discussion

This study systematically analyzed evidence from existing studies on the influence of culture and social norms in child labor. It further analyzed evidence on the normative interpretations of legislation and international standards that seek to abolish child labor practices. The findings, which have been categorized under six specific themes, are discussed within the context of cultural values that underpin the social normative interpretations.

4.1. Social Norms Precipitating Child Labor

A common theme from the studies suggests that social norms on informal apprenticeship training for children influence child labor practices in many contexts, including Africa, Europe and Asia. Child labor practice is strengthened by the cultural belief that involving children in informal training, either through family occupation or household chores, imbibes in them the spirit of hard work, strong work ethics and prepares them adequately to face life changes. Johansen [ 17 ] reports that there is an overriding acceptance of the belief that child labor and child work prepares children adequately for the future and makes them hard workers. Similar to the findings by Verner and Blunch [ 19 ], it is evident that parents are more willing to engage their children in work early to develop affection for work and good work ethics. It is therefore not surprising that children in Tajikistan were reported to start work as early as 4 years. The findings collectively highlight societies’ commitment to the social values of resilience and hard work. Values of resilience and hard work are influential in society, and considered cardinal components of common values that needs to be promoted [ 74 , 75 ]. However, the normative interpretations of these values, is found to be undesirable for some children. If children can only become hard workers when they start work early, or when they engage in child labor, then the relevance of hard work should be questioned. In the same vein, if resilience can only be achieved through child labor, then the value of resilience should be given a second thought. The findings is indicative of societies’ commitment to social values, which are instrumental for group membership [ 75 ] and survival. It also demonstrates that normative interpretations of these values, in terms of practices to achieve the values, differ and in some cases could be detrimental to the health and wellbeing of children (especially in the case of child labor). Although engaging children in farm work could be hazardous, parents may be compelled to send their children to work to ensure proper supervision and care. This may happen when there is no proper supervision for children at home, or when children could be at higher risk of experiencing violence at home. These adverse consequences, resulting from leaving children at home, may explain parents’ views on sending their children to farm.

On the surface, the values of resilience and hard work could lead to uncritical acceptance from people because they ultimately lead to success and wellbeing. This uncritical acceptance was evident in this study as children in some studies accepted their parents’ decisions to involve them in work, and considered child labor as a normal part of their development [ 67 , 70 ]. Normalization of child labor by children shows the intergenerational transmissions link of social norms that enforce child labor practices. Thus, it is important for interventions to target at breaking this intergenerational link, through a wholistic normative change intervention.

Some parents involved in the studies alluded to the influential role of gender norms in child labor. Gender norms and role specification informed child labor practices. It emerged that the acceptance of males as breadwinners, and females’ primary role of maintaining the family informed child labor decisions. As a result, most boys were found to engage in income generating works, such as cocoa farming, fishing and work in industries, whilst females were engaged more in domestic chores. The study by Delap [ 72 ] in Bangladesh found that boys who engaged in household chores were labeled as “women”. This social stigma reinforces the commitment to the gender norms as it introduces informal social control mechanisms. Evidence on gender norms in child labor also suggest that, overtime, child labor would be gender specific; whereby boys will engaged in income generating labor, with girls involved in household maintenance labor. If this preposition should hold, in the long run hazardous child labor and non-child labor would assume similar dimension [ 76 ].

Parents in the studies provided narratives that underlie the social norms on the economic value of children. Parents from rural and urban Ghana, South Africa, Tajikistan and Turkey [ 62 , 63 , 64 , 67 , 71 ] expressed the belief that children are traditionally mandated to work and contribute to family income. It emerged that certain occupations, such as fishing and farming, required the collective involvement of family members including children. There are specific tasks for children in such occupations. Evidence from the cross-continental studies mainly demonstrate the normative interpretation of childhood, which zoom into the long-standing debate on childhood and child labor [ 77 , 78 , 79 ]. Indeed, conceiving children to have economic value transgress the global accepted standards on childhood (contained in the UNCRC), which are mainly based on the Western conceptualization of childhood. These are imposed western standards; however socioeconomic improvements are needed to change values. The fact that the normative standards on the economic values of children is also accepted by children suggest that a different conception of childhood may be at work in such context. Viruru [ 79 ] has argued that the interaction between childhood and child labor is complex and this complexity could be fueled by cultural factors. Findings from the included studies show that the normative interpretation of the economic value of children undermines efforts to attain the global standards on childhood.

Children were likely to engage in child labor in a context where family occupations are commonly practiced. This is in line with the cultural commitment to ensure sustenance and succession of family occupations. Common occupations identified with child labor, such as farming and fishing, are traditionally defined as family occupations, which are required to be sustained and transcended onto the next generations. Involving children in work is a common pathway to ensure the sustenance of family occupation.

4.2. Normative Interpretation of Child Labor Standards

This review shows that children’s right to participate in decisions that affect their lives are interpreted within the normative framework of obedience and respect. Studies mainly from Ghana [ 61 , 66 ] have shown that children are not accorded the freedom to exercise their right to participation because child participation is culturally interpreted as measures that spoil children. Child participation could lead to children disrespecting adults, since the Ghanaian culture gives enormous power to parents and adults and expects children to listen to instructions from adults [ 51 , 53 ]. Child participation could also undermine the authority of adults and elders in the community. It can be argued that the normative interpretation of child participation right is part of the conscious cultural efforts to achieve the value of respect and obedience to authorities and parents.

Finally, children’s rights in general were considered by parents as alien and part of the measure that spoils the African child. It is argued that children’s rights are geared towards making parents less powerful in efforts to guide their children. However, the study did not specify types of rights that are alien to the African context and those that spoil children [ 66 ]. It is generally accepted that rights that empower the child and seek to make them independent contravenes the African culture, which promotes obedience and respect of elders’ decisions and instructions [ 80 , 81 , 82 ]. Such rights are deemed to challenge parents’ authority in the family. Yet, the African Charter on the Rights of the Child provides measures to promote children’s rights to decisions, participation and protection. This suggests that children’s rights may not be entirely foreign in the African context. Narratives from the parents confirmed that child work is an accepted pathway for children to build responsibility and independence. This may imply that the length of children’s involvement in work could vary by the socioeconomic differences within the family and community. In low-income families, children are forced to grow up quicker by taking on work and responsibilities, compared to children in middle-high income families where adolescence can be prolonged into the 20′s, varying by context and cultural differences.

4.3. Implication for Child Labor Practice and Research

Evidence discussed in this review has some implications for practiced measures that are required to eradicate child labor. The findings show that varied normative interpretations of key social values: respect and obedience, hard work, resilience, and sustenance and succession, influence child labor decisions. These negative normative interpretations are deep-rooted and legitimatized among children. A multi-pronged normative intervention program that seeks to change the negative normative interpretations is needed. In particular, a combination of normative change campaign with community education is needed to intensify education on the negative social norms. The education should aim at sensitizing communities to acknowledge the unfavorable outcomes of the existing normative interpretations of the common values and provide alternative justification/avenues communities can model into their accepted social standards. Children should not be left out in the normative change interventions because they appear to have legitimatized the negative interpretations that support child labor practices. Social sanctions should be instituted to control negative social norms and ensure conformity to the newly developed social standards. Modelling new social standards could be challenging. As a result, we advocate for a wholistic community approach that involves three stages: identification of the negative social norms on child labor, collectively develop alternative normative paths, and collectively develop implementation plans including social sanctions to ensure social control. Other important strategies that can help eliminate child labor include measures to promote access to school, increase school supplies, reduce transportation costs for students, and a conditional cash transfer program to stay in school. The school, health services and governmental programs can play a role in promoting children and parents’ understanding about the hazards and benefits of family’s work. Such holistic approach, involving efforts from the educational system, government, health and economic system (conditional cash transfer) will be useful to change the values and norms. It will help children and their families to appreciate the realities regarding how they are interpreting values/social norms and the impact on children.

A periodic evaluation of the child labor elimination interventions is needed to ensure that the adverse consequences are identified and curtailed ( cf . [ 83 ]). Child labor elimination programs may have hidden and undesired consequences of increasing child labor within poor communities [ 83 ]. These poor communities may develop alternative occupations/avenues, sometimes with poor conditions and incentive, because for some children work is the only means for survival. Therefore, it is important to supplement the social normative approach of eliminating child labor with an economic approach that provide incentives to poor families for them to develop alternative livelihoods.

Indeed, the acceptance of certain occupations, such as farming and fishing as family works, provide support for child labor practices. The normative change program should include measures that train communities to accept the unique career path of every child and the negative implications of forcing children into a supposed family occupation. Education should be acknowledged as the foundation not only for career in the formal sector but also relevant for those working in the informal sector. Technical and vocational education should be promoted as suitable alternatives for children whose parents deem them unfit for theory-oriented educational programs. Studies that seek to further explore the negative social norms and enable community members to provide alternative normative paths are desired. Intervention studies to change the negative social norms and model positive social norms is needed. A holistic assessment of the key promulgation in the UNCRC and ILO’s child labor standards in developing countries is needed to guide amendments and operationalizations within the local context.

4.4. Limitations

This study is not without limitations. Our search is limited to only English published academic articles on the subject. It is possible that relevant information on the social norms and child labor may be available in gray literature, including book chapters and reports. Even though we included the two big databases in the social sciences literature; Scopus and Web of Science, studies contained exclusively in other databases may be overlooked. We admit that some studies may have discussed the social norms in child labor without a strict use of the lingua or terminologies of norms, values, beliefs, culture, etc., and thus may have been mistakenly excluded from our review. The documented procedure will allow an updated review to be conducted. Throughout the manuscript we have adopted a loose definition of social norms “rules that is understood and shared by members of the social group (e.g., community) and guide behavior and decisions”. Our intention was to provide non-abstract level interpretations of the various means social norms that inform decisions including child labor. This approach and the way we have sought to argue about social normative interpretations vary slightly from the typical methods a classical cultural or anthropology researcher would use. This does not obliterate our utmost intention of this study, which is tied to practice. Furthermore, there was no pre-published protocol for this review.

5. Conclusions

This systematic review advances knowledge on social norms that influence decisions on child labor practices in the family. Findings from the included studies confirmed Parsons’ argument that uncritical acceptance of values as given could be detrimental to society. The findings showed that even though values of respect, hard work and inheritance are important, normative interpretations of them have tendencies of influencing child labor practices within the family. Norms on gender, inheritance and sustenance, value of education and the asset value of children are influential in parents’ decisions to involve their children in work/hard labor. The study findings provide directions for normative change programs targeting the negative interpretations of these values and social norms.

Acknowledgments

We are grateful to the China Medical Board Foundation (Grant number 21-396) for the funding support to cover the Article Processing Charge (APC).

Author Contributions

A.A. Conceptualized the problem, contributed to the literature review, data analysis and writing of manuscript. I.H. contributed to the conceptualization of the study, literature search, and writing of manuscript. C.R.E. contributed to the conceptualization of the research, he designed the search protocol, led the data analysis process, and wrote methods section. L.P.J. contributed to the conceptualization of the study, literature search, guided the review and discussion of findings. All authors have read and agreed to the published version of the manuscript.

This research was funded by the International Labour Organization (ILO) and International Organization for Migration (IOM) through the “RTA seed grant” awarded to Alhassan Abdullah, and the APC was funded by the China Medical Board Foundation (Grant number 21-396).

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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In This Article Expand or collapse the "in this article" section Child Labor

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Child Labor by Mary Lorena Kenny , Kathie Carpenter LAST REVIEWED: 25 April 2022 LAST MODIFIED: 25 April 2022 DOI: 10.1093/obo/9780199791231-0092

Approaches to research on child labor, and the development of appropriate action to combat it, have shifted in the past few decades. Children’s labor was previously considered “natural” as an inherent aspect of being poor, and rarely were their voices included in collection of data. Today, both quantitative and qualitative studies include first-person accounts to bolster their analysis. The umbrella term, “child labor,” has been disaggregated to order to highlight how context—gender, race, sexuality, urbanization and global shifts in labor and consumption, natural disasters—shape the nature, extent, interpretation, and representation of children’s work. Together with scholarship historicizing “childhood,” the family and household, and the ongoing efforts by nongovernmental organizations (NGOs), a rich source of information is available to help navigate the complexity of children’s work and the significance it has for children, their families, and the world. Special acknowledgement: This entry has been updated by guest reviewer Dr. Kathie Carpenter, associate professor and department head of global studies, University of Oregon. Her expertise has proven invaluable to this article.

This is a suggestive, not exhaustive, list. It draws from the thousands of books, articles, government reports, essays, newspaper commentaries, dissertations, traveler accounts, photographs, and films produced by political, academic, and humanitarian agencies that describe, decry, and advocate against child labor. Economic transformations and policies create new forms of labor, migration, and consumption. Emphasis on child labor may be embedded in studies on street children , human trafficking and modern-day slavery, human rights, domestic labor, sex work, and illicit drug production and distribution. Simply defining child labor is complex and contested, as pointed out by the International Labour Organization (ILO; see “ What Is Child Labour ”). Included here are websites that provide broad overviews of the causes and consequences of child labor, brief essays on their sociocultural contexts, and efforts to eliminate child labor (Office of Child Labor, Forced Labor, and Human Trafficking; International Programme on the Elimination of Child Labour; Understanding Children’s Work; see Becker 2017 ). Important emerging research areas include child labor and health ( Kuimi, et al. 2018 ; Ibrahim, et al. 2019 ) and the impact of global environmental change on child labor ( Brashares, et al. 2014 ). Posso 2020 contains case studies by a range of specialists linking policy prescriptions to theoretical and empirical studies. The website for Children and Work Network contains up-to-date listings of events such as speaker series and webinars, as well as detailed, informative case studies. Two overviews ( Lesson Plan: Child Labor in America , Child Labor Public Education Project ) and UNICEF’s website on Child Labour provide materials suitable for teaching at K–12 levels as well as higher education.

Becker, Jo. “Child Labor.” In Campaigning for Children . By Jo Becker, 59–82. Stanford, CA: Stanford University Press, 2017.

Uses case studies and storytelling to introduce the main issues surrounding child labor, including current challenges and considerations, and to document actions against it. Very accessible approach to complex issues.

Brashares, Justin S., Briana Abrahms, Kathryn J. Fiorella, et al. “Wildlife Decline and Social Conflict.” Science 345.6195 (2014): 376–377.

DOI: 10.1126/science.1256734

Shows how global environmental change is implicated in child labor, especially the worst forms. The pressure to exploit increasingly scarce wildlife while lowering production costs increases demand for labor. The authors argue against approaches that fail to address root causes, which are exacerbated by climate change.

Child Labor Public Education Project . University of Iowa Labor Center.

Comprehensive workshop materials for adults and K–12 students. Covers both historical and contemporary approaches. Includes activities and information sheets focused on causes and consequences from both US and international perspectives.

Child Labour . UNICEF.

Comprehensive overview of UNICEF’s child labor position and programming, with links to data, reports, and project descriptions. Written from an advocacy rather than academic perspective. Frequently updated, with sections on very current events, such as COVID-19 and child labor.

Children and Work Network .

A global group of researchers and practitioners dedicated to understanding and disseminating information about children’s work that is evidence based, informed by working children’s own experiences, and takes into account children’s overall well-being. Sponsors workshops, webinars, policy positions, and research series.

Ibrahim, Abdalla, Salma M. Abdalla, Mohammed Jafer, Jihad Abdelgadir, and Nanne de Vries. “Child Labor and Health: A Systematic Literature Review of the Impacts of Child Labor on Child’s Health in Low- and Middle-Income Countries.” Journal of Public Health 41.1 (2019): 18–26.

DOI: 10.1093/pubmed/fdy018

Review article linking child labor with adverse physical and mental health outcomes. Concludes that current policy approaches are inadequate. Primary research recommendation is that more comparative and longitudinal studies are urgently needed in order to clarify causal relationships and suitable policy solutions.

Kuimi, Brice L. B., Oduro Oppong-Nkrumah, Jay Kaufman, Jose I. Nazif-Munoz, and Arijit Nandi. “Child Labor and Health: A Systematic Review.” International Journal of Public Health 65.3 (2018): 663–672.

Review article noting strong correlation between poor health and child labor, but points out impossibility of determining causality due to lack of longitudinal studies. Highlights methodological problems, such as difficulty researching agricultural work, which is the greatest source of injuries because it often occurs within family context.

Lesson Plan: Child Labor in America . US Library of Congress.

Compiled by Joyce Kasman Valenza and Carl Atkinson, a complete unit on history of child labor in the United States, including primary-source material, activities, discussion topics, assignments, and teachers’ guides

Posso, Alberto, ed. Child Labor in the Developing World: Theory, Practice and Policy . Singapore: Springer Singapore, 2020.

DOI: 10.1007/978-981-15-3106-4

Edited volume with chapters analyzing causes and consequences of child labor in a range of regions and across a variety of sectors. Empirical grounding is used to inform policy analysis and make recommendations as well as provide new theoretical insights.

What Is Child Labour . International Labour Organization.

Presents ILO position on child labor, distinguishes between child labor and child work, and introduces the idea of “worst forms of child labor.” Provides links to other ILO information and positions on child labor. Includes a subheading on the International Programme on the Elimination of Child Labour (IPEC) . IPEC is a clearinghouse for information on the nature and extent of child labor worldwide policies, laws, and action plans. Brief factsheets provide basic information on types of labor.

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Article Contents

Introduction, methodology.

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Child labor and health: a systematic literature review of the impacts of child labor on child’s health in low- and middle-income countries

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Abdalla Ibrahim, Salma M Abdalla, Mohammed Jafer, Jihad Abdelgadir, Nanne de Vries, Child labor and health: a systematic literature review of the impacts of child labor on child’s health in low- and middle-income countries, Journal of Public Health , Volume 41, Issue 1, March 2019, Pages 18–26, https://doi.org/10.1093/pubmed/fdy018

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To summarize current evidence on the impacts of child labor on physical and mental health.

We searched PubMed and ScienceDirect for studies that included participants aged 18 years or less, conducted in low- and middle-income countries (LMICs), and reported quantitative data. Two independent reviewers conducted data extraction and assessment of study quality.

A total of 25 studies were identified, the majority of which were cross-sectional. Child labor was found to be associated with a number of adverse health outcomes, including but not limited to poor growth, malnutrition, higher incidence of infectious and system-specific diseases, behavioral and emotional disorders, and decreased coping efficacy. Quality of included studies was rated as fair to good.

Child labor remains a major public health concern in LMICs, being associated with adverse physical and mental health outcomes. Current efforts against child labor need to be revisited, at least in LMICs. Further studies following a longitudinal design, and using common methods to assess the health impact of child labor in different country contexts would inform policy making.

For decades, child labor has been an important global issue associated with inadequate educational opportunities, poverty and gender inequality. 1 Not all types of work carried out by children are considered child labor. Engagement of children or adolescents in work with no influence on their health and schooling is usually regarded positive. The International Labor Organization (ILO) describes child labor as ‘work that deprives children of their childhood, potential and dignity, and that is harmful to physical and mental development’. 2 This definition includes types of work that are mentally, physically, socially or morally harmful to children; or disrupts schooling.

The topic gained scientific attention with the industrial revolution. Research conducted in the UK, because of adverse outcomes in children, resulted in acts for child labor in 18 02. 3 Many countries followed the UK, in recognition of the associated health risks. The ILO took its first stance in 1973 by setting the minimum age for work. 4 Nevertheless, the ILO and other international organizations that target the issue failed to achieve goals. Child labor was part of the Millennium Development Goals, adopted by 191 nations in 20 00 5 to be achieved by 2015. Subsequently, child labor was included in the Sustainable Development Goals, 6 which explicitly calls for eradication of child labor by 2030.

Despite the reported decline in child labor from 1995 to 2000, it remains a major concern. In 2016, it was estimated that ~150 million children under the age of 14 are engaged in labor worldwide, with most of them working under circumstances that denies them a playful childhood and jeopardize their health. 7 Most working children are 11–14 years, but around 60 million are 5–11 years old. 7 There are no exact numbers of the distribution of child labor globally; however, available statistics show that 96% of child workers are in Africa, Asia and Latin America. 1

Research into the impacts of child labor suggests several associations between child labor and adverse health outcomes. Parker 1 reported that child labor is associated with certain exposures like silica in industries, and HIV infection in prostitution. Additionally, as child labor is associated with maternal illiteracy and poverty, children who work are more susceptible to malnutrition, 1 which predisposes them to various diseases.

A meta-analysis on the topic was published in 20 07. 8 However, authors reported only an association of child labor with higher mortality and morbidity than in the general population, without reporting individual outcome specific effects. 8 Another meta-analysis investigated the effects of adverse childhood experiences (ACEs), including child labor, on health. They reported that ACEs are risk factors for many adverse health outcomes. 9

To our knowledge, this is the first systematic review that attempts to summarize current evidence on the impacts of child labor on both physical and mental health, based on specific outcomes. We review the most recent evidence on the health impacts of child labor in low- and middle-income countries (LMICs) according to the World Bank classification. We provide an informative summary of current studies of the impacts of child labor, and reflect upon the progress of anti-child labor policies and laws.

Search strategy

We searched PubMed and ScienceDirect databases. Search was restricted to publications from year 1997 onwards. Only studies written in English were considered. Our search algorithm was [(‘child labor’ OR ‘child labor’ OR ‘working children’ OR ‘occupational health’ OR ‘Adolescent work’ OR ‘working adolescents’) AND (Health OR medical)]. The first third of the algorithm was assigned to titles/abstracts to ensure relevance of the studies retrieved, while the rest of the terms were not. On PubMed, we added […AND (poverty OR ‘low income’ OR ‘developing countries’)] to increase the specificity of results; otherwise, the search results were ~60 times more, with the majority of studies being irrelevant.

Study selection

Studies that met the following criteria were considered eligible: sample age 18 years or less; study was conducted in LMICs; and quantitative data was reported.

Two authors reviewed the titles obtained, a.o. to exclude studies related to ‘medical child labor’ as in childbirth. Abstracts of papers retained were reviewed, and subsequently full studies were assessed for inclusion criteria. Two authors assessed the quality of studies using Downs and Black tool for quality assessment. 10 The tool includes 27 items, yet not all items fit every study. In such cases, we used only relevant items. Total score was the number of items positively evaluated. Studies were ranked accordingly (poor, fair, good) (Table 1 ).

Characteristics of studies included

* The quality is based on the percentage of Downs and Black 10 tool, < 50% = poor, 50–75% = fair, > 75% = good.

** BMI, body mass index.

*** HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCV, hepatitis C virus.

Data extraction and management

Two authors extracted the data using a standardized data extraction form. It included focus of study (i.e. physical and/or mental health), exposure (type of child labor), country of study, age group, gender, study design, reported measures (independent variables) and outcome measures (Table 1 ). The extraction form was piloted to ensure standardization of data collection. A third author then reviewed extracted data. Disagreements were solved by discussion.

Search results

A flow diagram (Fig. 1 ) shows the studies selection process. We retrieved 1050 studies on PubMed and 833 studies on Science Direct, with no duplicates in the search results. We also retrieved 23 studies through screening of the references, following the screening by title of retrieved studies. By reviewing title and abstract, 1879 studies were excluded. After full assessment of the remaining studies, 25 were included.

Study selection process.

Characteristics of included studies

Among the included studies ten documented only prevalence estimates of physical diseases, six documented mental and psychosocial health including abuse, and nine reported the prevalence of both mental and physical health impacts (Table 1 ). In total, 24 studies were conducted in one country; one study included data from the Living Standard Measurement Study of 83 LMIC. 8

In total, 12 studies compared outcomes between working children and a control group (Table 1 ). Concerning physical health, many studies reported the prevalence of general symptoms (fever, cough and stunting) or diseases (malnutrition, anemia and infectious diseases). Alternatively, some studies documented prevalence of illnesses or symptoms hypothesized to be associated with child labor (Table 1 ). The majority of studies focusing on physical health conducted clinical examination or collected blood samples.

Concerning mental and psychosocial health, the outcomes documented included abuse with its different forms, coping efficacy, emotional disturbances, mood and anxiety disorders. The outcomes were measured based on self-reporting and using validated measures, for example, the Strengths and Difficulties Questionnaire (SDQ), in local languages.

The majority of studies were ranked as of ‘good quality’, with seven ranked ‘fair’ and one ranked ‘poor’ (Table 1 ). The majority of them also had mixed-gender samples, with only one study restricted to females. 24 In addition, valid measures were used in most studies (Table 1 ). Most studies did not examine the differences between genders.

Child labor and physical health

Fifteen studies examined physical health effects of child labor, including nutritional status, physical growth, work-related illnesses/symptoms, musculoskeletal pain, HIV infection, systematic symptoms, infectious diseases, tuberculosis and eyestrain. Eight studies measured physical health effects through clinical examination or blood samples, in addition to self-reported questionnaires. All studies in which a comparison group was used reported higher prevalence of physical diseases in the working children group.

Two studies were concerned with physical growth and development. A study conducted in Pakistan, 11 reported that child labor is associated with wasting, stunting and chronic malnutrition. A similar study conducted in India compared physical growth and genital development between working and non-working children and reported that child labor is associated with lower BMI, shorter stature and delayed genital development in working boys, while no significant differences were found among females. 12

Concerning work-related illnesses and injuries, a study conducted in Bangladesh reported that there is a statistically significant positive association between child labor and the probability to report any injury or illness, tiredness/exhaustion, body injury and other health problems. Number of hours worked and the probability of reporting injury and illness were positively correlated. Younger children were more likely to suffer from backaches and other health problems (infection, burns and lung diseases), while probability of reporting tiredness/exhaustion was greater in the oldest age group. Furthermore, the frequency of reporting any injury or illness increases with the number of hours worked, with significant variation across employment sectors. 13 A study in Iran reported that industrial workrooms were the most common place for injury (58.2%). Falling from heights or in horizontal surface was the most common mechanism of injury (44%). None of the patients was using a preventive device at the time of injury. Cuts (49.6%) were the most commonly reported injuries. 14

Other studies that investigated the prevalence of general symptoms in working children in Pakistan, Egypt, Lebanon, Jordan and Indonesia reported that child labor is negatively associated with health. 15 – 19 Watery eyes, chronic cough and diarrhea were common findings, in addition to history of a major injury (permanent loss of an organ, hearing loss, bone fractures, permanent disability). 20 One study, conducted in India reported that working children suffered from anemia, gastrointestinal tract infections, vitamin deficiencies, respiratory tract infections, skin diseases and high prevalence of malnutrition. 21 Another study—of poor quality—in India reported that child labor was associated with higher incidence of infectious diseases compared to non-working children. 22

Only a few studies focused on specific diseases. A study in Brazil compared the prevalence of musculoskeletal pain between working and non-working children. Authors reported that the prevalence of pain in the neck, knee, wrist or hands, and upper back exceeded 15%. Workers in manufacturing had a significantly increased risk for musculoskeletal pain and back pain, while child workers in domestic services had 17% more musculoskeletal pain and 23% more back pain than non-workers. Awkward posture and heavy physical work were associated with musculoskeletal pain, while monotonous work, awkward posture and noise were associated with back pain. 23 A study in Nicaragua, which focused on children working in agriculture, reported that child labor in agriculture poses a serious threat to children’s health; specifically, acute pesticides poisoning. 24

A study conducted in India reported that the prevalence of eyestrain in child laborers was 25.9%, which was significantly more than the 12.4% prevalence in a comparison group. Prevalence was higher in boys and those who work more than 4 h daily. 25 Another study conducted in India documented that the difference between working and non-working children in the same area in respiratory morbidities (TB, hilar gland enlargement/calcification) was statistically significant. 26

A study in Iran explored the prevalence of viral infections (HIV, HCV and HBV) in working children. 27 The study reported that the prevalence among working street children was much higher than in general population. The 4.5% of children were HIV positive, 1.7% were hepatitis B positive and 2.6% hepatitis C positive. The likelihood of being HIV positive among working children of Tehran was increased by factors like having experience in trading sex, having parents who used drugs or parents infected with HCV.

Lastly, one study was a meta-analysis conducted on data of working children in 83 LMIC documented that child labor is significantly and positively related to adolescent mortality, to a population’s nutrition level, and to the presence of infectious diseases. 8

Child labor and mental health

Overall, all studies included, except one, 28 reported that child labor is associated with higher prevalence of mental and/or behavioral disorders. In addition, all studies concluded that child labor is associated with one or more forms of abuse.

A study conducted in Jordan reported a significant difference in the level of coping efficacy and psychosocial health between working non-schooled children, working school children and non-working school children. Non-working school children had a better performance on the SDQ scale. Coping efficacy of working non-schooled children was lower than that of the other groups. 29

A study conducted in Pakistan reported that the prevalence of behavioral problems among working children was 9.8%. Peer problems were most prevalent, followed by problems of conduct. 30 A study from Ethiopia 31 reported that emotional and behavioral disorders are more common among working children. However, another study in Ethiopia 28 reported a lower prevalence of mental/behavioral disorders in child laborers compared to non-working children. The stark difference between these two studies could be due to the explanation provided by Alem et al. , i.e. that their findings could have been tampered by selection bias or healthy worker effect.

A study concerned with child abuse in Bangladesh reported that the prevalence of abuse and child exploitation was widespread. Boys were more exposed. Physical assault was higher towards younger children while other types were higher towards older ones. 32 A similar study conducted in Turkey documented that 62.5% of the child laborers were subjected to abuse at their workplaces; 21.8% physical, 53.6% emotional and 25.2% sexual, 100% were subjected to physical neglect and 28.7% were subjected to emotional neglect. 33

One study focused on sexual assault among working females in Nigeria. They reported that the sexual assault rate was 77.7%. In 38.6% of assault cases, the assailant was a customer. Girls who were younger than 12 years, had no formal education, worked for more than 8 h/day, or had two or more jobs were more likely to experience sexual assault. 34

Main findings of this study

Through a comprehensive systematic review, we conclude that child labor continues to be a major public health challenge. Child labor continues to be negatively associated with the physical and psychological health of children involved. Although no cause–effect relation can be established, as all studies included are cross-sectional, studies documented higher prevalence of different health issues in working children compared to control groups or general population.

This reflects a failure of policies not only to eliminate child labor, but also to make it safer. Although there is a decline in the number of working children, the quality of life of those still engaged in child labor seems to remain low.

Children engaged in labor have poor health status, which could be precipitated or aggravated by labor. Malnutrition and poor growth were reported to be highly prevalent among working children. On top of malnutrition, the nature of labor has its effects on child’s health. Most of the studies adjusted for the daily working hours. Long working hours have been associated with poorer physical outcomes. 18 , 19 , 25 , 26 , 35 It was also reported that the likelihood of being sexually abused increased with increasing working hours. 34 The different types and sectors of labor were found to be associated with different health outcomes as well. 13 , 18 , 24 However, comparing between the different types of labor was not possible due to lack of data.

The majority of studies concluded that child labor is associated with higher prevalence of mental and behavioral disorders, as shown in the results. School attendance, family income and status, daily working hours and likelihood of abuse, in its different forms, were found to be associated with the mental health outcomes in working children. These findings are consistent with previous studies and research frameworks. 36

Child labor subjects children to abuse, whether verbally, physically or sexually which ultimately results in psychological disturbances and behavioral disorders. Moreover, peers and colleagues at work can affect the behavior of children, for example, smoking or drugs. The effects of child labor on psychological health can be long lasting and devastating to the future of children involved.

What is already known on this topic

Previous reviews have described different adverse health impacts of child labor. However, there were no previous attempts to review the collective health impacts of child labor. Working children are subjected to different risk factors, and the impacts of child labor are usually not limited to one illness. Initial evidence of these impacts was published in the 1920s. Since then, an increasing number of studies have used similar methods to assess the health impacts of child labor. Additionally, most of the studies are confined to a single country.

What this study adds

To our knowledge, this is the first review that provides a comprehensive summary of both the physical and mental health impacts of child labor. Working children are subjected to higher levels of physical and mental stress compared to non-working children and adults performing the same type of work. Unfortunately, the results show that these children are at risk of developing short and long-term health complications, physically or mentally.

Though previous systematic reviews conducted on the topic in 19 97 1 and 20 07 8 reported outcomes in different measures, our findings reflect similar severity of the health impacts of child labor. This should be alarming to organizations that set child labor as a target. We have not reviewed the policies targeting child labor here, yet our findings show that regardless of policies in place, further action is needed.

Most of the current literature about child labor follow a cross-sectional design, which although can reflect the health status of working children, it cannot establish cause–effect associations. This in turn affects strategies and policies that target child labor.

In addition, comparing the impacts of different labor types in different countries will provide useful information on how to proceed. Further research following a common approach in assessing child labor impacts in different countries is needed.

Limitations of this study

First, we acknowledge that all systematic reviews are subject to publication bias. Moreover, the databases used might introduce bias as most of the studies indexed by them are from industrialized countries. However, these databases were used for their known quality and to allow reproduction of the data. Finally, despite our recognition of the added value of meta-analytic methods, it was not possible to conduct one due to lack of a common definition for child labor, differences in inclusion and exclusion criteria, different measurements and different outcome measures. Nevertheless, to minimize bias, we employed rigorous search methods including an extensive and comprehensive search, and data extraction by two independent reviewers.

Compliance with ethical standards

The authors declare that they have no conflict of interest.

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• developing countries
• mental health
• child labor

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Advancing social justice, promoting decent work ILO is a specialized agency of the United Nations

Issue paper

This issue paper brings together and reviews existing research on the interplay between climate change and child labour. It is aimed at providing an initial picture of some of the key channels through which climate change and climate change responses are linked to child labour, and the broad implications for policy moving forward.

The paper examines more than 100 articles from the peer-reviewed literature and reports from international organizations, think tanks and non-governmental organizations. The available evidence, though still limited, makes abundantly clear that climate change – and public and private responses to it - is already having profound impacts on child labour, and, following from this, on global progress towards ending all forms of child labour by the 2025 target date set by the Sustainable Development Goals. As the impacts of climate change grow and intensify, this will be even truer in the years up to and beyond the 2025 target date.

There is an urgent need to consider child labour in broader public and private action towards a just transition to climate-neutral economies and societies. This means, above all, ensuring that climate action is structured in a way that furthers child labour reduction goals and does not instead result in unintended negative consequences for child labour. Both public and private climate actions are relevant in this context.

Public climate action has implications for child labour across a range of policy areas. Safeguards, for example, are needed so that public policies promoting the clean energy transition do not create labour market disruptions that leave low-skill workers and their families in a position of greater vulnerability and more reliant on their children’s labour.

Climate change adaptation policies, such as environmentally sustainable methods to intensify agriculture production in the face of climate change, or public works schemes to buffer climate shocks, must also be designed in a way that reduces household dependence on child labour and do not instead result in greater demand for child labour.

In regulatory terms, combining both environmental and human rights considerations into national laws and regulations governing the behaviour of firms can play an important role in ensuring complementarity between these two regulatory goals.

Additional details

• ISBN: 978-92-2-039828-9 (Print); 978-92-2-038915-7 (Web PDF)

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Issue paper on child labour and climate change - Executive summary

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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Impact of the use of cannabis as a medicine in pregnancy, on the unborn child: a systematic review and meta-analysis protocol

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Introduction: The use of cannabis for medicinal purposes is on the rise. As more people place their trust in the safety of prescribed alternative plant-based medicine and find it easily accessible, there is a growing concern that pregnant women may be increasingly using cannabis for medicinal purposes to manage their pregnancy symptoms and other health conditions. The aim of this review is to investigate the use of cannabis for medicinal purposes during pregnancy, describe the characteristics of the demographic population, and to measure the impact on the unborn child and up to twelve months postpartum. Methods and analyses: Research on pregnant women who use cannabis for medicinal purposes only and infants up to one year after birth who experienced in utero exposure to cannabis for medicinal purposes will be included in this review. Reviews, randomised controlled trials, case control, cross-sectional and cohort studies, that have been peer reviewed and published between 1996 and April 2024 as a primary research paper that investigates prenatal use of cannabis for medicinal purposes on foetal, perinatal, and neonatal outcomes, will be selected for review. Excluding cover editorials, letters, commentaries, protocols, conference papers and book chapters. Effects of illicit drugs use, alcohol misuse and nicotine exposure on neonate outcome will be controlled by excluding studies reporting on the concomitant use of such substances with cannabis for medicinal purposes during pregnancy. All titles and abstracts will be reviewed independently and in duplicate by at least two researchers. Records will be excluded based on title and abstract screening as well as publication type. Where initial disagreement exists between reviewers regarding the inclusion of a study, team members will review disputed articles status until consensus is gained. Selected studies will then be assessed by at least two independent researchers for risk bias assessment using validated tools. Data will be extracted and analysed following a systematic review and meta-analysis methodology. The statistical analysis will combine three or more outcomes that are reported in a consistent manner. The systematic review and meta-analysis will follow the PRISMA guidelines to facilitate transparent reporting [1].

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study will use ONLY openly available human data from studies published in biomedical and scientific journals.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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