Pub Date : 2024-11-01DOI: 10.1016/j.xagr.2024.100404
Monica Lauridsen Kujabi MD, PhD , Natasha Housseine MD, PhD , Idrissa Kabanda MD , Rukia Msumi MD , Luzango Maembe MD , Mtingele Sangalala MD , Manyanga Hudson MD , Sarah Hansen BSc. Med. , Anna Macha MD , Brenda Sequeira D'mello MD , Dan Wolf Meyrowitsch PhD , Flemming Konradsen PhD , Andreas Kryger Jensen PhD , Kidanto Hussein MD, PhD , Nanna Maaløe MD, PhD , Thomas van den Akker MD, PhD
<div><h3>BACKGROUND</h3><div>Similar to many resource-constrained urban settings, cesarean deliveries in Dar es Salaam, Tanzania, have increased rapidly, from 17% in 2015 to 26% in 2022. Alarmingly, at the population level, the increase was not followed by improvements in perinatal outcomes, suggesting the overuse of cesarean delivery. Prolonged labor is the leading cause of women's first cesarean delivery. Therefore, understanding the management of prolonged labor preceding cesarean delivery is crucial for preventing nonmedically indicated cesarean deliveries across Tanzania and globally.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to estimate the proportion of cesarean deliveries with a written indication of prolonged labor that was performed in labors with uncomplicated progression.</div></div><div><h3>STUDY DESIGN</h3><div>This study was conducted at 5 urban maternity units in Dar es Salaam, Tanzania, from October 1, 2021, to August 31, 2022. Data were extracted from case files of women who gave birth via cesarean delivery with a written indication of prolonged labor. The timing of cesarean delivery decision was assessed against predefined definitions of prolonged labor at each stage/phase of labor. The proportion of cesarean deliveries performed in cases of uncomplicated progression was calculated. The exclusion criteria included referral to study sites because of prolonged labor or cervical dilatation of >6 cm upon admission, noncephalic presentation, multiple pregnancy, intrauterine fetal death, failed induction of labor, previous cesarean delivery, or other written indications for cesarean delivery.</div></div><div><h3>RESULTS</h3><div>The overall cesarean delivery rate was 32% (2949/9364). Of first-time cesarean delivery cases, 746 of 1517 patients (47.9%) had a written indication of prolonged labor. Finally, 456 of 746 patients (61.1%) met the inclusion criteria, of which 307 of 456 patients (67.3%) were admitted in the latent phase of labor. In 243 of 456 cesarean deliveries (53.3%) with an indication of prolonged labor, labor was not prolonged. This group included (1) women not being given a trial of labor (78/243 [32.1%]), (2) women in the first stage of active labor not crossing the partograph action line (145/243 [59.7%]), and (3) women in the second stage of labor lasting <1 hour (20/243 [8.2%]). Of note, 78 of 346 women (21.5%) in the first stage of active labor had a labor progression faster than 0.5 cm per hour preceding the decision for cesarean delivery.</div></div><div><h3>CONCLUSION</h3><div>Almost half of cesarean deliveries in unscarred uteri were because of prolonged labor. Despite a written indication of prolonged labor, approximately half of the cases did not have prolonged labor. Although care in low-resource settings has traditionally been categorized as “too little, too late,” this study finds care as “too much, too soon” in one of the world's fastest-growing urban areas. This finding highlights th
{"title":"Timing of cesarean section for prolonged labor in urban Tanzania: A criterion-based audit","authors":"Monica Lauridsen Kujabi MD, PhD , Natasha Housseine MD, PhD , Idrissa Kabanda MD , Rukia Msumi MD , Luzango Maembe MD , Mtingele Sangalala MD , Manyanga Hudson MD , Sarah Hansen BSc. Med. , Anna Macha MD , Brenda Sequeira D'mello MD , Dan Wolf Meyrowitsch PhD , Flemming Konradsen PhD , Andreas Kryger Jensen PhD , Kidanto Hussein MD, PhD , Nanna Maaløe MD, PhD , Thomas van den Akker MD, PhD","doi":"10.1016/j.xagr.2024.100404","DOIUrl":"10.1016/j.xagr.2024.100404","url":null,"abstract":"<div><h3>BACKGROUND</h3><div>Similar to many resource-constrained urban settings, cesarean deliveries in Dar es Salaam, Tanzania, have increased rapidly, from 17% in 2015 to 26% in 2022. Alarmingly, at the population level, the increase was not followed by improvements in perinatal outcomes, suggesting the overuse of cesarean delivery. Prolonged labor is the leading cause of women's first cesarean delivery. Therefore, understanding the management of prolonged labor preceding cesarean delivery is crucial for preventing nonmedically indicated cesarean deliveries across Tanzania and globally.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to estimate the proportion of cesarean deliveries with a written indication of prolonged labor that was performed in labors with uncomplicated progression.</div></div><div><h3>STUDY DESIGN</h3><div>This study was conducted at 5 urban maternity units in Dar es Salaam, Tanzania, from October 1, 2021, to August 31, 2022. Data were extracted from case files of women who gave birth via cesarean delivery with a written indication of prolonged labor. The timing of cesarean delivery decision was assessed against predefined definitions of prolonged labor at each stage/phase of labor. The proportion of cesarean deliveries performed in cases of uncomplicated progression was calculated. The exclusion criteria included referral to study sites because of prolonged labor or cervical dilatation of >6 cm upon admission, noncephalic presentation, multiple pregnancy, intrauterine fetal death, failed induction of labor, previous cesarean delivery, or other written indications for cesarean delivery.</div></div><div><h3>RESULTS</h3><div>The overall cesarean delivery rate was 32% (2949/9364). Of first-time cesarean delivery cases, 746 of 1517 patients (47.9%) had a written indication of prolonged labor. Finally, 456 of 746 patients (61.1%) met the inclusion criteria, of which 307 of 456 patients (67.3%) were admitted in the latent phase of labor. In 243 of 456 cesarean deliveries (53.3%) with an indication of prolonged labor, labor was not prolonged. This group included (1) women not being given a trial of labor (78/243 [32.1%]), (2) women in the first stage of active labor not crossing the partograph action line (145/243 [59.7%]), and (3) women in the second stage of labor lasting <1 hour (20/243 [8.2%]). Of note, 78 of 346 women (21.5%) in the first stage of active labor had a labor progression faster than 0.5 cm per hour preceding the decision for cesarean delivery.</div></div><div><h3>CONCLUSION</h3><div>Almost half of cesarean deliveries in unscarred uteri were because of prolonged labor. Despite a written indication of prolonged labor, approximately half of the cases did not have prolonged labor. Although care in low-resource settings has traditionally been categorized as “too little, too late,” this study finds care as “too much, too soon” in one of the world's fastest-growing urban areas. This finding highlights th","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100404"},"PeriodicalIF":0.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142594149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.xagr.2024.100413
Alim Swarray-Deen MD , Misturah Y. Adana MD, PhD , Micheal A. Alao MD , Victoria A.A. Agyen-Frimpong MD , Adekunle Fakunle PhD , Deda Ogum-Alangea PhD , David N. Adjei PhD , Kwame Yeboah MD, PhD , Yemi Raheem Raji MD , Samuel A. Oppong MD , James A. Ogunmodede MD , Kolawole Wahab MD , Kola Okuyemi MD
Background
Sickle cell disease (SCD) has evolved from a condition predominantly fatal in childhood to a chronic illness impacting many adults, including women of reproductive age. For females with SCD, pregnancy represents one of the greatest health threats, exacerbating existing health challenges and introducing new risks. Despite advancements in healthcare, routine screening for existing complications like pulmonary hypertension (PH) remains inconsistent, particularly in low- and middle-income countries (LMICs), where the prevalence of SCD is highest.
Objective
This study aimed to assess the feasibility of screening for PH in pregnant women with SCD in LMICs, with the goal of enhancing maternal health outcomes in this vulnerable population.
Study Design
A prospective multi-center feasibility study was conducted from September 2022 to February 2023 at teaching hospitals in Ghana and Nigeria. The study included pregnant women with SCD between 28 and 34 weeks of gestation. Screening for PH utilized a tricuspid regurgitation velocity (TRV) criterion (>2.5 m/s), with adherence to American Society of Echocardiography guidelines. Statistical analysis included descriptive statistics and proportions.
Results
Among 3091 pregnant women attending antenatal care, 88 had SCD (2.8%), and 55 were eligible for the study. We recruited 44 participants (mean age 28.9 years, SD 4.8), with 48% (21/44) SS genotype and 52% (23/44) SC genotype. Most participants (95.3%) had normal TRV (<2.5 m/s), with only one showing elevated TRV, successfully referred. Protocol adherence was 100%. Antenatal outcomes showed 95% echo uptake and 95.7% retention to term whilst postnatal echo follow-up was 43.5%. Notably, 27.1% (10/37) of deliveries required neonatal intensive care unit admission, and 18.2% were preterm. The sole participant with PH required intensive care unit care and experienced a preterm delivery with neonatal death on day 5.
Conclusion
Screening and referral for PH in pregnant women with SCD in LMICs are feasible but face challenges in early diagnosis, healthcare personnel availability, and postnatal follow-up. Strategic planning is crucial to address these challenges and improve outcomes in this high-risk population
{"title":"Screening for pulmonary hypertension in pregnant women with sickle cell disease in sub-Saharan Africa","authors":"Alim Swarray-Deen MD , Misturah Y. Adana MD, PhD , Micheal A. Alao MD , Victoria A.A. Agyen-Frimpong MD , Adekunle Fakunle PhD , Deda Ogum-Alangea PhD , David N. Adjei PhD , Kwame Yeboah MD, PhD , Yemi Raheem Raji MD , Samuel A. Oppong MD , James A. Ogunmodede MD , Kolawole Wahab MD , Kola Okuyemi MD","doi":"10.1016/j.xagr.2024.100413","DOIUrl":"10.1016/j.xagr.2024.100413","url":null,"abstract":"<div><h3>Background</h3><div>Sickle cell disease (SCD) has evolved from a condition predominantly fatal in childhood to a chronic illness impacting many adults, including women of reproductive age. For females with SCD, pregnancy represents one of the greatest health threats, exacerbating existing health challenges and introducing new risks. Despite advancements in healthcare, routine screening for existing complications like pulmonary hypertension (PH) remains inconsistent, particularly in low- and middle-income countries (LMICs), where the prevalence of SCD is highest.</div></div><div><h3>Objective</h3><div>This study aimed to assess the feasibility of screening for PH in pregnant women with SCD in LMICs, with the goal of enhancing maternal health outcomes in this vulnerable population.</div></div><div><h3>Study Design</h3><div>A prospective multi-center feasibility study was conducted from September 2022 to February 2023 at teaching hospitals in Ghana and Nigeria. The study included pregnant women with SCD between 28 and 34 weeks of gestation. Screening for PH utilized a tricuspid regurgitation velocity (TRV) criterion (>2.5 m/s), with adherence to American Society of Echocardiography guidelines. Statistical analysis included descriptive statistics and proportions.</div></div><div><h3>Results</h3><div>Among 3091 pregnant women attending antenatal care, 88 had SCD (2.8%), and 55 were eligible for the study. We recruited 44 participants (mean age 28.9 years, SD 4.8), with 48% (21/44) SS genotype and 52% (23/44) SC genotype. Most participants (95.3%) had normal TRV (<2.5 m/s), with only one showing elevated TRV, successfully referred. Protocol adherence was 100%. Antenatal outcomes showed 95% echo uptake and 95.7% retention to term whilst postnatal echo follow-up was 43.5%. Notably, 27.1% (10/37) of deliveries required neonatal intensive care unit admission, and 18.2% were preterm. The sole participant with PH required intensive care unit care and experienced a preterm delivery with neonatal death on day 5.</div></div><div><h3>Conclusion</h3><div>Screening and referral for PH in pregnant women with SCD in LMICs are feasible but face challenges in early diagnosis, healthcare personnel availability, and postnatal follow-up. Strategic planning is crucial to address these challenges and improve outcomes in this high-risk population</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100413"},"PeriodicalIF":0.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142658428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The worldwide increase in the cesarean delivery rate is a major public health concern and cause of significant debate. Although multiple studies have shown that higher cesarean delivery rates may be associated with adverse maternal and perinatal outcomes, the number of cesarean deliveries has been continuously increasing. In the Republic of Moldova, cesarean delivery increased from 15.75% in 2012 to 27.42% in 2022. However, the perinatal mortality remained unchanged at 11.6%. To understand the factors that determine the increasing trend in cesarean delivery and to approach new strategies to reduce unnecessary surgical delivery, a standardized tool is needed to assess and compare cesarean delivery rates.
OBJECTIVE
This study aimed to assess the changes in the rates and trends of cesarean delivery and to evaluate the contribution of different obstetrical populations to overall cesarean delivery rates in the Municipal Clinical Hospital using the Robson classification.
STUDY DESIGN
This was a cohort study conducted at the Municipal Clinical Hospital in Chisinau. The study included 13,882 women who gave birth in 2017, 2019, and 2022 at the Municipal Clinical Hospital. All births were classified into 10 Robson groups, using 6 basic variables (parity, cesarean delivery in medical history, labor onset, number of fetuses, gestational age, and fetal presentation). Statistical data were collected and analyzed using the Epi Info program (version 7.2.1.0; Centers for Disease Control and Prevention, Atlanta, GA).
RESULTS
The overall cesarean delivery rate was 20.02% (2779/13,882), with a significant increase from 18.59% (809/4351) to 21.59% (1134/5252) (P=.0003). Approximately one-third (1099/2279 [39.55%]) of all cesarean deliveries were performed before labor onset. The main contributor in all study years was group 5 (957/2779 [34.44%]). The next valuable group that contributed to the overall cesarean delivery rate was group 2 (393/2779 [14.14%]), followed by group 1 (333/2779 [11.98%]).
CONCLUSION
The Robson Ten-Group Classification System provides a clear and detailed record of the trends in cesarean delivery. In addition, because of the Robson Ten-Group Classification System's simplicity and exclusivity, it can be implemented in the Republic of Moldova. The main contributors to the overall cesarean delivery rate were women with a previous cesarean delivery (group 5), followed by nulliparous women of group 2 and group 1.
{"title":"Cesarean delivery in a tertiary institution of the Republic of Moldova: analysis using the Robson classification","authors":"Angela Marian-Pavlenco MD, PhD, Irina Siritanu MD, Tatiana Ribac MD, Valentin Friptu MD, PhD","doi":"10.1016/j.xagr.2024.100408","DOIUrl":"10.1016/j.xagr.2024.100408","url":null,"abstract":"<div><h3>BACKGROUND</h3><div>The worldwide increase in the cesarean delivery rate is a major public health concern and cause of significant debate. Although multiple studies have shown that higher cesarean delivery rates may be associated with adverse maternal and perinatal outcomes, the number of cesarean deliveries has been continuously increasing. In the Republic of Moldova, cesarean delivery increased from 15.75% in 2012 to 27.42% in 2022. However, the perinatal mortality remained unchanged at 11.6%. To understand the factors that determine the increasing trend in cesarean delivery and to approach new strategies to reduce unnecessary surgical delivery, a standardized tool is needed to assess and compare cesarean delivery rates.</div></div><div><h3>OBJECTIVE</h3><div>This study aimed to assess the changes in the rates and trends of cesarean delivery and to evaluate the contribution of different obstetrical populations to overall cesarean delivery rates in the Municipal Clinical Hospital using the Robson classification.</div></div><div><h3>STUDY DESIGN</h3><div>This was a cohort study conducted at the Municipal Clinical Hospital in Chisinau. The study included 13,882 women who gave birth in 2017, 2019, and 2022 at the Municipal Clinical Hospital. All births were classified into 10 Robson groups, using 6 basic variables (parity, cesarean delivery in medical history, labor onset, number of fetuses, gestational age, and fetal presentation). Statistical data were collected and analyzed using the Epi Info program (version 7.2.1.0; Centers for Disease Control and Prevention, Atlanta, GA).</div></div><div><h3>RESULTS</h3><div>The overall cesarean delivery rate was 20.02% (2779/13,882), with a significant increase from 18.59% (809/4351) to 21.59% (1134/5252) (<em>P</em>=.0003). Approximately one-third (1099/2279 [39.55%]) of all cesarean deliveries were performed before labor onset. The main contributor in all study years was group 5 (957/2779 [34.44%]). The next valuable group that contributed to the overall cesarean delivery rate was group 2 (393/2779 [14.14%]), followed by group 1 (333/2779 [11.98%]).</div></div><div><h3>CONCLUSION</h3><div>The Robson Ten-Group Classification System provides a clear and detailed record of the trends in cesarean delivery. In addition, because of the Robson Ten-Group Classification System's simplicity and exclusivity, it can be implemented in the Republic of Moldova. The main contributors to the overall cesarean delivery rate were women with a previous cesarean delivery (group 5), followed by nulliparous women of group 2 and group 1.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100408"},"PeriodicalIF":0.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142555040","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cervical cancer screening using HPV self-sampling presents a valuable opportunity to enhance access for underserved and never-screened women in Zimbabwe. However, to ensure the successful implementation of this innovative approach, it is crucial to understand the preferences of key stakeholders, particularly women, with regard to the various components of an HPV self-sampling intervention.
Objective
This study aimed to elicit rural women's preferences for HPV self-sampling.
Study design
A DCE questionnaire was administered to 215 women in Chidamoyo, Hurungwe Rural District. Women were asked to choose between two hypothetical screening choices defined by education, location of services, supervision of self-sampling, comfort of sampling device, results notification and care after HPV results. Data were analysed using fixed and mixed logistic regression models.
Results
Results indicated that the comfort of the sampling device had the most significant impact on women's preferences for HPV self-sampling. Women prioritised facility-based self-sampling, female-supervised self-sampling, and face-to-face education on cervical cancer and screening methods. The methods of results notification and care after HPV results did not significantly impact women's choices. The mixed effects results showed preference heterogeneity in some of the attributes. Interaction analyses suggested that preferences were largely homogenous across the following subgroups: never-screened, previously screened, young and older women. The stratified analysis also showed that preferences were consistent among the four subgroups.
Conclusion
Our findings highlight the importance of face-to-face education, comfortable and user-friendly sampling devices, female health worker supervision and health facility-based self-sampling for cervical cancer screening via HPV self-sampling. These insights could guide the design of patient-centric interventions to ensure high uptake and increased screening coverage.
{"title":"Rural women's preferences for cervical cancer screening via HPV self-sampling: a discrete choice experiment study in chidamoyo, Hurungwe District, Zimbabwe","authors":"Mathias Dzobo MSc , Tafadzwa Dzinamarira PhD , Michael Strauss MSc , Tivani Mashamba-Thompson PhD","doi":"10.1016/j.xagr.2024.100414","DOIUrl":"10.1016/j.xagr.2024.100414","url":null,"abstract":"<div><h3>Background</h3><div>Cervical cancer screening using HPV self-sampling presents a valuable opportunity to enhance access for underserved and never-screened women in Zimbabwe. However, to ensure the successful implementation of this innovative approach, it is crucial to understand the preferences of key stakeholders, particularly women, with regard to the various components of an HPV self-sampling intervention.</div></div><div><h3>Objective</h3><div>This study aimed to elicit rural women's preferences for HPV self-sampling.</div></div><div><h3>Study design</h3><div>A DCE questionnaire was administered to 215 women in Chidamoyo, Hurungwe Rural District. Women were asked to choose between two hypothetical screening choices defined by education, location of services, supervision of self-sampling, comfort of sampling device, results notification and care after HPV results. Data were analysed using fixed and mixed logistic regression models.</div></div><div><h3>Results</h3><div>Results indicated that the comfort of the sampling device had the most significant impact on women's preferences for HPV self-sampling. Women prioritised facility-based self-sampling, female-supervised self-sampling, and face-to-face education on cervical cancer and screening methods. The methods of results notification and care after HPV results did not significantly impact women's choices. The mixed effects results showed preference heterogeneity in some of the attributes. Interaction analyses suggested that preferences were largely homogenous across the following subgroups: never-screened, previously screened, young and older women. The stratified analysis also showed that preferences were consistent among the four subgroups.</div></div><div><h3>Conclusion</h3><div>Our findings highlight the importance of face-to-face education, comfortable and user-friendly sampling devices, female health worker supervision and health facility-based self-sampling for cervical cancer screening via HPV self-sampling. These insights could guide the design of patient-centric interventions to ensure high uptake and increased screening coverage.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100414"},"PeriodicalIF":0.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142586774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-01DOI: 10.1016/j.xagr.2024.100403
Aimee J. Lansdale MS , Mahesh C. Puri PhD , Nadia Diamond-Smith PhD
Background
Approximately 44% of Nepalese women ages 15–49, desiring to avoid pregnancy, do not use modern contraceptives, resulting in an estimated 539,000 unintended pregnancies annually.
Objectives
This study aims to investigate the association between young, newly married women's pregnancy intentions and subsequent pregnancies.
Study design
Data were collected longitudinally from 200 recently married women ages 18–25 in Nepal. Surveys conducted every six months over 18 months covered various health domains. The study used mixed-effects logistic regression models to account for repeated measurement of correlated data over time. The primary outcome was pregnancy. Pregnancy intention was determined based on responses to, “When would you like to have a child in case you were to have one?” Participants were recategorized into a dichotomous variable for analytical purposes: “Right away” or “Not right away.”
Results
A total of 133 participants became pregnant during the study, with sociodemographic characteristics showing minimal differences between pregnant and nonpregnant groups. Women intending to become pregnant right away had significantly higher odds of becoming pregnant (OR, 4.03; 95% CI, 2.51–6.48) after adjusting for covariates. Among those not intending immediate pregnancy, over 70% became pregnant, suggesting potential barriers to achieving reproductive goals.
Conclusions
Young, newly married women in Nepal intending immediate pregnancy have higher odds of becoming pregnant. However, a substantial proportion of those hoping to delay pregnancy still experience unintended pregnancies, indicating challenges in meeting reproductive goals. The findings underscore the need for addressing barriers to contraceptive access and societal norms impacting women's reproductive autonomy in Nepal.
{"title":"Pregnancy intentions and outcomes among young married women in Nepal","authors":"Aimee J. Lansdale MS , Mahesh C. Puri PhD , Nadia Diamond-Smith PhD","doi":"10.1016/j.xagr.2024.100403","DOIUrl":"10.1016/j.xagr.2024.100403","url":null,"abstract":"<div><h3>Background</h3><div>Approximately 44% of Nepalese women ages 15–49, desiring to avoid pregnancy, do not use modern contraceptives, resulting in an estimated 539,000 unintended pregnancies annually.</div></div><div><h3>Objectives</h3><div>This study aims to investigate the association between young, newly married women's pregnancy intentions and subsequent pregnancies.</div></div><div><h3>Study design</h3><div>Data were collected longitudinally from 200 recently married women ages 18–25 in Nepal. Surveys conducted every six months over 18 months covered various health domains. The study used mixed-effects logistic regression models to account for repeated measurement of correlated data over time. The primary outcome was pregnancy. Pregnancy intention was determined based on responses to, “When would you like to have a child in case you were to have one?” Participants were recategorized into a dichotomous variable for analytical purposes: “Right away” or “Not right away.”</div></div><div><h3>Results</h3><div>A total of 133 participants became pregnant during the study, with sociodemographic characteristics showing minimal differences between pregnant and nonpregnant groups. Women intending to become pregnant right away had significantly higher odds of becoming pregnant (OR, 4.03; 95% CI, 2.51–6.48) after adjusting for covariates. Among those not intending immediate pregnancy, over 70% became pregnant, suggesting potential barriers to achieving reproductive goals.</div></div><div><h3>Conclusions</h3><div>Young, newly married women in Nepal intending immediate pregnancy have higher odds of becoming pregnant. However, a substantial proportion of those hoping to delay pregnancy still experience unintended pregnancies, indicating challenges in meeting reproductive goals. The findings underscore the need for addressing barriers to contraceptive access and societal norms impacting women's reproductive autonomy in Nepal.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100403"},"PeriodicalIF":0.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11655809/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142866519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-15DOI: 10.1016/j.xagr.2024.100409
Bilel Jerbi Dr , Hajer Chourou Dr , Rim Ben Aziza Dr , Omar Jelassi Dr , Yosra Sdiri Dr , Wafa Belhadj Ammar Dr , Samia Kacem Dr , Nadia Aloui Dr , Radhouane Achour Dr
Congenital portosystemic shunt is a rare condition in which communications between the systemic venous circulation and the portal veins drain blood directly into the systemic circulation. Diagnosis may occur from the prenatal period to adulthood. Nevertheless, diagnosing and treating a congenital portosystemic shunt, particularly in the perinatal stage, remain challenging, as multiple complications can occur. This study aimed to describe the clinical characteristics of 3 cases of congenital portosystemic shunts diagnosed during pregnancy or the neonatal period, the diagnostic procedures, and their outcomes. This study reported 3 cases of full-term newborns with a congenital portosystemic shunt diagnosed at neonatal age. Case 1 was antenatally diagnosed with a congenital portosystemic shunt, which was confirmed postnatally via computed tomography and was associated with malformed ductus venosus and hypoplasia of the right portal vein. Cases 2 and 3 were siblings: a boy who had diffuse hemangiomatosis and a congenital portosystemic shunt complicated with severe persistent pulmonary hypertension and a girl who presented with a congenital portosystemic shunt and Kell alloimmunization. Congenital portosystemic shunts can be detected on prenatal ultrasounds during the etiologic workup of one of its complications or may be incidentally identified later in life. Children with congenital portosystemic shunts may develop various biological abnormalities, such as pulmonary hypertension, hypoxemia, encephalopathy, and liver tumors. A multidisciplinary approach and standardized protocols are required to optimize the management of congenital portosystemic shunts and minimize the short- and long-term consequences of congenital portosystemic shunts.
{"title":"Congenital portosystemic shunts: experience of a tertiary Tunisian referral center","authors":"Bilel Jerbi Dr , Hajer Chourou Dr , Rim Ben Aziza Dr , Omar Jelassi Dr , Yosra Sdiri Dr , Wafa Belhadj Ammar Dr , Samia Kacem Dr , Nadia Aloui Dr , Radhouane Achour Dr","doi":"10.1016/j.xagr.2024.100409","DOIUrl":"10.1016/j.xagr.2024.100409","url":null,"abstract":"<div><div>Congenital portosystemic shunt is a rare condition in which communications between the systemic venous circulation and the portal veins drain blood directly into the systemic circulation. Diagnosis may occur from the prenatal period to adulthood. Nevertheless, diagnosing and treating a congenital portosystemic shunt, particularly in the perinatal stage, remain challenging, as multiple complications can occur. This study aimed to describe the clinical characteristics of 3 cases of congenital portosystemic shunts diagnosed during pregnancy or the neonatal period, the diagnostic procedures, and their outcomes. This study reported 3 cases of full-term newborns with a congenital portosystemic shunt diagnosed at neonatal age. Case 1 was antenatally diagnosed with a congenital portosystemic shunt, which was confirmed postnatally via computed tomography and was associated with malformed ductus venosus and hypoplasia of the right portal vein. Cases 2 and 3 were siblings: a boy who had diffuse hemangiomatosis and a congenital portosystemic shunt complicated with severe persistent pulmonary hypertension and a girl who presented with a congenital portosystemic shunt and Kell alloimmunization. Congenital portosystemic shunts can be detected on prenatal ultrasounds during the etiologic workup of one of its complications or may be incidentally identified later in life. Children with congenital portosystemic shunts may develop various biological abnormalities, such as pulmonary hypertension, hypoxemia, encephalopathy, and liver tumors. A multidisciplinary approach and standardized protocols are required to optimize the management of congenital portosystemic shunts and minimize the short- and long-term consequences of congenital portosystemic shunts.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100409"},"PeriodicalIF":0.0,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142535958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-10DOI: 10.1016/j.xagr.2024.100407
Andrea J. Ibarra MD, MS , Hannah Campion MD , Cecilia Canales MD, MS , Brittany N. Burton , Alejandro Munoz MD, PhD , Robert S. White MD, MS , Runjia Li MS , Goundappa K. Balasubramani PhD , Janet M. Catov PhD, MS
Background
Neighborhood disadvantage, a social driver of health (SDOH), has been associated with adverse perinatal outcomes; yet little is known about its association with anesthetic choice.
Objective
The purpose of this study is to assess the association of neighborhood disadvantage and anesthetic choice for cesarean deliveries. We hypothesize that people from the most disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries compared to those from the most advantaged neighborhoods.
Study design
This single-center retrospective cohort study identified index cesarean deliveries performed between 2008 and 2017. People were categorized into no, low, moderate, and high disadvantage neighborhood using the area deprivation index. The odds of receiving general anesthesia versus neuraxial anesthesia (epidural, spinal, or combined spinal-epidural) were compared using logistic regression models.
Results
Of the 16,351 people with cesarean deliveries, 96.0% received neuraxial versus 4.0% general anesthesia. The rates of general anesthesia were 6.3%, 4.2%, 3.1%, and 2.4% for the high, moderate, low, and no disadvantage groups (P<.001), respectively. Indications for general anesthesia by obstetric indication were different by neighborhood disadvantage (P<.001), but no differences were observed by contraindications of neuraxial anesthesia (P=.091). Compared to the no disadvantage group, the high disadvantage group had higher odds of general anesthesia (aOR 2.0, 95% CI (1.5 to 2.7), P<.001). Results were unchanged after evaluating people in labor only.
Conclusions
People from disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries, even after considering clinical features. The general anesthesia rate is a meaningful benchmark in obstetric anesthesia that may contribute to disparities.
{"title":"Neighborhood disadvantage and general anesthesia utilization in cesarean delivery: a retrospective analysis","authors":"Andrea J. Ibarra MD, MS , Hannah Campion MD , Cecilia Canales MD, MS , Brittany N. Burton , Alejandro Munoz MD, PhD , Robert S. White MD, MS , Runjia Li MS , Goundappa K. Balasubramani PhD , Janet M. Catov PhD, MS","doi":"10.1016/j.xagr.2024.100407","DOIUrl":"10.1016/j.xagr.2024.100407","url":null,"abstract":"<div><h3>Background</h3><div>Neighborhood disadvantage, a social driver of health (SDOH), has been associated with adverse perinatal outcomes; yet little is known about its association with anesthetic choice.</div></div><div><h3>Objective</h3><div>The purpose of this study is to assess the association of neighborhood disadvantage and anesthetic choice for cesarean deliveries. We hypothesize that people from the most disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries compared to those from the most advantaged neighborhoods.</div></div><div><h3>Study design</h3><div>This single-center retrospective cohort study identified index cesarean deliveries performed between 2008 and 2017. People were categorized into no, low, moderate, and high disadvantage neighborhood using the area deprivation index. The odds of receiving general anesthesia versus neuraxial anesthesia (epidural, spinal, or combined spinal-epidural) were compared using logistic regression models.</div></div><div><h3>Results</h3><div>Of the 16,351 people with cesarean deliveries, 96.0% received neuraxial versus 4.0% general anesthesia. The rates of general anesthesia were 6.3%, 4.2%, 3.1%, and 2.4% for the high, moderate, low, and no disadvantage groups (<em>P</em><.001), respectively. Indications for general anesthesia by obstetric indication were different by neighborhood disadvantage (<em>P</em><.001), but no differences were observed by contraindications of neuraxial anesthesia (<em>P</em>=.091). Compared to the no disadvantage group, the high disadvantage group had higher odds of general anesthesia (aOR 2.0, 95% CI (1.5 to 2.7), <em>P</em><.001). Results were unchanged after evaluating people in labor only.</div></div><div><h3>Conclusions</h3><div>People from disadvantaged neighborhoods are more likely to receive general anesthesia for cesarean deliveries, even after considering clinical features. The general anesthesia rate is a meaningful benchmark in obstetric anesthesia that may contribute to disparities.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100407"},"PeriodicalIF":0.0,"publicationDate":"2024-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142538493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-09DOI: 10.1016/j.xagr.2024.100406
Silvina L. Heisecke DVM , Hebe Campaña MSc, PhD , María R. Santos BSc, PhD , Jorge S. López Camelo MSc, PhD , Mónica Rittler MD, PhD
Background
Interbirth interval (IBI), the time between consecutive births, has been tied to perinatal outcomes.
Objective
To analyze adverse perinatal events following short IBI in a large South American sample.
Study design
Observational, retrospective, hospital-based study including malformed and nonmalformed live- and stillbirths. Outcomes were preterm birth (PTB), low birth weight (LBW), and specific birth defects. Logistic regressions were used to evaluate the risk of selected variables for short IBI and for adverse outcomes after short IBI, adjusting by confounders. Bayesian networks exhibited relationships among short IBI, outcomes, and variables.
Results
Short IBI rate was 2%–3%. Maternal age and a previous abortion were the main confounders. A significant high risk for short IBI was found in mothers ≤19 years while mothers ≥30 were at low risk, mediated by a previous abortion. The risk of short IBI, adjusted by confounders, was significant for LBW but not for PTB. An unadjusted risk of short IBI was observed for gastroschisis, which disappeared after adjusting for confounders. Maternal age ≤19 and previous abortion were directly related with gastroschisis; the relationship between gastroschisis and short IBI occurred through any of these two variables. A direct relationship between gastroschisis and maternal age ≥30 was observed.
Conclusions
Only young mothers were directly related with short IBI. In older mothers, a short IBI mainly occurred after a previous abortion. Short IBI was a risk factor only for LBW. The PTB and gastroschisis relationship with short IBI was indirect, mediated by young maternal age and/or a previous abortion.
研究设计观察性、回顾性、基于医院的研究，包括畸形和非畸形活产和死产。研究结果包括早产（PTB）、低出生体重（LBW）和特殊出生缺陷。在对混杂因素进行调整后，使用逻辑回归评估了选定变量对短时间内转运和短时间内转运后不良结局的风险。贝叶斯网络显示了短时IBI、结果和变量之间的关系。产妇年龄和流产是主要的混杂因素。年龄小于 19 岁的母亲发生短 IBI 的风险明显较高，而年龄大于 30 岁的母亲发生短 IBI 的风险较低，这与曾有过人工流产有关。经混杂因素调整后，脐带绕颈症发生短IBI的风险显著，而先天性脑瘫发生短IBI的风险则不显著。未调整的胃畸形有短IBI风险，调整混杂因素后，该风险消失。孕产妇年龄≤19 岁和曾有过人工流产与胃裂直接相关；胃裂与短内径间的关系通过这两个变量中的任何一个发生。结论只有年轻母亲与 IBI 短直接相关。在年龄较大的母亲中，IBI过短主要发生在流产之后。内径短仅是低体重儿的一个风险因素。PTB和胃畸形与短IBI的关系是间接的，由年轻母亲的年龄和/或之前的人工流产介导。
{"title":"Short interbirth interval and adverse pregnancy outcomes: a Bayesian network approach","authors":"Silvina L. Heisecke DVM , Hebe Campaña MSc, PhD , María R. Santos BSc, PhD , Jorge S. López Camelo MSc, PhD , Mónica Rittler MD, PhD","doi":"10.1016/j.xagr.2024.100406","DOIUrl":"10.1016/j.xagr.2024.100406","url":null,"abstract":"<div><h3>Background</h3><div>Interbirth interval (IBI), the time between consecutive births, has been tied to perinatal outcomes.</div></div><div><h3>Objective</h3><div>To analyze adverse perinatal events following short IBI in a large South American sample.</div></div><div><h3>Study design</h3><div>Observational, retrospective, hospital-based study including malformed and nonmalformed live- and stillbirths. Outcomes were preterm birth (PTB), low birth weight (LBW), and specific birth defects. Logistic regressions were used to evaluate the risk of selected variables for short IBI and for adverse outcomes after short IBI, adjusting by confounders. Bayesian networks exhibited relationships among short IBI, outcomes, and variables.</div></div><div><h3>Results</h3><div>Short IBI rate was 2%–3%. Maternal age and a previous abortion were the main confounders. A significant high risk for short IBI was found in mothers ≤19 years while mothers ≥30 were at low risk, mediated by a previous abortion. The risk of short IBI, adjusted by confounders, was significant for LBW but not for PTB. An unadjusted risk of short IBI was observed for gastroschisis, which disappeared after adjusting for confounders. Maternal age ≤19 and previous abortion were directly related with gastroschisis; the relationship between gastroschisis and short IBI occurred through any of these two variables. A direct relationship between gastroschisis and maternal age ≥30 was observed.</div></div><div><h3>Conclusions</h3><div>Only young mothers were directly related with short IBI. In older mothers, a short IBI mainly occurred after a previous abortion. Short IBI was a risk factor only for LBW. The PTB and gastroschisis relationship with short IBI was indirect, mediated by young maternal age and/or a previous abortion.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100406"},"PeriodicalIF":0.0,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142535356","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-09DOI: 10.1016/j.xagr.2024.100402
Frank I. Jackson DO , Insaf Kouba MD , Natalie Meirowitz MD , Nathan A. Keller MD , Luis A. Bracero MD , Matthew J. Blitz MD, MBA
<div><h3>Background</h3><div>Prior studies evaluating the relationship between psychopharmacotherapy (PPT), and postpartum hemorrhage (PPH) have yielded inconsistent findings. Clarifying this potential relationship is important for effective counseling and risk stratification.</div></div><div><h3>Objectives</h3><div>Our primary objective was to evaluate the association between prenatal exposure to PPT (any drug class) and the occurrence of PPH requiring transfusion of packed red blood cells (PPH+pRBC) after systematically adjusting for known hemorrhage risk factors at the time of admission for delivery. Secondary objectives were to evaluate the association between individual PPT drug classes and PPH+pRBC, and the association between treatment intensity of mental health condition and PPH+pRBC. Finally, we evaluated the association between PPT and a broader definition of PPH that included deliveries requiring multiple uterotonic drugs.</div></div><div><h3>Study design</h3><div>This is a retrospective cross-sectional study of all pregnancies delivered at 23 weeks of gestational age or greater at seven hospitals within a large academic health system in New York between January 2019 and December 2022. There were no exclusion criteria, as postpartum hemorrhage risk assessment is necessary for all patients admitted for delivery. We assessed exposure to prenatal PPT, including selective serotonin reuptake inhibitors (SSRIs: escitalopram, fluoxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (SNRIs: duloxetine, venlafaxine), dopamine-norepinephrine reuptake inhibitors (DNRIs: buproprion), benzodiazepines (alprazolam, diazepam, lorazepam), and others (buspirone, trazodone, zolpidem). Multivariable logistic regression was performed to evaluate the relationship between PPT and PPH+pRBC, while systematically adjusting for known hemorrhage risk factors at the time of hospital admission. Similar regression analyses were performed to address the secondary objectives.</div></div><div><h3>Results</h3><div>A total of 107,425 deliveries were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.4%), followed by Hispanic patients (18.7%), Asian or Pacific Islander patients (13.2%), and non-Hispanic Black patients (12.3%). Prenatal exposure to PPT occurred in 3.6% of pregnancies (<em>n</em>=3,834). The overall rate of PPH+pRBC was 2.9% (<em>n</em>=3,162). PPH+pRBC occurred more frequently in pregnancies exposed to PPT than in pregnancies which were not exposed (5.5% vs. 2.8%, respectively; aOR 2.10, 95% CI: 1.79–2.44). SSRIs and benzodiazepine monotherapy were each associated with higher odds of PPH+pRBC than nonexposure. Compared to patients without a mental health condition, monotherapy was associated with nearly 2-fold increased odds and combination PPT was associated with nearly 4-fold greater odds of PPH+pRBC after adjustment for confounding variables (monotherapy: aOR 1.94, 95% CI: 1.64–2.28; combination PPT:
{"title":"Association between psychopharmacotherapy and postpartum hemorrhage","authors":"Frank I. Jackson DO , Insaf Kouba MD , Natalie Meirowitz MD , Nathan A. Keller MD , Luis A. Bracero MD , Matthew J. Blitz MD, MBA","doi":"10.1016/j.xagr.2024.100402","DOIUrl":"10.1016/j.xagr.2024.100402","url":null,"abstract":"<div><h3>Background</h3><div>Prior studies evaluating the relationship between psychopharmacotherapy (PPT), and postpartum hemorrhage (PPH) have yielded inconsistent findings. Clarifying this potential relationship is important for effective counseling and risk stratification.</div></div><div><h3>Objectives</h3><div>Our primary objective was to evaluate the association between prenatal exposure to PPT (any drug class) and the occurrence of PPH requiring transfusion of packed red blood cells (PPH+pRBC) after systematically adjusting for known hemorrhage risk factors at the time of admission for delivery. Secondary objectives were to evaluate the association between individual PPT drug classes and PPH+pRBC, and the association between treatment intensity of mental health condition and PPH+pRBC. Finally, we evaluated the association between PPT and a broader definition of PPH that included deliveries requiring multiple uterotonic drugs.</div></div><div><h3>Study design</h3><div>This is a retrospective cross-sectional study of all pregnancies delivered at 23 weeks of gestational age or greater at seven hospitals within a large academic health system in New York between January 2019 and December 2022. There were no exclusion criteria, as postpartum hemorrhage risk assessment is necessary for all patients admitted for delivery. We assessed exposure to prenatal PPT, including selective serotonin reuptake inhibitors (SSRIs: escitalopram, fluoxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (SNRIs: duloxetine, venlafaxine), dopamine-norepinephrine reuptake inhibitors (DNRIs: buproprion), benzodiazepines (alprazolam, diazepam, lorazepam), and others (buspirone, trazodone, zolpidem). Multivariable logistic regression was performed to evaluate the relationship between PPT and PPH+pRBC, while systematically adjusting for known hemorrhage risk factors at the time of hospital admission. Similar regression analyses were performed to address the secondary objectives.</div></div><div><h3>Results</h3><div>A total of 107,425 deliveries were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.4%), followed by Hispanic patients (18.7%), Asian or Pacific Islander patients (13.2%), and non-Hispanic Black patients (12.3%). Prenatal exposure to PPT occurred in 3.6% of pregnancies (<em>n</em>=3,834). The overall rate of PPH+pRBC was 2.9% (<em>n</em>=3,162). PPH+pRBC occurred more frequently in pregnancies exposed to PPT than in pregnancies which were not exposed (5.5% vs. 2.8%, respectively; aOR 2.10, 95% CI: 1.79–2.44). SSRIs and benzodiazepine monotherapy were each associated with higher odds of PPH+pRBC than nonexposure. Compared to patients without a mental health condition, monotherapy was associated with nearly 2-fold increased odds and combination PPT was associated with nearly 4-fold greater odds of PPH+pRBC after adjustment for confounding variables (monotherapy: aOR 1.94, 95% CI: 1.64–2.28; combination PPT: ","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"4 4","pages":"Article 100402"},"PeriodicalIF":0.0,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142535957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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