Impact of a National Program on antenatal care Care indicators in governmental sector Sector in Iran: Pilot Results of the first 18 months of intervention




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Impact of a National Program on antenatal Antenatal care Care indicators in governmental Governmental sector Sector in Iran: Pilot Results of the first 18 months of intervention

Nasrin Changizi 1, Mohammad Amir AmirKhani1, Marzieh Vahid Dastjerdi3 , Kamran Bagheri Lankarani 2, Maryam Moghani Lankarani3, Shervin Assari 3

  1. Maternal Health Organization Center (MHOMHC), Ministry of Health and Medical Education, Tehran, Iran

  2. Ministry of Health and Medical Education, Tehran, Iran

  3. Medicine and Health Promotion Institute, Tehran, Iran

Running Title: Improved Maternal Care in Iran

Abstract
Objective: To determine the impact of a national interventional program on national outpatient antenatal care (ANC) development program indicators in the governmental sector in Iran.

Methods: This prospective multicenter study conducted in governmental centers sector in in 14 cities provinces of in Iran between 2003 and 2005. Intervention included education of all ANC health care providers including gynecologists, general physicians, and midwifes in the area of intervention. Duration between the before and after program Intervention lasted forwas 18 months. Before (n=3978) and after (3958) the intervention, some ANC indicators were assessed and 2 assessments were performed before and after it.using Questionnaires questionnaires which were filled by trained personnel. Mothers were interviewed Participants were mothers who hadwhen admitted for delivery or at the time attended presented for vaccination of their 2 month infants, or those women who had been admitted for delivery. Respectively a total of 3978 and 3958 mothers were evaluated in first and second assessments.

Results: Our results showed the impact of Iranian maternal care development program on ANC in several areas. The educational program significantly increased the rate of receiving the frequency of at least one visit and at least 6 times of prenatal visits, perceived quality of post-partum care, and cesarean section, while significantly decreased the rate of high risk pregnanciesy, and complicated pregnancycomplications in recent pregnancy. However in the cases of complicated pregnancies, perceived satisfaction with care decreased. Cesarean section increased. Regarding post-partum cares, the number of subjects who did not received care during first 45 days after delivery increased. Perceived quality of post-partum cares also increased. Coverage of receiving complete components of post-partum visits significantly reduced. Significant changes were not seen regarding content of visits.

Conclusion: This In conclusion, the iimplemented a national educational outpatient maternal careANC development program in governmental sector proved to be effective by improving some ANC indicators in 18 months has affected ANC in Iran.

Key words:

Antenatal care, Antenatal care indicators, governmental health care system, prenatal visits, satisfaction



Introduction
Antenatal care (ANC) is to offer health information and services that can significantly improve the health of women and their infants. (4) The main goals of antenatal care (ANC) is to prevent, detect and treatment of complicated pregnanciesare prevention of some complications, such as anemia, and recognition of women with pregnancy complications for treatment or transfer. It is expected that women who are prone to development of pregnancy complicationsed pregnancy could can be identified to avert problems (1). Appropriate Early participation in ANC programs is are considered to promote favorable pregnancy outcomes (2).

Quality of ANC is a determinant of maternal mortality. One of the important determinants of safe delivery is ANC (3). Although certain some obstetric emergencies cannot be predicted through antenatal ANC screening, education in ANC women will capacitating mothers can be educated to recognize and act on symptoms leading to potentially serious conditions, and this which is consider as one of the strategies for will reducing reduce maternal mortality. One of the most important functions of ANC is to offer health information and services that can significantly improve the health of women and their infants. Appropriate Moreover, ANC during pregnancy appears to have a positive impact also on the utilization of postnatal healthcare services (4). Quality of ANC is one of the important determinants of the rate of safe deliveries (3).

Given the potential for additional resources, both governments and donors need evidence on whether higher levels of government spending on ANC health care will result in improved access / outcomes to the ANC specific health services that are most needed determined by to meet the Millennium Development Goals (5). Thus, ANC policy makers to improve it seems the best national ANC programs should consider both available country resource and for each country can be achieved by little change in standard pANC protocols according to each country resource (6).

In Iran, according to the Demographic and Health Survey (DHS) which performed at 2000, coverage of prenatal and postpartum care was 80% and 31%, respectively (7). Until 200, ANC services in this country had some main obstacles which included absence of a standard ANC protocol and not involving physicians in ANC services. In 1999Thus, , maternal health organization center (MHOMHC), as is the responsible center for policy making and resource allocation in ANC proclaimed that the national maternal health system needs a revision to overcome some of these suffers from some deficits. (such as absence of a standard program for prenatal and postnatal care and not involving physicians in prenatal and postnatal care), although according to the Demographic and Health Survey (DHS) which performed at 2000, coverage of prenatal and postpartum cares was 79.8% and 31% respectively (7). Thus, a national outpatient maternal care development program was implemented in governmental sector. In the current study we investigated the preliminary impact of results of this program after within the first 18 months implementation.



Material and Methods

This prospective study was a secondary analysis of a the national outpatient maternal care development program was implemented in governmental sector. This program started at . The program was conducted by maternal health organization (MHO) in 2003 to 2005 in 14 cities in 14 different provinces. The program was implemented by MHC.



Participants

Before initiation of the program (2003), and 18 months after it (2005), Respectively a total of 3978 and 3958 mothers were enrolled, respectivelyevaluated in first and second assessments. Participants were mothers who had had been admitted in hospital or delivery facilitating units for delivery or attended presented for vaccination of their 2 month infants or women who had been admitted in hospital or delivery facilitating units after delivery. Participants were cConsecutive sampling was doneor complete sample of clients to each center in the study period.



Ethical aspects

Anonymous self-report questionnaire addressing confidentiality was used. The study was approved by the institutional review board at the MOHME. All participants gave informed consent.



Process of Original surveyData collection

Data collected in this study included baseline data including socio-demographic and past pregnancy data, and ANC indicators including high risk and complicated pregnancy. Data was collected using via both self reported and chart review. Data was registered in questionnaires. Data collection was done by the personnel of the medical universities of thein each provinces. Medical university authorities of each province were responsible for educating their personnel and also the supervision on the data collection and data quality controlin the survey. During the study period, external evaluation was also performed by the MHOMHC, MoHME (not reported here). In the original survey, socio-demographic data was registered in a checklist, and ANC care was registered in a questionnaire. All The the processes survey was directly supervised by MHOMHC, Ministry of Health and Medical Education (MoHME).



Study questionnaire:

For this purpose a questionnaire was designed and filled by trained personnel. Survey used a qquestionnaire included with 45 items (10 categories of items) in health care for mothers who had presented for vaccination of their 2 month infants, or women who had been admitted in hospital or delivery facilitating units after delivery. This included This items assessed the 610 ANC indicators different aspects as bellow: 1) receiving at least one prenatal care, 2) receiving 6 times prenatal care, 3) receiving at least one prenatal care visit at the first 20 weeks of pregnancy, receiving at least 3 visits during 26-37 weeks, and receiving 2 visits in 38 to 40 weeks, 4) receiving especial care, if there is any previous history of high risk pregnancy (ectopic pregnancy, fetal abnormality, pre and post-term pregnancies, abortion, molar pregnancies, stillbirth, abortion, low birth weight (less than 2500 grams), macrosomia (birth weight higher than 4000 grams), infertility, cesarean section, dystocia, and multiple birth), 5) presence of any complication in recent pregnancy, and 6) type of delivery , 7)- Intrapartum care, 8) hemorrhage in the first two hours of delivery, 9) Coverage of at least one postpartum care during 45 days after delivery, 10) Postpartum complications and care including uterine infection, anemia, obstetrics fistulas, urine incontinence, urinary tract infection, breast abscess or mastitis, physical examination of breasts and extremities, and prescription of nutritional supplements i.e. vitamins and iron. Questionnaires were filled by trained personnel.



Change to the content of ANC revision visitsprogram

ANC development program included the following parts: 1) The new maternal care program which presented in this study differs from previous program by rreduceding ANC visits (targeting from 14 visits to 8 visits), 2) involvement of physicians in maternal careANC services, 3) minimizing un-necessary changing contents of each maternal care visits such as additional laboratory tests, 4) definition of a standard protocol for high risk pregnancies and complicatedions of pregnancy, 5) employing multidisciplinary approach by involving multiple administrative parts of the MoHME, 6) definition of levels 1 and 2 for of giving careANC and a protocol for refereeing complicated pregnancy complicated cases and 7) performing pilot evaluation before establishment of the designed program.



Educational process

The National outpatient maternal care development program was a program focusing onused training for trainer (tTOT).hree level of education, for training all parties involved in ANC In first step, a team consisted of members and experts of the scientific committee of the MHC trained a team from each medical university. This trained team of the province composed of 1-2 gynecologists who were faculty members of that university plus 3 officers of MHC of the province. In the second step, the trainees of each province acted as the trainers of all ANC health providers of their provinces (n=14).. Each layer was received education by the upper level. The highest level, was composed of a team consisted of members and experts of the scientific committee of the MHO. This team was responsible for educating a team from each university. The second layer was composed of 14 different University educating teams, one team for each university. This team composed of 1-2 gynecologists who were faculty member of that university plus three mangers of MHO of the province. They educated all governmental ANC health care providers in the city who were involved in ANC, includeding all gynecologists, general physicians, and midwifes.



Monitoring the program

The program was monitored from 1 to 5 up to five times, different in some ofthe cities. , during implementation to ensure oOverall quality of the educational process, structure and infrastructure of the program were evaluated. In for the program monitoring, 10 minor quality indices indicator regarding given services were employed. As the aim of this study was to present the impact of intervention, we did not report details of monitoring here.



Statistical analysis

Statistical analysis was performed by STATA software version eight8.0. 95% of confidence intervals (95% CI) were calculated base on Robustness method and Chi square test were used for comparison of the ANC indicators before and after the programvariables. P value < 0.05 considered statistically significant.



Results

Coverage of prenatal care

There was no significant difference regarding the rate of coverage of prenatal care (at least one ANC visit) before and after program between first and second assessments (97.7% vs. 98.9, p>0.05).

Receiving at least 6 prenatal visits increased Regarding the frequency of routine care, respectively from70.1% (95% CI: 66.7-72.4) and to 87.1% (95% CI: 85.8-88.4) of the subjects had at least 6 times of prenatal visits in first and second assessments (P<0.05). In high risk pregnancies, receiving at least 6 prenatal visits increased from When special cares were needed, the numbers were respectively 70.9% (68.5-73.2) and to 85% (95% CI: 83.4-86.6) (P<0.05).

Content of prenatal care

Table 1 shows the comparison of the rate of receiving different ANC services before and after program. comparison of contents of ANC before and after the program. Except at least one time performing ultrasound (at least one time) and at least one time CBC blood and urine analysis, all other ANC services parameters significantly increased, significantly.



Prenatal care in high risk pregnancies

Before intervention, 50.3% (95% CI: 48.5-52.1) had been identified as high risk pregnancy. After intervention, high risk pregnancies declined to 43.4% (95% CI: 41.9-44.9) which was statistically significant (P<0.05).

Details of associated comorbidities and high risk behaviors amongst pregnant women after the first and second assessments have been shown in table 2. Table 3 demonstrates complications in previous pregnancies.

Complications of recented pregnancy

Rate of complicated In recent pregnancy decreased from, 63.1% (95% CI: 61.3-64.8) had complications which reduced to 42.1% (95% CI: 41-43.2) in second assessment (p<0.05) (Table 42).



Satisfaction of high risk pregnant women with established programANC services

In the first assessment 97.2% (95% CI: 95-98) of the women with complicated pregnancy said that the given care was satisfactory. This percentage declined to 90.6%± (95% CI: 88.7-92.5). Also, similar reduction was seen in satisfaction of women with low risk pregnancies.



Cesarean section and post-partum cares

Cesarean section increased from 67.4% to 74.5% (95% CI: 72.3-75.7).



post-partum care

Regarding post-partum cares, the number of subjects who did not received care during 45 days after delivery increased from 74.5 % (95% CI: 72.5-76-3) to 84.3% (95% CI: 83.9-84.7) (P<0.05). Tables 5 3 and 6 4 show compare respectively post-partum care contents and percentagerate of each component of post-partum care that subjects mothers received in GC and NGC.

Quality of post-partum cares visit was increased from 31.2% (95% CI: 29-33.6) to 96% (95% CI: 95.5-96.5) (P<0.05). However, significant changes were not seen regarding content of visits. Coverage of receiving complete components of post-partum visits significantly reduced from 24.7% (95% CI: 22.7-27) to 21% (20.1-21.9). Table 7 5 shows the details of post-partum complications before and after in both types of care systemsprogram.

Discussion

Our results showed the impact of Iranian new a maternal care development program on ANC indicators. The changes included program an increased the in the rate of frequency of at least one ANC visit and at least 6 times of prenatal visits, cesarean section, and post-partum care, and a decreased decrease in the rate of high risk pregnancies, and complications complicated in recent pregnancy. However in the cases of complicated pregnancies, perceived satisfaction with ANC care decreased. Cesarean section increased. Regarding post-partum cares, the number of subjects who did not received care during first 45 days after delivery increased. Perceived quality of post-partum cares also increased. Coverage of receiving complete components of post-partum visits significantly reduced. Significant changes were not seen regarding content of visits.

Regarding frequency of prenatal care visits, there is a worldwide tendency to reduce numbers of prenatal visits (8-12). American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) have recommend that a woman with an uncomplicated pregnancy be examined every 4 weeks for the first 28 weeks of pregnancy, every 2 to 3 weeks until 36 weeks gestation, and weekly thereafter (13). However there is a worldwide tendency to reduce numbers of prenatal visits (8-12). Several studies have shown that the safety of reduction of prenatal visits for uncomplicated pregnancy is safe (8-12). Mc Duffie and associates (10) suggested that good perinatal outcome is achievable when with reduction in the numbers of ANC visits is reduces. (10) In another study by Villar et al. (8) that conducted in four countries including Argentina, Cuba, Saudi Arabia, and Thailand showed that a new ANC antenatal careprogram was compared to a new model which with fewer numbers of ANC visits had been predicted. In their study( the median number of visits was of 5) in participant in new model. They finally concluded that this new method have not adverse affect on maternal and perinatal outcomes. (8) In summary, eEmpirical evidence reveals that four 4 ANC visits are sufficient for uncomplicated pregnancies and more are necessary only in cases of complications (8). Thus, the World Health Organization currently recommends at leastthe minimum of four 4 ANC visits in the course of pregnancy (14).

Although, in our study the frequency of prenatal visits was higher than WHO recommendation (8), it was lesser than traditional program (13) and was associated with acceptable results similar to previous study by Villar and associates (8). Moreover, a great advantage of reduced antenatal visits is cost reduction in costs and burden and pressure to the health care system (8,9). This which is especially important in developing countries where there iswith limitedation in funding resources, and highly dense population. Although, in this study we did not calculate economic aspects of our new program, cost reduction in maternal health care system is expected predictable when the new program perform as a national program in all parts of the country.

Regarding the change in the level of satisfaction of pregnant women and following reduced reduction of prenatal visits in our study, literature shows different results (6-9,12). A study conducted in London showed that reduction of frequency of prenatal visits is an associated between a reduction in number of prenatal visits andwith decrease in the level of dissatisfaction of perceived by pregnant women (11). Similarly, Carroli et al. (9) in a systematic review showed that reduction of antenatal care visits may be associated with some degree of dissatisfaction(9). However Villar and associates in another studyhave suggested that reduction in antennal care visits can be establish implemented without any major resistance ofrom pregnant women (8). Generally,Other studies recommend that an acceptable degree of satisfaction can be achieved by regulating the frequency of cares based on individual needs (10, 15). However, increase in dissatisfaction might be also a result of an increase in the expectation of the participants due to improvement of their knowledge.In our study, we also observed a decline in satisfaction of pregnant women. However, it may be related to the questionnaires´ structure or increasing the expectation of the participants due to improvement of their knowledge.

Regarding the coverage of prenatal care, this study showed that a higher percentage of pregnant women participate participating in prenatal cares in Iran which is higher than some other developing studiescountries (16,17). In a community survey in Uganda, antenatal services and delivery care was assessed (17). Also iIn another one study in China, 36% of pregnant women had fewer than 5 prenatal visits, and about 9% had no prenatal visits (16). The 1992–1993 Indian National Family Health Survey revealed that only 64% of Indian mothers participated in ANC program and this percent slightly raised to 65% in 1998–1999 (1).

Maternal health care use is associated with the socio-economic status of the varies within developing countries and studies show differences between affluent and poor women, and between women living in urban and rural areas (18). In a systematic review, Simkhada et al. assessed the factors affect ANC utilization in developing countries(14). They showed that adequate utilization of ANC cannot be obtained merely by establishing health centers, and women’s status (socialo, political and economic) status is also has a vital role that needs to be considered. Given the precise monitoring which conducted in our study the high coverage of prenatal care may explain.

This study was partly merely based on self reported data given by the pregnant women and it this may influence the accuracy of data. This intervention was only done in governmental sector, and is not representative to the all country. Also, we did not report the results of in some situations, after the first assessment although the problem had been identified it cannot be resolved till theprogram evaluation here second evaluation. Another limitation is the secondary nature of this study.



In conclusion, our studywe revealed the promising impact of effect ofthe Iranian new maternal care development program on ANC indicators in the governmental health sector in Iran.

References
Table 1. Comparison of the rate of receiving different ANC services before and after interventionprogram

Variable




First assessment % (95%CI)

Second assessment %(95%CI)

Physical examination by physician*

51.3 (49.4-53.2)

66.7 *(65.7-67.7)

Blood and urine analysis*

89.9 (88.7-91)

87.9 *(87.3-88.5)

Height measurement*

71.7 (70-73.4)

82.9 *(81.9-83.9)

Weight measurement*

92.2 (90.9-93)

99.7* (99.6-99.8)

Measurement of blood pressure*

92 (90.9-93)

99.6*(99.5-99.7)

Abdominal examination*

79 (77.4-80.5)

91.8*(91.3-92.3)

Monitoring of fetal heart rate*

78.6 (77-80.1)

88.5*(87.7-89.3)

Using ultrasound (at least one time) *

74.5 (72.9-76.2)

66.1*(64.6-67.6)

Oral health*

58.5 (56.7-60.4)

72.8*(71.8-73.8)

Prescription of iron supplement*

90.3 (89.1-91.4)

99.5*(99.4-99.6)

Prescription of folic acid and/or multivitamins*

86.3 (84.9-87.5)

99.5*(99.4-99.6)

Pelvic examination

15.9 (14.2-17.7)

15.4(14.6-16.2)

*There were significant differences (P<0.05) between the first and second assessments.

Table 2. Comparison of medical comorbidities and high risk behavior before and after intervention



Problem or disease




First assessment % (95% CI)

Second assessment % (95% CI)

Diabetes mellitus

0.2 (0.1-0.5)

0.3 (0.2-0.4)

Heart disease

1.4 (1-1.9)

0.8 (0.6-1)

Renal disease

4.1 (3.5-4.9)

1.1* (0.9-1.3)

Respiratory diseases

1.1 (0.8-1.5)

0.7 (0.6-0.8)

Epilepsy

0.6 (0.4-1)

0.4 (0.3-0.5)

Anemia

7.4 (6.5-8.4)

6.2 (5.7-6.7)

Hypertension

1.5 (1.1-2)

1.5 (1.2-1.8)

Tuberculosis

0.1 (0-0.4)

0.1(0.03-0.17)

Smoking

3.8 (3.1-4.5)

1.3 (1.1-1.5)

*There were significant differences (P<0.05) between the first and second assessments.

Table 3. Comparison of history of complicated pregnancy before and after intervention



Complication




First assessment % (95% CI)

Second assessment % (95% CI)

Mole hydatiform

0.3 (0.2-0.6)

0.1(0.03-0.17)*

Ectopic pregnancy

0.4 (0.2-0.7)

0.2 (0.1-0.3)

Abnormal fetus

1.1 (0.8-1.5)

0.7 (0.5-0.9)

Preterm labor

4.3 (3.6-5.1)

3.8 (3.2-4.4)

Post term labor

1.5 (1.1-2)

0.8 (0.5-1.1)

Stillbirth

2.6 (2-3.2)

2.1 (1.7-2.5)

Abortion

14.3 (13.1-15.7)

2.3 (2-2.6)*

Low birth weight

6.2 (5.4-7.1)

5.7 (4.9-6.5)

Macrosomia

2.7 (2.2-3.4)

1.6 (1.2-2)*

Multiple birth

1.4 (1-1.9)

1.5 (1.1-1.9)

Dystocia

4.7 (1-5.5)

3.4 (2.8-4)

Infertility

3.9 (3.2-4.6)

3.5 (2.9-3.1)*

History of cesarean section

17.6 (16.2-19)

18.6 (17.4-19.8)

*There were significant differences (P<0.05) between the first and second assessments.

Table 42. Comparison of complications during recentin pregnancy before and after intervention



Complications




First assessment % (95% CI)

Second assessment % (95% CI)

Hypertension

6.5 (5.7-7.5)

6.2 (5.7-6.7)

Premature rupture of membranes*

2.4 (1.9-3)

4.8* (4.4-5.2)

Bleeding or spotting*

9.1 (8.1-10.2)

5.8* (5.5-6.1)

Urinary tract complications*

19.5 (18.1-21)

16.3* (15.5-17.1)

Blurred vision and severe headache*

7.2 (6.4-8.3)

3.3* (2.9-3.7)

Premature labor pain*

5 (4.3-5.9)

2 *(1.7-2.3)

Anemia*

12.5 (11.4-13.8)

9.8* (9.2-10.4)

Severe vomiting*

6.1 (5.2-7)

3.8 *(3.3-4.3)

Fever and chills

1.7 (1.3-2.3)

1.6 (1.3-1.9)

Convulsion, Shock, and loss of consciousness

0.5 (0.2-1.4)

0.5 (0.3-0.7)

Inappropriate weight gain*

12.2 (11-13.4)

5.6* (5.1-6.1)

*There were significant differences (P<0.05) between the first and second assessments.

Table 53. Comparison of post-partum care contents before and after intervention



Service




First assessment % (95% CI)

Second assessment % (95% CI)

Abdominal and pelvic examination

81.6 (79.7-83.3)

88.4 (79.9-88.9)

Assessment of bleeding*

85.1 (83.4-86.7)

91.2 *(90.7-91.7)

Measurement of blood pressure*

93.5 (92.2-94.6)

97.4* (97.1-97.7)

Measurement of pulse rate and body temperature

88.7 (87.1-90.1)

89.4 (88.7-90.1)

Education of breast feeding*

63.9 (61.6-66.1)

83.8* (83.2-84.4)

Education of alarm signs*

50.7 (48.4-53)

65.7* (64.8-66.6)

Self hygiene training*

56.9 (54.6-59.1)

73.3* (72.5-74.1)

Family planning*

50.2 (47.9-52.5)

65.6* (64.8-66.4)

*There were significant differences (P<0.05) between the first and second assessments.

Table 64. Comparison of post-partum care before and after intervention



Variable




First assessment % (95% CI)

Second assessment % (95% CI)

Measurement of blood pressure, pulse rate, and body temperature*

75.2 (73-77.3)

88.8* (89.8-87.8)

Examination of suture site*

42.6 (40.1-45.1)

60.1* (58.7-61.5)

Assessment of vaginal bleeding*

61.6 (59.1-64)

82.3* (81.1-83.5)

Evaluation of fecal and urine incontinence

62.2 (59.7-64.6)

59.3 (58.1-60.5)

Evaluation of breast feeding*

77.7 (75.6-79.7)

88.9* (88-89.8)

Breast and extremities examination

55.7 (53.2-58.1)

54.7 (53.4-56)

Prescription of nutrient supplements (iron and multivitamin) *

84.7 (82.9-86.5)

92.5 *(91.7-93.3)

*There were significant differences (P<0.05) between the first and second assessments.

Table 75. Comparison of post-partum complications before and after intervention in governmental and non-governmental centers



Complication




First assessment % (95% CI)

Second assessment % (95% CI)

Endometritis*

18.3 (13.6-23.8)

2.4* (2.1-2.7)

Anemia*

14.1 (9.9-19.2)

0.9 *(0.6-1.2)

Obstetric fistula

0.9 (0.1-3.1)

0.07 (0.04-0.1)

Urinary incontinence*

3 (1.2-6.1)

0.2* (0.1-0.3)

Breast abscess or mastitis*

9.8 (6.3-14.4)

1.6* (1.3-1.9)

Wound infection*

15.5 (11.1-20.7)

2.2 *(0.9-3.5)

Bleeding*

17.6 (12.9-23.1)

2.2 *(1.9-2.5)

*There were significant differences (P<0.05) between the first and second assessments.




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