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PubMed2006

Cesarean delivery on maternal request: maternal and neonatal outcomes.

OBJECTIVE: To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES: We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION: We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS: We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION: The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.

Cesarean Section↗
PubMed2004

Safety of vaginal birth after cesarean: a systematic review.

OBJECTIVE: To evaluate the benefits and harms of vaginal birth after cesarean compared with repeat cesarean delivery. DATA SOURCES: The computerized databases MEDLINE, EMBASE, HealthSTAR, Cochrane CENTRAL, and National Centre for Reviews and Dissemination Database of Abstracts of Reviews of Effectiveness, along with reference lists and national experts, were used to conduct this review. METHODS OF STUDY SELECTION: All studies that reported data for maternal or infant outcomes in women with prior cesarean delivery were eligible. Methodological quality was evaluated for each study with the criteria of the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Twenty of 6,828 potentially relevant articles (55,506 patients) were included in the analysis. TABULATION, INTEGRATION, AND RESULTS: Two authors independently abstracted information on study design, sample size, participant characteristics, and maternal and fetal health outcomes by using a standardized protocol. Rates of vaginal delivery in women undergoing a trial of labor ranged from 60% to 82%. There was no significant difference in maternal deaths or hysterectomy between trial of labor and repeat cesarean. Uterine rupture was more common in the trial-of-labor group, but rates of asymptomatic uterine dehiscence did not differ. Studies conflicted on the effect of induction of labor on these outcomes. Data regarding infant outcomes were poor. CONCLUSION: Safety in childbirth for women with prior cesarean is a major public health concern. Methodological deficiencies in the literature evaluating the relative safety of vaginal birth after cesarean compared with repeat cesarean delivery are striking. The identification of high-risk and low-risk groups of women and settings for morbidity remains a key research priority.

Cesarean Section, Repeat↗
PubMed1989

Immunoliposomes with different acid sensitivities as probes for the cellular endocytic pathway.

By combining dioleoylphosphatidylethanolamine (DOPE) with oleic acid (OA), palmitoylhomocysteine (PHC) or dipalmitoylsuccinylglycerol (DPSG) we have prepared pH-sensitive liposomes with different acid sensitivities. DOPE/OA liposomes are the most acid sensitive, while DOPE/DPSG liposomes are the least acid sensitive. Incubation of DOPE/OA liposomes with mouse L929 cells reduces the pH-sensitivity of these liposomes by altering the lipid composition. Using diphtheria toxin fragment A as a marker for cytoplasmic delivery, we find that the delivery kinetics of pH-sensitive immunoliposomes closely correlates with the modified acid sensitivities of the liposomes. Immunoliposomes encounter pH 6-6.2 with a t1/2 of 5-15 min after internalization. By contrast, acidification of the endosomes to pH 5.0 takes longer (t1/2 approximately 25 min). We also used a whole cell null point technique (Yamishiro and Maxfield (1987) J. Cell Biol. 105, 2713-2721) to directly determine the average pH encountered by the endocytosed immunoliposomes. We find that acidification determined by the null point method proceeds less rapidly than that estimated from DTA delivery data. This is likely due to the fact that the measured DTA delivery is done by those liposomes which first arrive at the endosomes with sufficient acidity. Our data suggests that DOPE/PHC immunoliposomes deliver at the early endosome while DOPE/DPSG immunoliposomes deliver at the late endosomes. The DOPE/OA immunoliposomes, with the altered composition and acid sensitivity, deliver with a kinetics intermediate between the other two immunoliposomes. Thus, pH-sensitive liposomes represent useful probes for studying the kinetics of endosome acidification.

Animals↗
PubMed2006

Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.

OBJECTIVE: To estimate the potential savings, both in terms of costs and lengths of stay, of one-week increases in gestational age for premature infants. The purpose is to provide population-based data that can be used to assess the potential savings of interventions that delay premature delivery. DATA: Cohort data for all births in California in 1998-2000 that linked vital records data with those from hospital discharge abstracts, including those of neonatal transport. All infants with a gestational age between 24 and 37 weeks were included. There were 193,167 infants in the sample after deleting cases with incomplete data or gestational age that was inconsistent with birth weight. METHODS: Hospital costs were estimated by adjusting charges by hospital-specific costs-to-charges ratios. Data were aggregated across transport into episodes of care. Mean and median potential savings were calculated for increasing gestational age, in one-week intervals. The 25th and 75th percentiles were used to estimate ranges. RESULTS: The results are presented in matrix format, for starting gestational ages of 24-34 weeks, with ending gestational ages of 25 to 37 weeks. Costs and lengths of stay decreased with gestational age from a median of $216,814 (92 days) at 24 weeks to $591 (2 days) at 37 weeks. The potential savings from delaying premature labor are quite large; the median savings for a 2 week increase in gestational age were between $28,870 and $64,021 for gestational ages below 33 weeks, with larger savings for longer delays in delivery. Delaying deliveries <29 weeks to term (37 weeks) resulted in savings of over $122,000 per case, with the savings being over $206,000 for deliveries <26 weeks. CONCLUSIONS: These results provide population-based data that can be applied to clinical trials data to assess the impacts on costs and lengths of stay of interventions that delay premature labor. They show that the potential savings of delaying premature labor are quite large, especially for extremely premature deliveries.

California↗
PubMed2004

Provision of family planning services in Lesotho.

CONTEXT: One of Lesotho's population goals is to achieve replacement-level fertility by 2011, but the contraceptive prevalence rate of 41% is considerably below the target of 70-75%. METHODS: A situation analysis framework was used to assess family planning providers' readiness to provide services and women's perceptions of service delivery. Data were collected in 1997-1998 through surveys of 38 service delivery points and 52 providers, and focus group discussions with 50 women. RESULTS: Most facilities were open five days a week, during working hours; closure during lunchtime and on weekends restricted access by employed people. There were no clear guidelines on the provision of family planning methods, and providers created their own rules and restrictions. Some women were discouraged by provider bias, lack of visual privacy and recurrent shortages of their preferred brand of pills. Although the government had a uniform pricing policy for contraceptive methods, costs varied and generally were higher in rural than in urban areas. In rural areas, transportation costs increased the overall cost of using family planning methods. CONCLUSIONS: Expanding women's access to service sites, developing guidelines for family planning providers and ensuring that standard prices are adopted should be government priorities if contraceptive prevalence is to increase.

Adult↗
PubMed2005

Nuchal cords in term and postterm deliveries--do we need to know?

OBJECTIVE: To analyze the effect of nuchal cords on perinatal features at delivery of term and postterm pregnancies. METHODS: A total of 11,748 women with planned vaginal deliveries, including 9,574 term and 2,174 postterm deliveries, were analyzed for intrapartum events, clinical peripartum management, mode of delivery, and neonatal outcome. The presence of nuchal cords was diagnosed clinically at the time of delivery. Data were obtained from our perinatal database between 1995 and 2004 for retrospective analysis. RESULTS: The incidence of nuchal cords in term and postterm deliveries was 33.7% and 35.1%, respectively. Multiple nuchal cords were present in 5.8% of term and 5.5% of postterm deliveries. Intrapartum signs of fetal compromise were increased in all groups, albeit not all reaching statistical significance in postterm deliveries. Meconium staining was significantly increased only in multiple nuchal cords of postterm deliveries (42.1% compared with 30.1%, P < .05). Mode of delivery was unchanged in all nuchal cord groups. Unfavorable neonatal blood gas values were significantly more frequent in all nuchal cord groups. Nevertheless, 5-minute Apgar scores less than 7 were not more common, and admission to neonatal unit was not required more frequently. Neonatal mean birth weight was significantly lower in all nuchal cord groups. CONCLUSION: Nuchal cords do not influence clinical management at delivery, and neonatal primary adaption is not impaired. Our data show that ultrasonographic nuchal cord assessment is not necessary at the time of admission for delivery. LEVEL OF EVIDENCE: II-3.

Adult↗
PubMedDate not supplied

Recovery from childbirth: looking back 6 months after delivery.

Women's perceptions of their recovery from childbirth were investigated by open-ended interviews of 96 mothers of health, full-term infants 6 months after delivery. Data included factors affecting physical, mental, and emotional recovery; sources of help and hindrance; ideas of what each women would do differently after the delivery of another child; and overall evaluation of how the months after delivery compared with expectations. Content analysis of the data revealed that 25% of the women did not feel physically recovered from childbirth at 6 months postpartum. Husbands and other family members were major sources of help. Prolonged labor and cesarean delivery were the major hindrances to recovery. More household and child-care help was desired after delivery of another child. Almost half of the women found the first 6 months after delivery more difficult than anticipated. The findings suggest that pregnant women need more information about lifestyle adjustments after childbirth.

Adaptation, Psychological↗
PubMed1995

The effectiveness of preterm-birth prevention educational programs for high-risk women: a meta-analysis.

OBJECTIVE: To evaluate whether preterm-birth prevention educational programs are effective at reducing neonatal mortality, low birth weight (LBW), and preterm delivery. DATA SOURCES: A MEDLINE literature search of English-language studies was performed, supplemented by a bibliography search of original research and review articles to locate studies assessing preterm-birth prevention programs. METHOD OF STUDY SELECTION: We identified 31 studies that reported results from trials evaluating preterm-birth prevention programs. From this group, only the six randomized controlled trials evaluating preterm-birth prevention education programs satisfied criteria of homogeneity to be included in a meta-analysis. One of these six studies was a subset of another study and was excluded except when reporting outcomes that were not included in the larger report. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers assessed study methodology and identified the following outcomes: LBW frequency, preterm birth frequency, neonatal survival, birth weight, gestational age at delivery, and preterm labor diagnosis rates. When data were combined using meta-analytic techniques, no significant benefits were found for preterm-birth education programs in preventing neonatal death (cumulative relative risk [RR] 1.00, 95% confidence interval [CI] 0.99-1.01), LBW rates (RR 0.99, 95% CI 0.88-1.11), or preterm delivery rates (RR 1.08, 95% CI 0.92-1.27). The only statistically significant effect of preterm birth education programs appears to be an increase in the frequency at which preterm labor is diagnosed (RR 1.71, 95% CI 1.41-2.08). CONCLUSION: Preterm-birth prevention educational programs appear to have little benefit in reducing preterm birth and may result in an increased rate of diagnosis of preterm labor.

Female↗
PubMed2001

The long-term effects of Medicaid managed care on obstetrics care in three California counties.

OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.

Aid to Families with Dependent Children↗
PubMed1982

Satisfaction with maternity care: a matter of communication and choice.

The purpose of this study was to determine the level of satisfaction with maternity care and whether satisfaction was related to the patterns of communication between caretakers and patient and to specific clinical procedures used during labor and delivery. Data, gathered in a statewide survey, indicated widespread satisfaction with prenatal labor and delivery care. Level of satisfaction was related to both the quality of communication and the fulfillment of preferences about the management of labor and delivery. There was a general consensus among respondents about the desirability of childbirth coaches, controlled breathing and relaxation techniques, and freedom to move around and the undesirability of medication rendering one unconscious for delivery. There was considerable variation in desire concerning medication during labor, use of a fetal monitor, presence of family members and choice atmosphere. The implications for alternatives in maternity care are discussed.

Adolescent↗
PubMed1999

Vanishing forceps delivery.

This study evaluates the effect of decreasing cesarean rates and increasing regional anesthesia use on the frequency of forceps deliveries. Data of women who delivered at our community hospital from 1990 through 1997 are reviewed. In 1994, the members of our department adopted several strategies to decrease cesarean deliveries. The cesarean rate decreased whereas regional analgesia use increased. We studied the frequency and type of vaginal operative deliveries during this 8 year period. These data were evaluated by chi2 analysis. Data of women who delivered in the first 4 years (group 1) were compared with data of those who delivered in the second 4 years (group 2). A p < 0.05 was considered significant. The demographic and clinical characteristics of these women remained unchanged during the study period. The total cesarean rate decreased from 23.2% in group 1 to 17.9% in group 2 (p < 0.0001). The proportion of women who received regional anesthesia increased from 18.8 in group 1 to 25.7 in group 2 (p < 0.0001). Vaginal operative deliveries increased from 3.6 to 5.5 (p < 0.0001), whereas the proportion of forceps deliveries decreased from 2.2 to 1.5 (p = 0.001). Perinatal morbidity and mortality did not change. The decrease in cesarean rate and increase in regional anesthesia use were associated with an increase in operative deliveries; however, forceps deliveries continue to decrease in our community hospital.

Analgesia, Obstetrical↗
PubMedDate not supplied

Mechanisms of full-term and preterm labor: factors influencing uterine activity.

OBJECTIVE: To review factors influencing uterine activity leading to delivery. DATA SOURCES: A search was conducted on MEDLINE and CINAHL under the terms "preterm labor," "preterm delivery," and "physiology of labor and preterm labor." STUDY SELECTION: One-hundred fifty articles were reviewed, with selection based on physiologic concepts judged to be most relevant to nursing practice. DATA SYNTHESIS: In this review, factors initiating labor and preterm labor (PTL) are identified, along with areas for further research. CONCLUSIONS: Despite research on what initiates labor, it is unknown how the various mechanisms are integrated. Nurses are in a position to conduct research to help further the understanding of the labor and PTL processes. Nurses can use their assessment skills to help identify women at risk for PTL and delivery.

Female↗
PubMed2000

Development of a web-based picture archiving and communication system using satellite data communication.

Using the JAVA language we have developed a Web-based picture archiving and communication system (PACS) which allows a remote hospital to access medical images. An asymmetric satellite data communication system (ASDCS) provided a receive-only link for data delivery and a conventional terrestrial link (which could be the conventional telephone network) allowed data transmission. The satellite communication link was 10-30 times faster than the conventional terrestrial link. To increase image transmission speeds over the Internet connection, JPEG and wavelet compression methods were used. The resulting images were evaluated quantitatively by measuring the peak signal:noise ratio and qualitatively by radiologists. Compression ratios of 10:1 or less were deemed acceptable for diagnostic purposes. The system appears to be suitable for teleradiology and telemedicine.

Computer Communication Networks↗
PubMed2005

First-trimester group B Streptococcus colonization of the cervix: a risk factor for maternal colonization at term?

OBJECTIVE: To identify the prevalence of first-trimester cervical group B Streptococcus (GBS) colonization in routine obstetric patients and whether a relationship exists between first-trimester cervical GBS colonization and maternal GBS bacteriuria or GBS colonization at term. STUDY DESIGN: An institutional review board-approved prospective, cohort study was performed. The study population included consecutively recruited, unselected obstetric patients who delivered at our medical center, presented for care in thefirst trimester and were followed for the duration of their pregnancies. Each patient consented to have an extra culture swab for GBS status obtained at the time of her first prenatal visit when a routine examination was performed. Urine and third-trimester culture data were also collectedfrom each study subject. RESULTS: Of the 90 women with complete delivery data, 17 (19%) hadfirst-trimester cervical cultures positive for GBS. Women with first-trimester cervical GBS colonization were more likely to have third-trimester colonization on screening cultures than were women whose initial cultures were negative (35% vs. 14%, p = 0.05). The sensitivity of a GBS-positive cervical culture for detecting the coexisting presence of GBS bacteriuria was 38%, with a positive predictive value (PPV) of 31% and negative predictive value of 89%. When the outcome of interest was expanded to include GBS bacteriuria or third trimester colonization, the PPV of a positive cervical culture increased to 73%. CONCLUSION: First-trimester GBS colonization of the cervix may be as sensitive as antepartum GBS bacteriuria, an established risk factor, for predicting maternal GBS colonization at term.

Adult↗
PubMed1994

An analysis of birth weight by gestational age using a computerized perinatal data base, 1975-1992.

OBJECTIVE: To develop birth weight-for-gestational age nomograms based on a computerized perinatal data base collected prospectively from 1975-1992. METHODS: Using information from over 60,000 singleton deliveries (January 1975 through October 1992) at the MetroHealth Medical Center in Cleveland, Ohio, standard curves for normal birth weights were computed. Nomograms were developed for the overall population and for subgroups determined by factors known to affect fetal growth, including sex, race, smoking status, and gestational diabetes. The nomograms included the tenth, 50th, and 90th percentiles of birth weights for 24-44 weeks' gestation. Gestational age was based on clinical obstetric estimates confirmed by Dubowitz assessment of the neonate. In addition, third-order regression models were developed to predict median birth weight using gestational age. These models were validated using delivery data for the months of November and December, 1992, which were not included in model development. RESULTS: The most significant predictors of median birth weight were the first-, second-, and third-order gestational ages, which explained over 80% of the total variation in birth weight. Other significant factors influencing birth weight included infant gender, maternal race, parity, smoking, and diabetes status. Among the marginally significant factors influencing birth weight were pay status and maternal age. In general, before 33 weeks' gestation, there were few differences in the birth weight percentiles of various groups except for those with diabetes; infants of diabetic women exhibited greater birth weights as early as 26 weeks' gestation. CONCLUSIONS: Considering the large size of the data base and the diverse background of the study population, we believe that these nomograms provide useful norms of birth weight for an indigent urban population. These norms enhance the obstetrician's and neonatologist's ability to identify true cases of retardation or acceleration of intrauterine growth. Simple mathematical models provide easy calculation of the median birth weights for 24-44 weeks while adjusting for many confounding factors.

Adult↗
PubMed2004

Levator function before and after childbirth.

BACKGROUND: Vaginal childbirth is assumed to affect pelvic floor muscle function as a result of direct trauma and/or neuropathy. AIMS: To assess levator function by ultrasound prior to and after delivery and correlate changes with delivery data. METHODS: A total of 200 nulliparous women were seen at 6-18 and 32-37 weeks' gestation as well as 2-5 months post-partum. Appointments consisted of an interview, paper towel test, flowmetry and translabial ultrasound (supine and after voiding). The most effective of at least three contractions was used for evaluation according to a previously published method quantifying cranioventral displacement of the bladder neck. Labour and delivery details were collected through data collection sheets and the institutional database. RESULTS: A total of 173 women were seen in late pregnancy; 169 returned on average 93 days post-partum. At the last visit, a reduction of cranioventral lift from 11.2 mm (SD 4.5) to 8.8 mm (SD 4.2) was noted (P <0.001) which correlated weakly with active second stage (Spearman's r=-0.196, P=0.013), passive second stage (r=-0.15, P=0.059) and total second stage of labour (r=-0.225, P=0.004). Good antenatal levator function was not protective of changes in levator function or pelvic organ support. CONCLUSIONS: Childbirth reduces bladder neck displacement on levator contraction. The main obstetric determinant affecting levator function seems to be the length of the second stage. A Caesarean section in the second stage appears to exert no protective effect. It seems to be full engagement of the fetal head, not childbirth itself, that impairs levator function.

Cohort Studies↗
PubMed1994

Incidence and contribution of predisposing factors to transverse lie presentation.

OBJECTIVES: Reassessment of predisposing factors to transverse lie presentation. METHODS: Retrospective analysis of delivery data on 92 women with transverse lie presentation, using ultrasonography, and 92 randomly chosen control vertex deliveries. RESULTS: The association between transverse lie and multiparity, prematurity, placenta previa, polyhydramnios and uterine anomalies is reaffirmed. Predisposing factors were found in 66% of primiparas but in only 33% of multiparas. CONCLUSIONS: Known predisposing factors to transverse lie presentation withstood a closer and more accurate assessment of their incidence.

Adult↗
PubMedDate not supplied

Urinary incontinence in pregnancy and the puerperium.

OBJECTIVE: To describe the incidence of urinary incontinence (UI) during pregnancy and the puerperium and to identify potential contributing factors. DESIGN: A descriptive correlational design, using participant interviews and reviews of the existing medical records to determine the incidence of UI in pregnancy and the puerperium and to examine relationships between and among several variables. The variables included parity, episiotomy, use of forceps/vacuum extractor, type of anesthesia, prolonged Stage II labor, and race. Data were collected via two personal interviews and review of medical records. The first interview was conducted during the recruitment of each participant; the second was a telephone interview conducted 4 to 6 weeks postpartum. Data collected from the medical records included obstetric history, weeks of gestation, and estimated date of delivery. Data were entered into data files for analysis with SPSS 8.0 and summarized with descriptive statistics. SETTING: A secluded area of a university teaching hospital prenatal clinic. PARTICIPANTS: A convenience sample of 50 pregnant women, at least 18 years old, who received their care at a large university hospital prenatal clinic in the southeastern part of the United States. RESULTS: First Interview (N = 50). More than half (62%; n = 31) of the sample reported some degree of involuntary urine loss during their pregnancy. The racial distribution of those reporting UI was the following: white (70%; 21 out of 30); African American (44%; 8 out of 18); Hispanic/Asian (100%; n = 2). Among the participants who experienced UI (n = 31), 76% (n = 23) reported that their health care provider never asked if they were experiencing any UI symptoms. Second Interview (n = 24). Only 48% of the initial participants could be contacted for the second interview because of changes in residence or telephones being disconnected with no forwarding number. Of the women in this sample who reported UI during the first interview (59%; n = 14), 7 (50%) continued to experience UI 4 to 6 weeks postpartum. The 2 remaining participants who reported UI 4 to 6 weeks postpartum (22%) had not experienced UI during pregnancy. Of the participants experiencing postpartum UI, 77% (n = 7) were white. Almost half of the participants with postpartum UI were ages 35 or older (44%; n = 4). Among the participants reporting episiotomy (n = 4), 3 (75%) reported having UI 4 to 6 weeks postpartum. CONCLUSIONS: Study results support the conclusion that childbirth, specifically vaginal birth, is a major factor in developing UI in the early postpartum period. Age, race, and use of episiotomy appear to be contributing risk factors.

Adult↗