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Original article
Anaemia in pregnancy and in the immediate postpartum period. Prevalence and risk factors in pregnancy and childbirth
Anemia en el embarazo y el posparto inmediato. Prevalencia y factores de riesgo
Xavier Urquizu i Brichsa,
Corresponding author
xurquizu@gmail.com

Corresponding author.
, Mónica Rodriguez Carballeirab, Antonio García Fernándeza, Emilio Perez Picañolc
a Servicio de Obstetricia y Ginecología, Hospital Universitari MútuaTerrassa, Terrassa, Spain
b Servicio de Medicina Interna, Hospital Universitari MútuaTerrassa, Terrassa, Spain
c Servicio Obstetricia y Ginecología, Hospital Universtari Germans Trias i Pujol, Badalona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In general&#44; the health of women in the postpartum has been little studied and has been given little attention by both clinicians and researchers and by women themselves&#46; Morbidity&#44; both physical and mental&#44; is probably underestimated and ignored&#44; reason why it represents a serious or very serious problem to women&#39;s health&#44; both short- and long-term&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Postpartum anaemia has been forgotten as the rest of postpartum complications&#46; In fact&#44; the problem was described and published many years ago&#46; In the distant 1953&#44; an article by Wolff in the journal <span class="elsevierStyleItalic">Obstetrics &#38; Gynaecology</span> already made mention of this problem&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> In our healthcare area&#44; the Spanish Society of Gynaecology and Obstetrics also recognizes that anaemia in the postpartum period is a common situation&#44; probably poorly attended in many cases&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Postpartum anaemia and iron deficiency represent a very important public health problem&#44; both due to its prevalence and its socioeconomic consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Deleterious effects have been documented on certain economic and social issues&#44; including child care&#44; household chores and social and professional activities&#44; with a decrease in productivity associated with both physical and intellectual tasks&#44; which can have a significant socio-economic impact&#44; especially in industrialized countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Most national and international scientific bodies which have issued recommendations on postpartum anaemia &#40;<span class="elsevierStyleItalic">Center for Disease Control and Prevention</span>&#44; <span class="elsevierStyleItalic">The American College of Obstetricians and Gynaecologists</span>&#44; <span class="elsevierStyleItalic">Institute of Medicine</span>&#44; Spanish Society of Gynaecology and Obstetrics&#41; recognize the lack of scientific evidence&#44; which is reflected in the variety of recommendations published&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> In this sense&#44; it is unclear whether to do a population&#47;universal screening or only do it to risk groups&#59; it is also unclear when should be the best time to do the screening or the interpretation of the same &#40;before hospital discharge or a week after delivery&#41;&#44; and when and for how long they should be treated&#44; as physiological changes occur in iron homeostasis in the first postpartum days or weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4&#44;7&#8211;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; there is no consensus regarding the risk factors that cause greater chance of developing postpartum anaemia&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;10</span></a> or the type of delivery most likely to be associated with anaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;8</span></a> There is also no consensus on the optimal value of haemoglobin &#40;Hb&#41; at the time of delivery so as to reduce postpartum anaemia&#44; figures that perhaps should be reassessed based on the results of this study&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of the study was to assess the prevalence of anaemia in the immediate postpartum period in our healthcare area&#44; determine risk factors for anaemia in this period&#44; and ascertain which antepartum Hb value correlates with a lower postpartum anaemia&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Prospective&#44; observational and longitudinal study&#44; which included 1426 women&#46; All patients who gave birth consecutively&#44; during the 9-months of the study period&#44; which took place between 01&#47;11&#47;2009 and 31&#47;10&#47;2010&#44; adults &#40;18<span class="elsevierStyleHsp" style=""></span>yr old or older&#41; and who agreed to participate and signed the informed consent were included in the study&#46; Patients were included in the study during the pregnancy monitoring visits&#44; in the first trimester&#44; carried out at the University Hospital M&#250;tua Terrassa and its Primary Care Centres &#40;ASSIR&#41; of reference&#44; by professionals from the Department of Obstetrics and Gynaecology of the said centres&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The sample was calculated assuming a risk &#40;<span class="elsevierStyleItalic">¿</span>&#41; of 2&#37;&#44; a confidence level of 95&#37; and a population probability of 10&#37;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The data were collected from medical records &#40;pregnancy record book&#44; partogram and postpartum clinical course&#41;&#44; a case report form specific for this study and blood tests performed during pregnancy monitoring&#44; the day of delivery admission and before discharge &#40;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h postpartum&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Monitoring of patients during pregnancy followed the usual course according to our centre&#39;s pregnancy control protocol&#44; adding two 2 additional blood tests&#44; antepartum and postpartum Hb&#46; The blood tests were performed between weeks 8&#8211;12 of pregnancy &#40;1st trimester&#41;&#44; weeks 24&#8211;28 &#40;2nd trimester&#41;&#44; weeks 32&#8211;35 &#40;3rd trimester&#41;&#44; the day of delivery admission &#40;antepartum Hb&#41; and before discharge &#40;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h postpartum&#44; postpartum Hb&#41;&#46; All study patients were included and monitored at M&#250;tua Terrassa centres&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study variables were Hb &#40;g&#47;dl&#41; measured in the Sysmex XE-2100 haematology automated analyser with an immunoturbidimetry technique&#46; Anaemia during the 3 pregnancy trimesters &#40;WHO&#44; UNICEF&#44; 1997&#41;&#44; the day of delivery and postpartum<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> was defined as Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>g&#47;dl was defined as severe anaemia&#44; between 8 and 9&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl as moderate anaemia and 10&#8211;10&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl as mild&#46; The delivery types studied were normal vaginal birth&#44; forceps&#44; vacuum assisted and elective and emergency&#47;intrapartum caesarean section&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Other variables were obesity&#44; according to the 2001 body mass index &#40;BMI&#41; &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; WHO classification&#44; new-born birth weight&#44; birth complications &#40;uterine rupture&#44; uterine atony&#44; retained placenta&#44; dissecting aneurysm&#41;&#44; the presence or absence of episiotomy and vaginal tears&#44; toxic habits&#44; iron supplementation &#40;amount of elemental iron received during pregnancy&#41;&#44; parity&#44; ethnicity&#44; patient age&#44; gestational age&#44; hours of delivery&#44; obstetric complications and pregnancy risk factors according to the <span class="elsevierStyleItalic">Protocol de seguiment de l&#8217;embar&#224;s a Catalunya</span> &#40;pregnancy monitoring protocol in Catalonia&#41; &#40;2nd revised edition&#41; of the <span class="elsevierStyleItalic">Department of Health of the Generalitat de Catalunya</span>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical study</span><p id="par0065" class="elsevierStylePara elsevierViewall">The description of the data was performed with standard deviations &#40;SD&#41; for continuous variables and percentages &#40;&#37;&#41; for categorical variables&#46; The univariate analysis was performed with Student&#39;s <span class="elsevierStyleItalic">T</span> test to compare the continuous variables means when these were normally distributed and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test when they were not&#46; Categorical variables were analyzed with Fisher&#39;s <span class="elsevierStyleItalic">F</span> test or Chi square&#46; In the univariate analysis the variables that had previously been associated with postpartum anaemia in the published literature were chosen&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The multivariate analysis to determine independent risk factors of postpartum anaemia was performed using a logistic regression model using the Bacward Stepwise &#40;Wald&#41; method and as input&#47;output criteria of the PIN 0&#44;05 and POUT 0&#46;10 model&#46; The variables included in the multivariate analysis were those in the univariate analysis which were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; or considered clinically relevant&#58; antepartum anaemia&#44; type of delivery&#44; hours of delivery&#44; foetal birth weight&#44; ethnicity&#44; parity&#44; BMI&#44; and intra-&#47;postpartum complications&#46; A simple regression analysis was performed to assess the relationship between antepartum and postpartum anaemia&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The SPSS version 19&#46;0 was used in the processing of data&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#44; respectively&#44; show the general characteristics of the study population during the antepartum and postpartum&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The prevalence of postpartum anaemia was 49&#46;7&#37;&#46; The percentage of anaemia during pregnancy gradually increased until the third trimester&#44; when it started to decrease significantly until the time of delivery&#46; Postpartum anaemia significantly increased again due to delivery&#44; especially in patients who had antepartum anaemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">10&#37; of patients had anaemia during delivery&#46; Of these&#44; 88&#46;3&#37; had postpartum anaemia with different degrees of severity&#46; A third had mild anaemia&#44; half had moderate anaemia and 16&#37; severe anaemia&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Among patients with postpartum anaemia&#44; the prevalence of instrumental delivery and caesarean section was significantly higher &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Postpartum anaemia was observed in 82&#37; of all deliveries made with forceps&#44; 67&#37; of those vacuum assisted and 58&#46;2&#37; of caesarean sections&#44; while in normal vaginal births&#44; postpartum anaemia was only found in 37&#46;2&#37; of cases&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The drop in Hb with each of these deliveries followed a similar pattern &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Regarding the ethnicity of patients&#44; Central-South American and sub-Saharan puerperal women had a significantly higher rate of postpartum anaemia than the North African&#44; Asian and Caucasian&#44; with no differences between North African and Caucasian &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Grouping the patients by hemispheres&#44; patients in the southern hemisphere &#40;Central-South America and sub-Saharan&#41; presented a significantly higher postpartum anaemia in the multivariate analysis compared to those in the northern hemisphere &#40;Caucasian&#44; North African and Asian&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Perineal injuries during childbirth also contributed to postpartum anaemia&#46; Patients with <span class="elsevierStyleSmallCaps">III&#8211;</span>IV degree tears and&#47;or episiotomy had significantly higher prevalence of postpartum anaemia than patients without episiotomy or <span class="elsevierStyleSmallCaps">I</span>&#8211;<span class="elsevierStyleSmallCaps">II</span> degree tears&#46; The most severe anaemias were observed in those patients who had major complications such as atony and dissecting aneurysm&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Parity influenced in different ways depending on the number of previous children &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; Nulliparous and multiparous patients had higher anaemia than those with one or two children&#44; with statistically significant differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; A greater presence of instrumental deliveries &#40;36&#46;3 versus 10&#46;6&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; was detected in nulliparous women while a higher prevalence of antepartum anaemia &#40;17&#46;6 versus 10&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; was detected in multiparous women &#40;&#8805;3 children&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Excessive weight gains during pregnancy &#40;&#62;18<span class="elsevierStyleHsp" style=""></span>kg&#41; was also associated with a greater decrease in haemoglobin &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl in increments &#60;18<span class="elsevierStyleHsp" style=""></span>kg versus 1&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl in increments &#62;18<span class="elsevierStyleHsp" style=""></span>kg&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;019&#41;&#44; related with an increase in the rate of instrumental and caesarean deliveries in patients with greater weight gain during pregnancy&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The univariate analysis also showed that patients with high-risk pregnancies showed significant differences in Hb drop&#44; but this condition lost significance in the multivariate analysis because it is not a classification designed for anaemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The most important complications and risk factors evaluated in the study were&#58; social dystocia with&#47;without insufficient control of pregnancy with 5&#46;3&#37; &#40;75&#47;1426&#41;&#59; hypertensive disorders of pregnancy with 1&#46;5&#37; &#40;22&#47;1426&#41; and 0&#46;4&#37; of HELLP syndromes&#59; 1&#46;1&#37; &#40;15&#47;1426&#41; had severe anaemia during one of the trimesters&#59; gestational diabetes in 3&#46;9&#37; &#40;56&#47;1426&#41;&#59; obesity in 3&#46;4&#37; &#40;49&#47;1426&#41;&#59; and thyroid disorders in 2&#46;5&#37; &#40;36&#47;1426&#41;&#46; 1&#46;5&#37; &#40;22&#47;1426&#41; were twin pregnancies&#44; 0&#46;6&#37; &#40;&#40;9&#47;1426&#41; had a intergenesic period lower than 12 months&#44; and 0&#46;5&#37; &#40;7&#47;1426&#41; had inflammatory bowel disease&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Macrosomia was not significantly associated with postpartum anaemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; although when the weight of new-borns was recoded according to their median &#40;3&#46;270<span class="elsevierStyleHsp" style=""></span>g&#41;&#44; the rate of postpartum anaemia in patients with neonates &#8804;3270<span class="elsevierStyleHsp" style=""></span>g was 45&#37; compared with 54&#37; in those &#62;3270<span class="elsevierStyleHsp" style=""></span>g &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The following variables were introduced in the multivariate logistic regression analysis&#58; antepartum anaemia&#44; type of delivery&#44; hours of delivery&#44; foetal birth weight&#44; ethnicity&#44; parity&#44; BMI and intra-&#47;postpartum complications&#46; The factors independently associated with postpartum anaemia were antepartum anaemia&#44; type of birth&#44; ethnicity&#44; number of previous children and the hours of delivery &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; Factors that were associated with greater intensity were antepartum anaemia &#40;measured on the day of delivery&#41;&#44; which multiplied the risk by 6&#46;16 and the type of delivery&#44; because the instrumental delivery multiplied the risk by 4&#46;61 and the caesarean section by 2&#46;28&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In the linear regression analysis&#44; we found that there was a statistically significant linear association between the Hb on the delivery day and the immediate postpartum one so that you a formula defined by the following equation can be established&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0150" class="elsevierStylePara elsevierViewall">Based on this formula we can confirm that the patient should arrive to the delivery day with an Hb of 12&#46;63<span class="elsevierStyleHsp" style=""></span>g&#47;dl to ensure an Hb<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>g&#47;dl in the immediate postpartum&#44; a value which defines postpartum anaemia for most organizations and scientific societies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The study data showed that having antepartum anaemia was the most important cause for immediate postpartum anaemia and that the most anaemia-inducing delivery was an instrumental delivery &#40;forceps and vacuum&#41;&#44; being also the one that had a higher percentage of severe anaemias &#40;18&#46;9&#37;&#41;&#46; In the forceps delivery or caesarean section&#44; the drop in Hb was 2&#46;5 and 1&#46;8 times higher&#44; respectively&#44; in comparison with the normal vaginal birth&#46; All these data highlight the role of delivery in postpartum anaemia&#44; because although only 10&#37; of patients arrive to the day of delivery with anaemia&#44; half of the puerperal women had postpartum anaemia 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after it&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The lowest anaemia-inducing delivery&#44; normal vaginal birth without complications&#44; showed a haemoglobin loss of 1&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;dl which carries a significant rate of anaemias if we consider the normal Hb pre- and postpartum parameters proposed by the official institutions&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Given the importance of antepartum anaemia and blood loss at delivery&#44; the target Hb before delivery should be higher than the figures recommended by official institutions&#44; such as WHO&#44; <span class="elsevierStyleItalic">Institute of Medicine</span> or the <span class="elsevierStyleItalic">Center for Disease Control and Prevention</span> &#40;Hb<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> According to the formula described under the results section&#44; we suggest that patients arrive at the day of delivery with an Hb<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>12&#46;6<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; which would ensure that most patients will not have anaemia at 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h after it&#46; On the other hand&#44; if pregnant women arrived at delivery with an Hb level of 11<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; all would be anaemic in the immediate postpartum period as a result of normal delivery blood loss and even more if they had to undergo caesarean section or an instrumental delivery&#46; For these reasons&#44; and based on the results of this study&#44; the recommended Hb figures that pregnant women should aim at on the day of delivery should be re-evaluated&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">On the other hand&#44; the importance of antepartum anaemia is based on the fact that it is one of the few postpartum anaemia risk factors which we can influence clearly and easily with suitable therapeutic and dietary measures during pregnancy&#44; unlike other described risk factors that cannot be changed&#44; or can be modified but with greater difficulty &#40;type of delivery&#44; episiotomy&#44; postpartum complications&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Iron treatment should be essential&#44; before&#44; during and after pregnancy and delivery&#46; Numerous studies show insufficient iron intake in women during the 3 months prior to pregnancy&#44; throughout pregnancy and postpartum&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The second cause of postpartum anaemia was the type of delivery&#46; Most published articles attributed an increased blood loss and a higher rate of anaemia to a caesarean delivery&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;13</span></a> According to the results obtained in this study&#44; the most anaemia-inducing delivery was the instrumental one&#44; followed by caesarean section&#46; For this reason&#44; one of the actions that could significantly reduce postpartum anaemia would be to optimize the rate of instrumental deliveries and caesarean sections&#46; Similarly&#44; due to their involvement in postpartum anaemia&#44; the practice of episiotomy should be restricted to those cases where they are strictly necessary&#44; trying not to increase the III&#8211;IV degree tears&#44; which also increase it significantly&#44; as described by other authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#44;14</span></a> although the multivariate analysis showed that anaemia was more closely related to the type of delivery than with perineal injury&#46; Episiotomy and vaginal tear repairs should be quick and careful to reduce blood loss&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">We observed a higher prevalence of pre- and postpartum anaemia in the Central and South American population&#44; a fact that corroborates the findings in some American studies where Hispanic ethnicity was associated with increased risk of postpartum anaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> The postpartum anaemia observed in this study is attributable to a higher rate of antepartum anaemia&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Based on published risk factors regarding the development of postpartum anaemia&#44; some authors have described different clinical scales to determine subgroups of puerperal women at increased risk of anaemia&#46; Because of the dispersion of risk factors in different studies published&#44; the scales contain different variables according to the authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;10&#44;14</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">In this study&#44; parity also appears as an important factor in the development of postpartum anaemia&#46; Patients who had their first child had the same postpartum anaemia than grand multiparous women&#44; as referenced by other authors&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> and significantly higher than secundiparous or tertiparous women&#46; The mechanism of action of anaemia was different between the 2 groups of patients&#46; While anaemia in primiparous women was related to the type of delivery&#44; in the multiparous &#40;&#8805;3 children&#41; it was related to antepartum anaemia&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Like other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8&#44;15&#44;16</span></a> pre-pregnancy obesity and increased BMI &#40;especially if &#62;18<span class="elsevierStyleHsp" style=""></span>kg&#41;&#44; were correlated with a higher rate of postpartum anaemia&#44; although they are not independent predictors&#44; but depend on the type of delivery&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">And why is all of this important&#63; Because in the medical literature it is well established that anaemia both during pregnancy and postpartum have deleterious consequences for mother and baby&#46; Antepartum anaemia has been associated with preterm delivery&#44; intrauterine growth retardation&#44; increased need for blood transfusion&#44; anaemic signs and symptoms&#44; decrease in iron deposits&#44; anaemia and cognitive and socioemotional disorders in the newborn&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#44;18</span></a> A recent publication showed the relationship between iron therapy and a reduced risk of autistic disorders&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> as well as with prenatal Hb levels&#44; cognitive and early motor functions impairment during the first year of life&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Postpartum anaemia has been associated with decreased cognitive abilities&#44; emotional instability&#44; postpartum depression in the mother<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21&#44;22</span></a> and changes in the mother-child relationship that can lead to psychoneurological disorders in the development of the latter&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Postpartum anaemia is also associated with maternal mortality&#44; mostly in developing countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;24</span></a> Anaemia occurring at birth in women of reproductive age has shown to be related to decreased work capacity&#44; impaired memory and concentration and decreased immune function&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25&#44;26</span></a> facts which may have serious socio-economic and public health consequences&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Studies published on postpartum anaemia show very different prevalence&#46; This is due&#44; among other reasons&#44; to the heterogeneity at the time of conducting the study on anaemia&#44; to the diversity of populations studied and to the socioeconomic conditions of the countries studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;7&#44;9&#44;15&#44;24&#44;27&#8211;29</span></a> For these reasons it is important to study specific populations&#44; as it is clear&#44; in the light of the results of the study&#44; immediate postpartum anaemia is a condition of high prevalence that may represent a major public health issue&#44; especially in some types of childbirth and in certain groups of patients with risk factors&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">It is also necessary to deepen the understanding of the causes and consequences of anaemia in this period and assess what would be the best strategies to solve this problem&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The dispersion of risk factors and populations studied&#44; together with the different definitions of postpartum anaemia &#40;Hb figures&#44; time of the study&#41; are essential regarding the lack of solid evidence&#46; Therefore&#44; the recommendations of the various institutions and scientific societies do not coincide when specifying when&#44; how&#44; and who should be subjected to screening and treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4&#44;7&#44;9&#44;30</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Following the results of the study&#44; it would be interesting to expand our knowledge about postpartum anaemia so as to define clinical strategies&#44; but also about cost-efficiency regarding screening and treatment&#46; We need to establish whether it would be better to make a universal screening or limit this screening to the patients at risk&#44; in order to reduce costs and avoid unnecessary treatments&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another point that should be questioned is the meaning of the Hb in the third trimester&#44; as it greatly differs from the Hb at birth&#46; This is due to the iron treatment received during the second half of pregnancy&#44; in which there is great variability in the time of initiation of treatment&#44; the doses received and the type of iron preparation&#44; reasons that make it difficult to establish the relationship with the postpartum anaemia&#46; Some authors&#44; like Arija in 2014&#44; have initiated study protocols &#40;ECLIPSE&#41; to determine the best dose of iron during pregnancy&#44; relating it to both perinatal as well as maternal outcomes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In summary&#44; the most important modifiable factors associated with postpartum anaemia are&#44; in order of importance&#44; anaemia during pregnancy&#44; instrumental delivery&#44; caesarean section and intra-&#47;postpartum complications&#46; It is necessary&#44; therefore&#44; to correct the antepartum anaemia &#40;being more aggressive in treating iron from the second half of pregnancy&#41; and strive to minimize intrapartum instrumental interventions and caesarean sections&#44; as well as fast and careful correction of complications&#44; minimizing possible episiotomies without increasing vaginal tears&#46; Clinical studies on the impact and progression of anaemia in the immediate postpartum and the relationship of this with anaemia in the late postpartum&#44; 6&#8211;8 weeks after birth&#44; are needed&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical issues and conflicts of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The researchers participating in the study declare no conflict of interest&#46; They also declare not having received any fees from a pharmaceutical company or any other institution&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The study was approved by the Clinical Research Ethics Committee &#40;CREC&#41; of the <span class="elsevierStyleItalic">Hospital Universitari M&#250;tua Terrassa</span>&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">All patients were informed of the nature of the study&#44; tests&#44; confidentiality of data and study objectives and were invited to sign an informed consent in order to participate in the study&#46;</p></span></span>"
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    "fechaRecibido" => "2015-09-17"
    "fechaAceptado" => "2016-01-28"
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          "clase" => "keyword"
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            0 => "Anaemia"
            1 => "Delivery"
            2 => "Pregnancy"
            3 => "Postpartum period"
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          "palabras" => array:4 [
            0 => "Anemia"
            1 => "Parto"
            2 => "Embarazo"
            3 => "Per&#237;odo posparto"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of the study was to assess the prevalence of anaemia in the immediate postpartum period &#40;48&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; determine the risk factors and the value of haemoglobin before birth to reduce postpartum anaemia&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; observational and longitudinal study that included 1426 women who delivered consecutively and agreed to participate in the study&#46; Different variables&#44; analytical&#44; epidemiological&#44; foetal and maternal symptoms were studied&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The prevalence of anaemia in the postpartum period was 49&#46;7&#37;&#46; The most important risk factors were antepartum anaemia and type of delivery&#46; The types of delivery most influencing postpartum anaemia were&#44; forceps &#40;82&#46;3&#37;&#41;&#44; the ventouse 67&#37;&#44; caesarean section &#40;58&#46;2&#37;&#41; and vaginal delivery &#40;37&#46;2&#37;&#41;&#46; In the multivariate study was found as the most important independent risk factors&#44; the haemoglobin in the delivery day &#40;OR 6&#46;16&#44; CI&#58; 3&#46;73&#8211;10&#46;15&#41; and instrumental delivery &#40;OR&#58; 4&#46;61&#44; CI&#58; 3&#46;44&#8211;6&#46;19&#41;&#46; Other independent risk factors were haemoglobin in the third trimester&#44; episiotomy and perineal tears&#44; ethnicity&#44; birth weight&#44; parity and intra&#47;postpartum complications&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anaemia in the immediate postpartum is a prevalent problem&#46; The factors most associated postpartum anaemia were antepartum anaemia and instrumental delivery&#46; If patients arrive at the day of delivery with haemoglobins &#8805;12&#46;6<span class="elsevierStyleHsp" style=""></span>g&#47;dl and were restricted to necessary instrumented deliveries and caesarean sections&#44; episiotomies and we could avoid perineal tears we can decrease anaemia in the immediate postpartum period very significantly&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio fue evaluar la prevalencia de la anemia en el posparto inmediato &#40;48-72<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; determinar los factores de riesgo y el valor &#243;ptimo de la hemoglobina antes del parto para reducir la anemia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo&#44; observacional y longitudinal que incluy&#243; a 1&#46;426 mujeres de forma consecutiva que accedieron a participar en el estudio&#46; Se estudiaron diferentes variables&#44; anal&#237;ticas&#44; epidemiol&#243;gicas y cl&#237;nicas tanto fetales como maternas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de anemia en el posparto inmediato fue del 49&#44;7&#37;&#46; Los factores de riesgo m&#225;s importantes fueron la anemia preparto y el tipo de parto&#46; Con el f&#243;rceps hubo un 82&#44;3&#37; de anemia posparto&#44; con el vacuum un 67&#37;&#44; con la ces&#225;rea un 58&#44;2&#37; y con el parto eut&#243;cico un 37&#44;2&#37;&#46; En el estudio multivariado se encontraron como factores de riesgo independientes m&#225;s importantes&#58; la hemoglobina el d&#237;a del parto &#40;OR&#58; 6&#44;16&#59; IC<span class="elsevierStyleSmallCaps">&#58;</span> 3&#44;73-10&#44;15&#41; y el parto instrumentado &#40;OR&#58; 4&#44;61&#59; IC&#58; 3&#44;44-6&#44;19&#41;&#46; Otros factores de riesgo independientes fueron la hemoglobina del tercer trimestre&#44; la episiotom&#237;a y los desgarros perineales&#44; la etnia&#44; el peso del neonato&#44; la paridad y las complicaciones intra- y&#47;o posparto&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La anemia en el posparto es un problema frecuente&#46; Los factores que m&#225;s se asociaron fueron el parto instrumentado y la anemia preparto&#46; Si las pacientes llegaran al d&#237;a del parto con hemoglobina<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>12&#44;6<span class="elsevierStyleHsp" style=""></span>g&#47;dl y optimiz&#225;ramos la tasa de partos instrumentados y ces&#225;reas&#44; restringiendo las episiotom&#237;as sin aumentar los desgarros perineales de alto grado podr&#237;amos conseguir una disminuci&#243;n muy significativa de la anemia en el posparto inmediato&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Urquizu i Brichs X&#44; Rodriguez Carballeira M&#44; Garc&#237;a Fern&#225;ndez A&#44; Perez Pica&#241;ol E&#46; Anaemia en el embarazo y el posparto inmediato&#46; Prevalencia y factores de riesgo&#46; Med Clin &#40;Barc&#41;&#46; 2016&#59;146&#58;429&#8211;435&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Age &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#46;7 &#40;19&#8211;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Height &#40;cm&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">161&#46;3 &#40;141&#8211;183&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Weight &#40;kg&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pregnancy start</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;7 &#40;39&#8211;138&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pregnancy end</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;3 &#40;48&#8211;143&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Average weight increase</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">BMI</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mean pregnancy start</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;6 &#40;4&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mean pregnancy end</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;9 &#40;4&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mean BMI increase</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Ethnicity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1413&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Caucasian</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">951 &#40;67&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">North African</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">210 &#40;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Central and South American</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">199 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Sub-Saharan</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Asian</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Toxic habits</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1426&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Without toxic habits</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1205 &#40;84&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">With toxic habits</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">221 &#40;15&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Tobacco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">217 &#40;15&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;0&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Parity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1426&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Primigravida</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">716 &#40;50&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Secundigravida</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">511 &#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tertigravida</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">142 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Multigravidas &#40;&#8805;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Risk rating</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1426&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Low-risk pregnancy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">542 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">High risk pregnancy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">884 &#40;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Iron treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1298&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">With treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1139 &#40;87&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1131 &#40;99&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Intravenous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Without treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">159 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Amount of elemental iron &#40;mg&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1139&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Day</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>47 &#40;1&#8211;315&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8121<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6749 &#40;8&#8211;60&#46;270&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Antepartum characteristics of the study population&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Gestational age &#40;week&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Hours of delivery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4 &#40;0&#8211;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Foetal birth weight &#40;g&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;272<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4893&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Type of delivery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;425&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Eutocic&#40;normal&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">852 &#40;59&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Forceps</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">202 &#40;14&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Spatulas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vacuum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122 &#40;8&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Caesarean sections</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">236 &#40;16&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Elective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60 &#40;25&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Intrapartum&#47;Emergencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">176 &#40;74&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Delivery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1230&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Spontaneous</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">880 &#40;71&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Guided</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">124 &#40;10&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Manual</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">226 &#40;18&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Perineal injury</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Elective episiotomy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">471&#40;33&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">I&#8211;II degree tear</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">498 &#40;35&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">III&#8211;IV degree tear</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Without injuries</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">420 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Postpartum complications &#40;uterine atony&#44; retained placenta&#44; dissecting aneurysm&#44; etc&#46;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">40 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Intra- and postpartum characteristics of the study population&#46;</p>"
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            "identificador" => "at3"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">First trimester anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#47;1333&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Second trimester anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">414&#47;1336&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Third trimester anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">296&#47;1365&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antepartum anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">129&#47;1346&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postpartum anaemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">640&#47;1287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Severity of anaemia in postpartum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1287&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without anaemia &#40;Hb<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">647&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mild &#40;Hb 10 to 10&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">313&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate &#40;Hb 8 to 9&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">266&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Severe &#40;Hb<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk factors</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Postpartum anaemia</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Yes &#40;No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>676&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">No &#40;No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>611&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&#59; OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Anaemia during pregnancy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>First trimester anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;6&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;001&#59; 2&#46;63 &#40;1&#46;44&#8211;4&#46;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Second trimester anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">266 &#40;41&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">168 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&#59; 1&#46;75 &#40;1&#46;37&#8211;2&#46;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Third trimester anaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">225 &#40;34&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86 &#40;14&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&#59; 3&#46;11 &#40;2&#46;53&#8211;4&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Antepartum anaemia &#40;delivery day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">109 &#40;17&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;001&#59; 7&#46;05 &#40;4&#46;11&#8211;12&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Type of delivery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Normal vaginal birth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">310 &#40;45&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">466 &#40;76&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Instrumental delivery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">236 &#40;34&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caesarean section&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130 &#40;19&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78 &#40;12&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Ethnicity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="7" align="left" valign="middle">0&#46;11</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">439 &#40;65&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">409 &#40;67&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>North African&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92 &#40;13&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sub-Saharan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>South American&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">115 &#40;17&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74 &#40;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pregnancy classified as high risk</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">411 &#40;51&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">384 &#40;62&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Perineal injury during birth &#40;episiotomy&#44; vaginal tears&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">442 &#40;72&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">424 &#40;68&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;002&#59; 1&#46;45 &#40;1&#46;13&#8211;1&#46;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Postpartum complications &#40;uterine atony&#44; dissecting aneurysm&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;004&#59; 2&#46;87 &#40;1&#46;28&#8211;6&#46;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Foetal weight</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8805;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3270</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g &#40;median&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">356 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">273 &#40;44&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;003&#59; 1&#46;38 &#40;1&#46;44&#8211;2&#46;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Parity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 23870206
Original language: English
DOI:10.1016/j.medcle.2016.06.050
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