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Articles 361 - 390 of 1688

Full-Text Articles in Maternal, Child Health and Neonatal Nursing

The Association Between Early Exposure To Antibiotics And Childhood Asthma Incidence, Victoria Fischer Jan 2024

The Association Between Early Exposure To Antibiotics And Childhood Asthma Incidence, Victoria Fischer

Soaring: A Journal of Undergraduate Research

This review examines the association between early exposure to antibiotics and the incidence of asthma in childhood, highlighting significant public health concerns related to antibiotic overuse. The misuse of antibiotics not only contributes to antibiotic resistance but may also impact long-term health outcomes, particularly respiratory diseases like asthma. Emerging evidence suggests that early antibiotic exposure may disrupt gut microbiota, altering immune responses and increasing the risk of asthma development. A systematic review of twenty-seven studies identified a significant correlation between antibiotic use in infancy and subsequent asthma diagnoses. However, there remains a need for further research to delineate the extent …


Maternal Health Crisis: Implicit Bias/Cultural Humility Education For Perinatal Nurses, Carmen Rezak Jan 2024

Maternal Health Crisis: Implicit Bias/Cultural Humility Education For Perinatal Nurses, Carmen Rezak

Regis University Student Publications (comprehensive collection)

Abstract

Today, perinatal nurses are challenged to provide equitable care for a very diverse and

high-risk pregnant/postpartum patient population. Pregnant women of color are mistrustful of

the health care system and concerned about their care and risks when admitted to the hospital for

fear that they are not listened to or treated with the same respect and intent as their white patient

counterparts. Reverend Martin Luther King, Jr., in a 1966 speech, made in connection with the

Medical Committee for Human rights stated, “Of all the forms of inequality, injustice in health is

the most shocking and inhumane.” Nurses play …


Furry Friends & Brighter Futures: Enhancing The Life Skills Of Toddlers With Autism Through Animal Assisted Therapy, Abigail Rosales Tolentino Jan 2024

Furry Friends & Brighter Futures: Enhancing The Life Skills Of Toddlers With Autism Through Animal Assisted Therapy, Abigail Rosales Tolentino

Nursing | Senior Theses

Autism Spectrum Disorder (ASD) encompasses a broad spectrum of challenges that impact social interaction, communication, and behavior. While Applied Behavior Analysis (ABA) stands as a common therapeutic approach, there is a growing recognition of the need for personalized interventions. Animal Assisted Therapy (AAT) emerges as a promising avenue for enhancing social interactions. This study focuses on the utilization of dogs in AAT for toddlers aged 12 to 36 months with confirmed ASD diagnoses. The experimental group will undergo a combined intervention involving standard ABA therapy alongside weekly AAT sessions, whereas the control group will receive standard ABA therapy alone. Pre- …


The Impact Of Nursing Education On The Implementation Of Kangaroo Care: Neurodevelopment Outcomes In Preterm Infants, Giana Usac Jan 2024

The Impact Of Nursing Education On The Implementation Of Kangaroo Care: Neurodevelopment Outcomes In Preterm Infants, Giana Usac

Nursing | Senior Theses

Preterm birth poses a significant risk to the normal trajectory of brain development, particularly in the cortex, which is responsible for higher cognitive functions, motor control, and socio-emotional processing. However, Kangaroo Mother Care (KMC) has emerged as an important early intervention capable of improving neurodevelopmental outcomes in preterm newborns. This quantitative research proposal aims to assess the influence of nurse education on KMC practices, identifying pivotal periods in infancy when KMC has the most significant impact on neurodevelopment outcomes in preterm infants. The literature critique focuses on the efficacy of nursing education, the optimization of KMC regarding duration and frequency, …


The Effects Of Adverse Childhood Experiences And Racism On The Risk For Poor Birth Outcomes In Women Of Color, Audrey Hermosura Jan 2024

The Effects Of Adverse Childhood Experiences And Racism On The Risk For Poor Birth Outcomes In Women Of Color, Audrey Hermosura

Nursing | Senior Theses

Background: Adverse childhood experiences, or ACEs, are traumatic challenges experienced before the age of 18. These adversities have lifelong effects on physiologic and mental health. A relationship has been made between the number of ACEs and occurrences of poor birth outcomes. The toxic stress that accumulates from ACEs compounded by racism increases the risk for poor birth outcomes in women of color. Understanding the importance of screening for these events can mitigate the negative effects on women’s health during and after gestation. Purpose: This current paper, in addition to a literature review, proposes a research design to validate the feasibility …


Does Intimate Partner Violence Affect A Child's Developing Brain, Betsy Calloway Jan 2024

Does Intimate Partner Violence Affect A Child's Developing Brain, Betsy Calloway

Graduate Research Projects

No abstract provided.


Ob-Pdcds Polish, Marianne E. Weiss, Malgorzata Nagorska Jan 2024

Ob-Pdcds Polish, Marianne E. Weiss, Malgorzata Nagorska

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Ped-Pdcds Norwegian, Marianne E. Weiss, Nina Ellefsen Lindberg Jan 2024

Ped-Pdcds Norwegian, Marianne E. Weiss, Nina Ellefsen Lindberg

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Pdcds-Adult Korean, Marianne E. Weiss, Kim Jeoung Hee Jan 2024

Pdcds-Adult Korean, Marianne E. Weiss, Kim Jeoung Hee

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Ped-Pdcds Norwegian, Marianne E. Weiss, Nina Ellefsen Lindberg Jan 2024

Ped-Pdcds Norwegian, Marianne E. Weiss, Nina Ellefsen Lindberg

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Doulas In Modern Health Care, Gabriella J. Lawrence Jan 2024

Doulas In Modern Health Care, Gabriella J. Lawrence

Soaring: A Journal of Undergraduate Research

This paper looks into whether the implementation of doulas by all hospitals would benefit mothers before, during, and after childbirth. Through previous research it is shown how traumatizing birth can be for mothers who don't feel that they have control within the labor and delivery room. High rates of augmentation, epidural anesthesia, and cesarean sections within hospitals are all causes of postpartum anxiety and depression among new mothers. By researching who a doula is and what they can do for mothers during childbirth, we can get a better understanding on how to prevent mental health disorders that are caused by …


Ped-Pdcds Turkish, Marianne E. Weiss, Ayfer Ekim Jan 2024

Ped-Pdcds Turkish, Marianne E. Weiss, Ayfer Ekim

Post-Discharge Coping Difficulty Scale (PDCDS)

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Adult Qdts, Spanish, Marianne E. Weiss Jan 2024

Adult Qdts, Spanish, Marianne E. Weiss

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Peds Qdts, Japanese, Marianne E. Weiss, K Sasaki, R Wakimizu, R Fukuzawa Jan 2024

Peds Qdts, Japanese, Marianne E. Weiss, K Sasaki, R Wakimizu, R Fukuzawa

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Pdcds - Adult Portugese (Brazil), Marianne E. Weiss, Clediane Trindade Jan 2024

Pdcds - Adult Portugese (Brazil), Marianne E. Weiss, Clediane Trindade

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Adult Qdts, Urdu, Marianne E. Weiss, Ambreen Gowani Jan 2024

Adult Qdts, Urdu, Marianne E. Weiss, Ambreen Gowani

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Ob Qdts, Chinese, Marianne E. Weiss, Lili Wei Jan 2024

Ob Qdts, Chinese, Marianne E. Weiss, Lili Wei

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Caregiver Qdts, Korean, Marianne E. Weiss, Heui-Kyeong Kwon Jan 2024

Caregiver Qdts, Korean, Marianne E. Weiss, Heui-Kyeong Kwon

Quality of Discharge Teaching Scale

The Readiness for Hospital Discharge Scale, Quality of Discharge Teaching Scale, and Post-Discharge Coping Difficulty Scale were developed by Dr. Marianne Weiss to measure nurse-sensitive discharge care processes and patient outcomes. Three versions of the scales were developed concurrently for different patient populations – Adult medical-surgical patients, Parents of hospitalized children, and Postpartum Patient mothers (see Weiss & Piacentine, 2006, Weiss et al., 2007, and Bobay et al., 2018 for description of the development and initial testing). Additional scales and information about translation rights are located at Marquette Nursing.

PERMISSION TO USE

The Readiness for Discharge Scale, Quality of Discharge …


Ironing Out The Details: Early Detection And Treatment Of Iron Deficiency In A Level 4 Nicu, Rachel Mills Jan 2024

Ironing Out The Details: Early Detection And Treatment Of Iron Deficiency In A Level 4 Nicu, Rachel Mills

2024

No abstract provided.


Guideline For Breastfeeding Difficulty, Collin Naugher Jan 2024

Guideline For Breastfeeding Difficulty, Collin Naugher

Doctor of Nursing Practice (DNP) Scholarly Projects - Archive

Background

The American Academy of Pediatrics recommends exclusive breastfeeding for all infants until six months of age. In the United States, the exclusive breastfeeding rate is 52%, with a goal of 73% by Healthy People 2030 at six weeks of age. Breastfeeding difficulty will occur 70% of the time in mother-baby dyads, requiring some intervention by the primary care provider during the breastfeeding course. This study aims to build a clinical practice guideline that can guide interventions to improve successful breastfeeding rates in a birthing center.

Methods

The literature search was performed and condensed to an evidence table where studies …


Increasing Awareness Of Implicit Bias And Systemic Racism Among Clinical Staff Caring For Non-Hispanic Black Maternal Patients, Melissa Courtney Jan 2024

Increasing Awareness Of Implicit Bias And Systemic Racism Among Clinical Staff Caring For Non-Hispanic Black Maternal Patients, Melissa Courtney

DNP Projects

Background: Kentucky is ranked 17th in the nation for the highest maternal mortality rate in the U.S. with a rate of 22.9 per 100,000, and 78 percent of those maternal deaths were considered preventable. The Non-Hispanic Black maternal death rate in the U.S. and Kentucky is 2.9 times higher than that of the Non-Hispanic White maternal counterparts (Kentucky Department of Public Health Division of Maternal and Child Health (KDPHDMCH), 2022). The fundamental cause of maternal health inequities is structural racism, which leads to poor treatment and experiences in the healthcare system (Chinn et al., 2020). Structural racism and implicit …


Implementation Of An Induction Of Labor Protocol, Rebecca A. Erickson Jan 2024

Implementation Of An Induction Of Labor Protocol, Rebecca A. Erickson

Doctor of Nursing Practice (DNP) Practice Innovation Projects

Background: Nationwide focus has been placed on the reduction of incidence of adverse maternal and neonatal outcomes in nulliparous, term, singleton, vertex (NTSV) patients.
Local Problem: Nursing leaders of a maternal child health unit in the upper Midwest recognized a need to reduce the rate of adverse maternal outcomes with evidence-based practice. The facility does not currently have an induction of labor (IOL) protocol.
Methods: The California Maternal Quality Care Collaboration Toolkit to Support Vaginal Birth and Reduce Primary Cesarean Sections was used to create an IOL protocol to prevent adverse maternal outcomes. Categorical outcome data was compared for 6 …


Implementation Of An Oral Sucrose Protocol For Advanced Practice Providers, Cori Shatto Jan 2024

Implementation Of An Oral Sucrose Protocol For Advanced Practice Providers, Cori Shatto

Doctor of Nursing Practice (DNP) Practice Innovation Projects

Background/Purpose: Pain in infancy due to immunization administration often goes untreated. The pain infants experience leads to negative effects on neurodevelopment and pain response. Needle fear develops in infancy and can extend into adulthood, leading to vaccine avoidance and endemic outbreaks. Methods: In a family practice clinic in an upper Midwest state, an oral sucrose protocol was implemented for use by advanced practice providers (APPs). Prior to education on the protocol, a survey was administered to assess the providers’ knowledge, attitudes, and practice (KAP) in relation to oral sucrose. The providers were educated on the benefits and intended use of …


Breastfeeding Support In Your Pocket: Evaluating The Impact Of A Mobile App On Maternal Success, Maygan Brandt Jan 2024

Breastfeeding Support In Your Pocket: Evaluating The Impact Of A Mobile App On Maternal Success, Maygan Brandt

Nursing | Senior Theses

Background: Breastfeeding has well-known benefits for both the nursing infant and the birthing parent. It bolsters the newborn immune system, and reduces the risk of future health conditions in both parties. Due to these advantages, several health organizations internationally recommend exclusive breastfeeding until 6 months of age. However, only a fraction of infants in the United States meet this goal each year. Improved rates and duration of exclusive breastfeeding will lead to better long-term health outcomes for patients. The use of smartphone applications for breastfeeding education and support has not been thoroughly researched. Objective: This thesis explores the feasibility of …


Post-Discharge Malaria Chemoprevention In Children Admitted With Severe Anaemia In Malaria-Endemic Settings In Africa: A Systematic Review And Individual Patient Data Meta-Analysis Of Randomised Controlled Trials, Kamija Phiri, Carole Khairallah, Titus Kwambai, Kalifa Bojang, Aggrey Dhabangi, Robert Opoka, Richard Idro, Kasia Stepniewska, Michael Boele Van Hensbroek, Chandy C John Jan 2024

Post-Discharge Malaria Chemoprevention In Children Admitted With Severe Anaemia In Malaria-Endemic Settings In Africa: A Systematic Review And Individual Patient Data Meta-Analysis Of Randomised Controlled Trials, Kamija Phiri, Carole Khairallah, Titus Kwambai, Kalifa Bojang, Aggrey Dhabangi, Robert Opoka, Richard Idro, Kasia Stepniewska, Michael Boele Van Hensbroek, Chandy C John

Paediatrics and Child Health, East Africa

Background: Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also have an increased risk of mortality or readmission after hospital discharge. We conducted a systematic review and individual patient data meta-analysis to determine the efficacy of monthly post-discharge malaria chemoprevention in children recovering from severe anaemia.

Methods: This analysis was conducted according to PRISMA-IPD guidelines. We searched multiple databases on Aug 28, 2023, without date or language restrictions, for randomised controlled trials comparing monthly post-discharge malaria chemoprevention with placebo or standard of care among children (agedyears) admitted with severe anaemia in malaria-endemic …


The Impact Of Spanish Classes For Labor And Delivery Nurses On Postpartum Depression Incidence Among Hispanic Women, Leilani Gutierrez Jan 2024

The Impact Of Spanish Classes For Labor And Delivery Nurses On Postpartum Depression Incidence Among Hispanic Women, Leilani Gutierrez

Nursing | Student Research Posters

Postpartum depression (PPD) is a form of clinical depression that affects individuals after childbirth and is characterized by feelings of sadness, anxiety, and other symptoms that impact daily functioning. After childbirth, postpartum depression and anxiety are experienced by 70-80% of new mothers (South Dakota Department of Health). The likelihood being twice as high for Hispanic women compared to caucasian women. Postpartum depression impacts 30-43% of Hispanic mothers who have recently given birth. Research indicates that poor childbirth experiences can lead to postpartum depression (Lara-Cinisomo et al,. 2023). The connection between language obstacles in the maternal care of Hispanic women and …


Doula Support For Hispanic Women, Marilyn Cervantes-Munoz, Daisy Arango-Hernandez Jan 2024

Doula Support For Hispanic Women, Marilyn Cervantes-Munoz, Daisy Arango-Hernandez

Nursing | Senior Theses

Purpose

This quantitative study will seek to provide valuable insight into the needs and preferences of Hispanic women during labor with the potential benefit of doula support in minimizing their pain.

Methods

A quasi-experimental design study will be conducted, randomizing a convenient sample into two groups consisting of one experimental and one control group, with the objective of evaluating the efficacy of doula presence as a source for pain management in Hispanic women. One hundred Hispanic women will be recruited under the following criteria: 18 years or older, a single fetus pregnancy, gestational age 37 weeks and above, and no …


Empowering Maternal Resilience: A Prenatal Education Program For Mothers And Their Chosen Support Persons For Postpartum Depression, Jennifer Medina Jan 2024

Empowering Maternal Resilience: A Prenatal Education Program For Mothers And Their Chosen Support Persons For Postpartum Depression, Jennifer Medina

Nursing | Senior Theses

Previous research studies have demonstrated the positive impact education and social support has on reducing the risk of postpartum depression (PPD) when used separately. However, there exists a clear gap in understanding the combined effects of integrating both education and social support during the prenatal period on PPD. This longitudinal quasi-experimental study aims to evaluate the impact of an in-person prenatal PPD prevention program for the birthing person, requiring the presence of a support person on the reduction of PPD. Participants and their chosen support persons will receive information on PPD, including risk factors, signs and symptoms, preventative measures, and …


Evaluating The Effectiveness Of Culture Based Nurse-Led Education For Postpartum Depression In Primiparous Asian-American Women, Colleen Peralta Jan 2024

Evaluating The Effectiveness Of Culture Based Nurse-Led Education For Postpartum Depression In Primiparous Asian-American Women, Colleen Peralta

Nursing | Senior Theses

The postpartum period is a critical period in regards to maternal health, marked by various physical, emotional, and psychological changes. Among the vulnerabilities that arise, postpartum depression (PPD) poses significant risks. More specifically, Asian-American mothers with postpartum depression face unique challenges, including the stigma surrounding mental health. As mental health stigma remains prevalent within the Asian-American community, it can make it challenging for mothers to seek out mental health care for postpartum depression. To investigate, primary research articles about the perceptions and experiences of PPD and the interventions used to improve PPD outcomes were examined. A plan for a future …


The Impact Of Spanish Language Training For Labor And Delivery Nurses On Postpartum Depression Incidence Among Hispanic Women, Leilani Gutierrez Jan 2024

The Impact Of Spanish Language Training For Labor And Delivery Nurses On Postpartum Depression Incidence Among Hispanic Women, Leilani Gutierrez

Nursing | Senior Theses

Postpartum depression and anxiety are experienced by 70-80% of new mothers, and the likelihood is twice as high for Hispanic women compared to caucasian women. Supportive techniques to help monolingual mothers in labor are lacking. A translator's assistance on the hospital floor, such as a video call from an iPad, is often impersonal and lacks the supportive atmosphere that women preparing to give birth need. The primary objective of this study is to explore the potential benefits of providing Spanish-speaking courses to labor and delivery nurses, particularly in cultivating a nurturing and supportive atmosphere for Hispanic mothers during childbirth. By …