Maternal and Child Health Commons^™

The Psychosocial Impact Of Covid-19 Mitigation Measures On Frontline Staff Providing Sexual Health And Family Planning Services In Kenya: A Mixed-Methods Study, Ferdinand Okwaro, Abdu Mohiddin, Marleen Temmerman

Centre of Excellence in Women and Child Health

Background The recognition of the unintended impact of COVID-19 mitigation measures to the availability of sexual and reproductive health (SRH) services led to the initiation of mitigation and health systems support mechanisms within public health facilities by the Ministry of Health (MoH) in Kenya to maintain pre-Covid-19 levels of SRH service provision. These recovery mechanisms however concentrated on policy and infrastructural elements of service provision with limited attention given to the psychosocial impacts of COVID-19 on health care workers (HCWs). This paper examines the psychosocial impact of COVID-19 on front line family planning (FP) and sexually transmitted infections (STI) management …

Improved Obstetric Hemorrhage Care Through Toolkit Revision: A Quality Improvement Project, Samantha Kalkstein, Amber Woodring

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

Obstetric hemorrhage (OBH) remains a leading cause of preventable maternal morbidity and mortality in the United States. Accurate risk identification is critical for initiating timely interventions; however, current risk assessment practices vary significantly. This quality improvement (QI) project aimed to implement the California Maternal Quality Care Collaborative (CMQCC) OBH Risk Assessment Tool on the labor and delivery (L&D) unit of a community-based hospital to standardize risk stratification and improve interdisciplinary communication. Guided by the Johns Hopkins Nursing Evidence-Based Practice model, the project involved a gap analysis, staff education, and the introduction of a paper-based CMQCC tool formatted for visibility and …

A Qualitative Analysis Of The Lived Experience Of Active-Duty Servicewomen Receiving Perinatal Care Within The Military Health System., Caitlin Russell, Emily Balog, Anne Teitelman, Rosemary Polomano

Rowan-Virtua School of Osteopathic Medicine Departmental Research

OBJECTIVES: We explored the lived experiences of active-duty servicewomen (ADSW) accessing and receiving care during the perinatal period (from discovery of pregnancy to 1 year postpartum) within the Military Health System.

STUDY DESIGN: Using qualitative methods, we conducted semi-structured interviews between September 2022 and February 2023 with 23 ADSW participants who were pregnant or within their first year postpartum. Data were analyzed using inductive coding and thematic analysis techniques.

RESULTS: Participants reported bureaucratic hurdles and long wait times for accessing care, too little choice in providers, and inadequate coordination between civilian and military care providers. Those who experienced perinatal complications …

Holistic Approach To Managing Grade 3 Vaginismus: An Obg Physiotherapy Perspective, Nagma Khan

Internet Journal of Allied Health Sciences and Practice

Background: Vaginismus is a condition characterized by involuntary pelvic floor muscle contractions, which can make vaginal penetration painful or impossible. This disorder has both physical and psychological components, often leading to significant emotional distress, anxiety, and relationship difficulties. Effective management requires a holistic, multidisciplinary approach, combining physical therapy with psychological support. This case report examines the treatment of a 29-year-old woman with grade 3 vaginismus, highlighting the role of Obstetrics & Gynaecology (OBG) physiotherapy in improving both physical symptoms and emotional well-being.

Case Presentation: A 29-year-old female presented with grade 3 vaginismus, with a history of severe pelvic floor tension …

The Real Story Of “The Happy Mother”: A Narrative Inquiry Exploring The Construction Of Motherhood And Postpartum Depression, Elizabeth Erin Falconer

Seton Hall University Dissertations and Theses (ETDs)

The transition to motherhood is a complex and challenging period, during which mothers undergo a considerable number of biological, hormonal, and identity changes. The first six to eight weeks following childbirth is a time of great susceptibility to postpartum depression for mothers. Despite its prevalence, there is a lack of research beyond the biological understanding of the experience. Prior literature has examined the biological aspects of postpartum depression and its societal influences on motherhood. However, no prior study has explored how postpartum depression impacts mothers’ construction and understanding of motherhood through investigating their subjective, lived experiences. This study fills that …

Europe–Africa Collaboration: Working Together To Strengthen Health Research, Implementation, And Equitable Systems, Lara Pandya, Irene Norstedt, Martin Seychell, Emer Cooke, Isabel Barranco, Niklas Blomberg, Marleen Temmerman, Michael Makanga

Centre of Excellence in Women and Child Health

No abstract provided.

Analyzing High-Risk Fertility Behavior For Sustainable Maternal-Child Health: A 2017 Sociodemographic Study In Urban And Rural Indonesia, Asti Annisa Utami, Fadhaa Aditya Kautsar Murti, Popy Yuniar, Milla Herdayati

Kesmas

Indonesia's goal of achieving Indonesia Emas 2045 hinges on improving Maternal-Child Health (MCH), essential for building a healthy and competitive population. Despite some advancements, the Maternal Mortality Rate (MMR) and Under-five Mortality Rate (U5MR) remain high, particularly because of High-Risk Fertility Behavior (HRFB). The HRFB poses significant risks to MCH, affecting both urban and rural women. This study aimed to identify the factors associated with HRFB in these areas to enhance MCH outcomes and support Indonesia's sustainable health goals. This cross-sectional study used a secondary dataset from the 2017 Indonesian Demographic Health Survey. A total of 20,530 women of reproductive …

Exploring Covid-19 Vaccination Behavior: A Cross-Country Study Among Pregnant And Postpartum Women In Brazil, Ghana, Kenya, And Pakistan, Rupali Limaye, Berrhaun Fesshaye, Emily Miller, Prachi Singh, Saleem Jessani, Muhammad Asim, Ferdinand Okwaro, Sarah Saleem, Marleen Temmerman, Muhammad Asim

Centre of Excellence in Women and Child Health

Pregnant women infected with SARS-CoV2 are more likely to be hospitalized and require ventilation, compared to non-pregnant women. Although the development of the COVID-19 vaccine was regarded as a scientific breakthrough among many, the pace of development in combination with delayed and unclear recommendations for maternal vaccination led to slower vaccine uptake among this population. We explored the decision-making process for COVID-19 vaccination among pregnant and postpartum women in four countries: Brazil, Ghana, Kenya, and Pakistan through 201 in-depth interviews. A grounded theory approach was used for analysis, and a socio-ecological framework was used to synthesize emerging themes. Four levels …

Exploring Covid-19 Vaccination Behavior: A Cross-Country Study Among Pregnant And Postpartum Women In Brazil, Ghana, Kenya, And Pakistan, Rupali Limaye, Berhaun Fesshaye, Emilly Miller, Prachi Singh, Saleem Jessani, Muhammad Asim, Ferdinand Okwaro, Caroline Badzi, Emefa Amoah, Marleen Temmerman

Centre of Excellence in Women and Child Health

Pregnant women infected with SARS-CoV2 are more likely to be hospitalized and require ventilation, compared to non-pregnant women. Although the development of the COVID-19 vaccine was regarded as a scientific breakthrough among many, the pace of development in combination with delayed and unclear recommendations for maternal vaccination led to slower vaccine uptake among this population. We explored the decision-making process for COVID-19 vaccination among pregnant and postpartum women in four countries: Brazil, Ghana, Kenya, and Pakistan through 201 in-depth interviews. A grounded theory approach was used for analysis, and a socio-ecological framework was used to synthesize emerging themes. Four levels …

Contribution Of Maternal Adherence To The Effect Of Multiple Micronutrient Supplementation During Pregnancy: A Systematic Review And Individual Participant Data Meta-Analysis, Emily R. Smith, Filomena Gomes, Seth Adu-Afarwuah, Victor M. Aguayo, Shams El Arifeen, Zulfiqar Ahmed Bhutta, Ellen C. Caniglia, Parul Christian, Arjumand Rizvi, Sajid Bashir Soofi

Centre of Excellence in Women and Child Health

Multiple micronutrient supplements (MMS) in pregnancy reduces risk of infant low birthweight (LBW) and improves other maternal and infant outcomes compared with iron and folic acid (IFA) supplements alone. However, the impact of timing of initiation and adherence on the MMS effectiveness in real-world programs remains unclear. To address this, we conducted a 2-stage individual participant data meta-analysis that included 15 randomized trials (61,204 pregnant women) and assessed whether the relative effect of MMS differed by the following: adherence alone; adherence in combination with gestational age at initiation; and the total number of tablets taken. We also evaluated the observational …

Covid-19 Vaccine Attitudes And Behaviors Among Pregnant Women In Nairobi, Kenya With Diverse Socio-Economic And Educational Backgrounds, Jessica Schue, Ferdinand Okwaro, Ingrid Gichere, Daizy Cherono, Mandeep Sura, Emilly Miller, Berhaun Fesshaye, Prachi Singh, Marleen Temmerman

Centre of Excellence in Women and Child Health

Introduction: Pregnant women are at increased risk of severe manifestations of COVID-19, resulting in ICU admission, mechanical ventilation, and death compared to non-pregnant women. COVID-19 vaccines were approved for use in pregnant women in early 2022 by the World Health Organization, but permissive policies toward vaccine women differed by country. As education has been associated with vaccine uptake, this study sought to examine the association between socio-economic or educational status and vaccination behaviors, including reasons for vaccination or non-vaccination among pregnant women seeking health care services in Nairobi, Kenya.

Methods: This study administered a survey to pregnant women at the …

Covid-19 Vaccine Attitudes And Behaviors Among Pregnant Women In Nairobi, Kenya With Diverse Socio-Economic And Educational Backgrounds, Jessica Schue, Ferdinand Okwaro, Ingrid Gichere, Daizy Cherono, Mandeep Sura, Emily Miller, Berhaun Fesshaye, Prachi Singh, Grace Belayneh Belayneh, Rupali Limaye, Marleen Temmerman

Centre of Excellence in Women and Child Health

Introduction

Methods

Placental Transfer Of Sars-Cov-2 Antibodies In Mother-Neonate Pairs: A Prospective Nested Cohort Study, Alex Mugo, Angela Koech, Liberty Cantrell, Moses Mukhanya, Isaac Mwaniki, Joseph Mutunga, Merryn Voysey, Rachel Craik, Marleen Temmerman, Geoffrey Omuse

Centre of Excellence in Women and Child Health

Background: Newborns depend on the transfer of IgG across the placenta to acquire protection against pathogens. We assessed the placental transfer of SARS-CoV-2 antibodies, primarily derived from infection, from seropositive pregnant women enrolled in a pregnancy cohort in Kilifi, Kenya.

Methods :The study was nested within a prospective observational multi-country cohort study. All available paired maternal delivery and cord blood samples were selected. Maternal sera were tested for SARS-CoV-2 receptor binding domain (RBD) IgM/IgG total antibodies using the Wantai assay. For positive samples, maternal and corresponding cord blood samples were tested for SARS-CoV-2 IgG antibodies against the spike (anti-spike) and …

Placental Transfer Of Sars-Cov-2 Antibodies In Mother-Neonate Pairs: A Prospective Nested Cohort Study, Alex Mugo, Angela Koech, Liberty Cantrell, Moses Mukhanya, Isaac Mwaniki, Joseph Mutunga, Merryn Voysey, Rachel Craik, Peter Dadelszen, Marleen Temmerman, Geoffrey Omuse

Centre of Excellence in Women and Child Health

Background

Newborns depend on the transfer of IgG across the placenta to acquire protection against pathogens. We assessed the placental transfer of SARS-CoV-2 antibodies, primarily derived from infection, from seropositive pregnant women enrolled in a pregnancy cohort in Kilifi, Kenya.

Methods

The study was nested within a prospective observational multi-country cohort study. All available paired maternal delivery and cord blood samples were selected. Maternal sera were tested for SARS-CoV-2 receptor binding domain (RBD) IgM/IgG total antibodies using the Wantai assay. For positive samples, maternal and corresponding cord blood samples were tested for SARS-CoV-2 IgG antibodies against the spike (anti-spike) and …

Jaminan Kesehatan Nasional Pada Ibu Bersalin: Sebuah Studi Cross Sectional Di Nusa Tenggara Timur, Indonesia, Amanda Firdausya Bahaji, Faris Muhammad, Putri Ayu, Rizani Alia Davina, Vetty Yulianty

Jurnal Ekonomi Kesehatan Indonesia

Maternal Mortality Rate (MMR) in Indonesia remains high, particularly in East Nusa Tenggara (NTT). This study analyzes the relationship between National Health Insurance (JKN) ownership and mothers choosing childbirth facilities in NTT. This study employs a cross-sectional design with a quantitative approach, utilizing secondary data from the 2017 Indonesian Demographic and Health Survey (IDHS), which was conducted from October to November 2024. The study population includes mothers who gave birth in NTT during the 2017 IDHS period, with a sample of 1,236 respondents selected using a stratified two-stage cluster sampling technique. Data analysis was performed using the chi-square test to …

Risk And Protective Factors Associated With Teenage Pregnancy And Intergenerational Interventions: A Scoping Review Protocol, Zamasomi Luvuno, Wilbroda Hlolosile Chiya, Silingene Joyce Ngcobo, Deshini Naidoo, Serwaa Omowale, Tracy Zhandire, Elizabeth Musili Joseph-Shehu, Busisiwe Purity Ncama, Sinegugu E Duma

Faculty, Staff and Student Publications

Introduction: Teenage pregnancy remains a critical global health issue, particularly in low- and middle-income countries. The intergenerational transmission of teenage pregnancy underscores the need for targeted interventions. Existing research on intergenerational approaches is fragmented, with varying methodologies and outcomes. This scoping review seeks to address this gap by answering the following research questions: What are the available intergenerational interventions for teenage pregnancy, and what are the associated risks and protective factors for early and late teenage pregnancy?

Methods and analysis: This study does not involve primary data collection and therefore does not require ethical approval. The review will be conducted …

Geographic Inequalities, And Social-Demographic Determinants Of Reproductive, Maternal And Child Health At Sub-National Levels In Kenya, Janette Karimi, Anitah Cherono, Victor Alegana, Martin Mutua, Hellen Kiarie, Rose Muthee, Marleen Temmerman, Peter Gichangi

Centre of Excellence in Women and Child Health

Background; Global initiatives have emphasized tracking indicators to monitor progress, particularly in countries with the highest maternal and child mortality. Routine data can be used to monitor indicators for improved target setting at national and subnational levels. Our objective was to assess the geographic inequalities in estimates of reproductive, maternal and child health indicators from routine data at the subnational level in Kenya.

Methods; Monthly data from 47 counties clustered in 8 regions, from January 2018 to December 2021 were assembled from the District Health Information Software version 2 (DHIS2) in Kenya. This included women of reproductive age receiving family …

Born Too Soon: Every Story Counts: Lessons In Ethical, Inclusive Storytelling From Born Too Soon, Mary V. Kinney, Amy Reid, Mercy Juma, Anna Gruending, Olufunke Bolaji, Doris Mollel, Denise Suguitani, Silke Mader, Karen Walker, Marleen Temmerman, Joy Lawn

Centre of Excellence in Women and Child Health

Storytelling is increasingly recognized as a powerful tool in public health communication, particularly for addressing complex and stigmatized health issues. In the context of pregnancy and childbirth, personal narratives have proven effective in shaping perceptions, empowering women, complementing health education, and driving policy and legal reforms. Preterm birth remains a significant global challenge, and lived experiences of affected families offer critical insights that illuminate systemic gaps and advocate for the rights of babies, mothers, families, and healthcare workers. The Born Too Soon 2023 campaign placed people—especially women, families, communities, and healthcare workers—at the core of its advocacy efforts. This commentary …

Supporting The Mental Health Of Adolescent Mothers In Kenya And Mozambique: Pilot Protocol For The Thriving Mamas Programme, Tatiana Taylor Salisbury, Maria Suzana Bata Maguele, Fernando Chissale, Málica De Melo, Margrette Hanselmann, Kethakie Lamahewa, Evaline Chepchirchir Langat, Flávio Mandlate, Lucy Nyaga, Marleen Temmerman

Centre of Excellence in Women and Child Health

Background: Poor mental health among adolescent girls during pregnancy and the year after birth (the perinatal period) has been found to have a significant detrimental effect on girls and their children. The Innovative approaches to adolescent perinatal wellbeing (INSPIRE) project co-designed an intervention (Thriving Mamas) to improve adolescent perinatal mental health in Kenya and Mozambique. The aim of the current study is to pilot test the co-designed intervention to understand how it can be adapted for further testing or scale-up.

Methods :A mixed-method, pilot cluster-randomised, efectiveness-implementation Hybrid Type II trial will be conducted among 80 adolescent girls (aged 15–19 years) …

Epidemiology Of Shigella Species And Serotypes In Children: A Retrospective Substudy Of The Mal-Ed Observational Birth Cohort Study, Elizabeth T. Rogawski Mcquade, Jie Liu, Mustafa Mahfuz, Alexandre Havt, Furqan Kabir, Adil Kalam, Fatima Aziz, Sahrish Muneer, Najeeha Talat Iqbal, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Shigellosis is a leading cause of diarrhoea in children globally. We aimed to assess the burden of specific Shigella species and Shigella flexneri serotypes, characterise their clinical syndromes and natural immunity, and evaluate their relevance as causes of diarrhoea and linear growth faltering.
Methods: In the MAL-ED birth cohort study, children younger than 17 days were enrolled from Nov 3, 2009, to Feb 29, 2012, in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, Tanzania, and South Africa and were followed up for 2 years. In this retrospective substudy, we retested Shigella quantitative PCR-positive diarrhoeal and non-diarrhoeal stool samples with molecular …

Intersectoral Interventions: Integration For Impact On Preterm Birth, Etienne V. Langlois, Maria El Bizri, Kelly Thompson, Amy Reid, Merette Khalil, Giulia Gasparri, Joy E. Lawn, Teesta Dey, Judith Robb-Mccord, Marleen Temmerman

Centre of Excellence in Women and Child Health

Progress: The last two decades have seen a growing focus on intersectoral interventions to improve maternal and newborn health and well-being outcomes, as refected in eforts to achieve the Millennium Development Goals (MDGs) and advance the Sustainable Development Goals (SDGs). Preterm births are linked to cross-sectoral determi‑ nants that afect health outcomes and human capital across the life-course, necessitating an intersectoral approach that addresses these multifaceted challenges.

Programmatic priorities: Recognizing that social, biological and economic determinants signifcantly infuence health outcomes, it is critical that robust health systems are reinforced by a comprehensive intersectoral approach. Evidence suggests that the factors infuencing …

The Impact Of Implementing The Women's Reproductive Rights Agenda On Climate Change, Marleen Temmerman, Emilie Peeters, Celine Delacroix, Malachi Arunda, Sara Khalid, Claudia Hanson, Samuel Ojong

Centre of Excellence in Women and Child Health

The 1994 International Conference on Population and Development (ICPD) established sexual and reproductive health and rights (SRHR) as foundational to sustainable development. Thirty years later, advancing women's reproductive rights (WRR), encompassing agency, decision-making autonomy, and universal access to family planning—remains critical not only for health and gender equity but also for mitigating environmental degradation. By reducing unintended pregnancies and empowering women to align childbearing with personal and ecological capacity, WRR alleviates ecological stressors such as deforestation while enhancing health resilience in climate-vulnerable communities. Yet, despite well-documented linkages between population dynamics and environmental change, contemporary climate policies and funding mechanisms persistently …

Reproductive Health In America: A System Ran By Sexism And Male Control, Hailey Mccool

Merge

No abstract provided.

A Comparative, Quantitative Analysis Of Birth Outcomes Among Women With Intellectual Or Developmental Disabilities, Jocelyn T. Reddix

MUSC Theses and Dissertations

Women who are pregnant or planning to give birth deserve equitable resources, respect, and assurances to ensure a healthy and safe pregnancy, including women of childbearing age who are diagnosed with intellectual or developmental disabilities (IDD). These women are more likely to experience negative perinatal, delivery, and postpartum health outcomes (Tarasoff et al., 2020). Healthcare providers, clinicians, and the family and friends of those with IDD must understand the impact and implications of the prenatal and postpartum journey for this group of women. This comparative research examined 2021 birth outcomes of women in the United States with IDD compared to …

Development Of A Light-Based Platform To Assess Cervical Mucus Barrier Function And Physical Mucus Properties, Elizabeth J. Buzbee

McKelvey School of Engineering Graduate Student Theses & Dissertations

Preterm birth is the leading cause of neonatal morbidity and mortality worldwide, yet current clinical tools for predicting its risk lack specificity and reliability. Cervical mucus plays a crucial role in maintaining pregnancy by forming a barrier that protects the uterus against infection. This study investigates the use of laser speckle rheology as a noninvasive technique to assess cervical mucus biomechanics. Synthetic cervical mucus was fabricated at varying hydration levels and tested using a conventional rheometer that confirmed that the mechanical properties of the synthetic mucus samples were representative of physiological cervical mucus. These results were compared to the complex …

A Comprehensive Literature Review Of Barriers To Hormone Therapy Utilization: Strategies For Improving Menopause Management In Women Aged 40-60, Suhan Lee

Capstone Experience: Master of Public Health

Menopause is a natural transition marked by the cessation of ovarian activity, often accompanied by vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM), and psychological changes that significantly impact women’s quality of life. Hormone therapy (HT) has been the primary treatment for managing menopausal symptoms, particularly VMS, providing substantial relief when initiated within 10 years of menopause. Despite its effectiveness, HT usage has declined dramatically over the past two decades primarily due to barriers such as stigma, safety, misinformation, provider hesitancy, financial barriers, and cultural beliefs. This comprehensive literature review explores key factors influencing HT decision-making, including the media’s role …

Breaking Barriers To Smoking Cessation: Applying The Baby & Me - Tobacco Free Program To Improve Maternal And Child Health In Omaha, Nebraska, Madison Ravens

Capstone Experience: Master of Public Health

Smoking during pregnancy remains a pressing public health concern, contributing to adverse outcomes such as preterm birth, low birth weight, and developmental complications. In Nebraska, about 10% of pregnant women continue to smoke throughout pregnancy—above the national average, highlighting a critical gap in maternal health interventions. The Baby & Me – Tobacco Free (BMTF) program provides an evidence-based solution through structured counseling, carbon monoxide (CO) monitoring, and incentive-based rewards to support smoking cessation among pregnant women. This capstone project utilized the Getting to Outcomes framework to develop a detailed implementation plan to support Tobacco Free Nebraska (TFN) in launching the …

The State Of Abortion Training In Medical School And Family Medicine Residency Curricula: A Scoping Literature Review, Eric James Reece

Capstone Experience: Master of Public Health

This project aims to assess how abortion education has been integrated into medical training over the past decade, with a particular focus on understanding its current state in medical schools and family medicine residencies, including those offering specialized programs affiliated with RHEDI (Reproductive Health Education in Family Medicine) and TEACH (Training in Early Abortion for Comprehensive Healthcare). Given the ever-evolving legal landscape following the June 4^th, 2022 Supreme Court case of Dobbs v. Jackson Women’s Health Organization, this review explores how both federal- and state-level legal restrictions impact access to abortion training and attempts to identify gaps …

Literature Review: Prazosin Used For Ptsd In Pregnancy, Afshan Khan, Natali Sharma, Rebekah M. Dietrich, Martin Forsberg

Rowan-Virtua Research Day

Posttraumatic Stress Disorder (PTSD) affects 3–4% of pregnant and postpartum individuals and is associated with complications such as preterm birth, low birth weight, and postpartum depression. Pharmacologic treatment options during pregnancy are limited by concerns about fetal safety.

Methods: A literature review was conducted focusing on studies reporting maternal or neonatal outcomes following prazosin exposure in pregnancy.

Results: One observational study of 11 pregnancies found 54.5% had uneventful outcomes, with rates of preterm birth, miscarriage, and preeclampsia similar to the general population. Hypotension and limited lactation data remain concerns.

Conclusion: Early evidence suggests prazosin may be a relatively safe and …

Pain Management In Pregnant Women With Opioid Use Disorder: A Systematic Review, Adeena Javed

Rowan-Virtua Research Day

Background: The prevalence of opioid use disorder (OUD) among pregnant individuals has risen significantly, posing challenges in managing labor and postpartum pain. Factors such as opioid tolerance, opioid-induced hyperalgesia, and concerns about relapse complicate analgesic strategies. Despite these complexities, evidence-based guidelines for pain management in this population remain limited.

Hypothesis: Pregnant women with OUD experience disparities in pain management during labor and postpartum periods, leading to suboptimal outcomes.

Methods: A systematic review was conducted, analyzing peer-reviewed studies from databases including PubMed and Embase. Inclusion criteria encompassed studies focusing on pain management in pregnant women with OUD. Data extraction focused on …