Pregnancy-related Deaths Research Articles

Screening for Cardiovascular Disease in Pregnancy: Is There a Need?

Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.

THE EFFECT ON KNOWLEDGE AND ATTITUDE LEVELS OF FAMILY PLANNING EDUCATION GIVEN TO SYRIAN REFUGEE WOMEN

The use of family planning services prevents about one in three pregnancy-related deaths and 44% of neonatal deaths. The study was conducted with the aim of assessing the effectiveness of family planning education given to refugee women coming from Syria to Hatay province in Turkey. The research was planned as a quasi-experimental study with a non-randomized control group and a pre/post-test design. The experimental group were interviewed at the beginning, right after training and after one month. The control group were not given education. A personal information form, a Family Planning Information Form, and the Family Planning Attitude Scale were used to collect data. Data analysis was performed with the use of frequencies, percentages, means, minimum and maximum values, medians, standard deviations, the chi-square test, and the paired sample t test. After providing education to the Syrian refugee women, family planning knowledge and attitudes had significantly improved in the experimental group compared to the control group (p<0.05). The family planning education program, which was given while taking into account cultural considerations and native language, significantly developed the women’s knowledge and attitudes. It was recommended that family planning education programs should be included in all clinics focusing on women’s health.

Pregnant Women With Substance Use Disorders: The Harm Associated With Punitive Approaches

(N Engl J Med. 2021;384:2364–2367) In the United States, a plan has been issued to reduce maternal mortality. An estimated 8.2% of pregnancy-related deaths involve substance use disorders (SUDs), as reported in a 2017 study. Between 2006 and 2017, the proportion of pregnancies in women with SUDs rose from 3.6% to 7.4%.

Color lines: Disparities in pharmacy treatment, education, and practice

Color lines: Disparities in pharmacy treatment, education, and practice

Development of a clinical prediction model for perinatal deaths in low resource settings.

SummaryBackgroundMost pregnancy-related deaths in low and middle income countries occur around the time of birth and are avoidable with timely care. This study aimed to develop a prognostic model to identify women at risk of intrapartum-related perinatal deaths in low-resourced settings, by (1) external validation of an existing prediction model, and subsequently (2) development of a novel model.MethodsA prospective cohort study was conducted among pregnant women who presented consecutively for delivery at the maternity unit of Zanzibar's tertiary hospital, Mnazi Mmoja Hospital, the Republic of Tanzania between October 2017 and May 2018. Candidate predictors of perinatal deaths included maternal and foetal characteristics obtained from routine history and physical examination at the time of admission to the labour ward. The outcomes were intrapartum stillbirths and neonatal death before hospital discharge. An existing stillbirth prediction model with six predictors from Nigeria was applied to the Zanzibar cohort to assess its discrimination and calibration performance. Subsequently, a new prediction model was developed using multivariable logistic regression. Model performance was evaluated through internal validation and corrected for overfitting using bootstrapping methods.Findings5747 mother-baby pairs were analysed. The existing model showed poor discrimination performance (c-statistic 0·57). The new model included 15 clinical predictors and showed promising discriminative and calibration performance after internal validation (optimism adjusted c-statistic of 0·78, optimism adjusted calibration slope =0·94).InterpretationThe new model consisted of predictors easily obtained through history-taking and physical examination at the time of admission to the labour ward. It had good performance in predicting risk of perinatal death in women admitted in labour wards. Therefore, it has the potential to assist skilled birth attendance to triage women for appropriate management during labour. Before routine implementation, external validation and usefulness should be determined in future studies.FundingThe study received funding from Laerdal Foundation, Otto Kranendonk Fund and UMC Global Health Fellowship. TD acknowledges financial support from the Netherlands Organisation for Health Research and Development (grant 91617050).

Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group.

The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Reducing Implicit Bias in Maternity Care: A Framework for Action

Reducing Implicit Bias in Maternity Care: A Framework for Action

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia

Examination of maternal near-miss experiences in the hospital setting among Black women in the United States.

The high rate of maternal mortality among Black women in the United States continues to gain attention; yet research has not yet fully illuminated the precursors to these events, most impactful among them being "maternal near misses." A maternal near miss occurs when a woman nearly dies but survives a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Researchers have focused on reviewing patient medical records after sentinel maternal events to help determine major contributors to them; however, qualitative studies with near-miss survivors, especially among Black women, may be a more useful approach. Using a qualitative methodology, we conducted semi-structured interviews with 12 Black women to explore how they perceived the care provided to them during their near-miss experiences. Our study also employed a phenomenology framework to understand the lived experience of Black women who had a maternal near miss in the context of a hospital setting. We interviewed 12 women between October 2020 and March 2021. All participants had a maternal near miss between the years 2010 and 2020 and were aged between 19 and 41 years when they had their near-miss experience. These women identified communication, patient-provider relationship, skills/competency of staff, provider discrimination, systems issues, and emotional distress as major contributors to their experiences. Maternal near misses serve as a precursor to maternal mortality events. By listening to patients and their families recount their perspectives on what leads up to these near misses, we can unearth valuable lessons that can aid in the development of strategies and interventions to decrease the numbers of pregnancy-related deaths; especially among Black women who suffer disproportionately from maternal morbidity and mortality. Based on these findings, we recommend that hospitals and OB-GYN practices consider the unique predispositions of their Black patients; account for their own personal biases, revisit the near-miss experiences of past patients to keep patients central to care and build rapport between patients and hospital birthing support staff; and center discussions about improvements in care around racist structures and systems.

Can I Be Pregnant? – Diagnostic Challenges in Ruptured Chronic Ectopic Pregnancy

Ectopic pregnancy is an obstetric emergency which accounts for 4% of all pregnancy-related deaths. All women of child bearing age with abdominal pain or vaginal bleeding presenting to the Emergency Department should be evaluated for ectopic pregnancy. However, there have been many reported cases of diagnostic challenges of ectopic pregnancy. One rare variant of ectopic pregnancy that can be easily overlooked is chronic ectopic pregnancy. We present this case of a 39-yearold female, who presented with acute abdomen and free fluid in her abdomen. Urine pregnancy test indicated she was not pregnant. However, intraoperative findings confirmed left tubular pregnancy. We would like to highlight three major diagnostic challenges we faced in this case i.e.; (i) women of child bearing age with abdominal pain should always be evaluated for ectopic pregnancy; (ii) diagnosis of ectopic pregnancy should not be dismissed even though the pregnancy test is negative; and (iii) the role of computed tomography (CT) scan in acute abdomen of unclear aetiology. As a rule, all haemodynamically unstable acute abdomen should be sent to the operation theatre. Haemodynamically stable patients should be carefully evaluated to facilitate surgical management.

Case Report on Ectopic Pregnancy with Septicmia

Introduction: Ectopic pregnancy is a complication of pregnancy in which the embryo implants outside the uterus. Abdominal discomfort and vaginal bleeding are common signs and symptoms, but only around half of the women who are affected experience both. The discomfort can be severe, dull, or crampy. If there is bleeding into the abdomen, pain may radiate to the shoulder. A rapid heart rate, fainting, or shock may occur as a result of severe bleeding. The foetus, with a few exceptions, is unable to live. Obstetricians and gynaecologists face a number of obstacles when dealing with emergencies in Jehovah's Witnesses.
 Main symptoms and/or important clinical findings: She is a 20-year-old woman who had an emergency diagnostic laparotomy for a ruptured ectopic pregnancy with pyosalpinx and septicemia on February 14, 2021. Her diagnostic Ultrasonography has been completed. A complete blood investigation has been completed. She was moderately symptomatic before 8 days, when she was primigravida with 2 months of pregnancy, and then she got abdomen cramps that worsened with time.
 The main diagnoses, therapeutic interventions and outcomes: She is a 20-year-old woman who had a post-surgical case of Explore Laparotomy For Ruptured Ectopic Pregnancy with pyosalpinx and septicemia, as well as acute abdominal pain. Her treatment began on the day of admission with IV fluids, antibiotics and injectables. Started, advised for Zonac suppository PR, and finished all necessary research. 
 Nursing Perspectives: Laboratory techniques are urgently required. In order to limit the development of treatments to enhance the outcome.
 Conclusion: Although it is rare for an ectopic pregnancy to go past the first trimester, it does happen. Thus, it is necessary to rule out ruptured ectopic pregnancy in all cases of surgical abdominal urgency during pregnancy, as it is life-threatening to the mother if proper diagnosis and care are delayed. Despite the fact that early intervention saves lives and minimizes morbidity, ectopic pregnancy still accounts for 4 to 10% of all pregnancy-related deaths and is associated with a high rate of ectopic site gestations in subsequent pregnancies.

The opioid epidemic: how have buprenorphine waivered OB/GYNs impacted treatment availability in New York?

Opioid use disorder (OUD) is a known risk factor for pregnancy-related maternal deaths and greatly contributes to other obstetrical and neonatal complications. Physicians are urged to obtain a US Drug Enforcement Administration (DEA) waiver (x-waiver) to reduce use associated risks through prescribing buprenorphine. This study aims to observe the number and geographic distribution of x-waivered physicians in New York (NY), with a focus on OB/GYN providers.

The association between traumatic birth events and opioid relapse after delivery

Opioid overdose has emerged as the top cause of pregnancy-related death in some states, including Florida. Traumatic birth events (TBE) are associated with postpartum posttraumatic stress disorder (PTSD) and depression. We sought to examine the association between TBE and opioid relapse in the first year after delivery.

Testing of CVD risk assessment quality measures for pregnant and postpartum women

Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. The California Maternal Quality Care Collaborative (CMQCC) developed a CVD algorithm to guide stratification and initial work up of pregnant and postpartum women. We aimed to demonstrate the feasibility to calculate meaningful and actionable CVD risk assessment measures and evaluate their potential as National Quality Forum quality measures.

The Pregnancy-Related Mortality Impact of a Total Abortion Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant.

In this research note, I estimate one component of the mortality impact of denying all wanted induced abortions in the United States. This estimate quantifies the magnitude of an increase in pregnancy-related deaths that would occur solely because of the greater mortality risk of continuing a pregnancy rather than having a legal induced abortion. Using published statistics on pregnancy-related mortality ratios, births, and abortions, I estimate U.S. pregnancy-related deaths by race and ethnicity before and in the first and subsequent years of a hypothetical total abortion ban. The number of estimated deaths following a total abortion ban is determined by assuming three conditions: that all wanted induced abortions are denied, that each abortion denied leads to 0.8 births, and that there is a corresponding increase in exposure to pregnancy-related mortality. I find that in the first year of such a ban, estimated pregnancy-related deaths would increase from 675 to 724 (49 additional deaths, representing a 7% increase), and in subsequent years to 815 (140 additional deaths, for a 21% increase). Non-Hispanic Black people would experience the greatest increase in deaths (a 33% increase in subsequent years). Estimated pregnancy-related deaths would increase for all races and ethnicities examined. Overall, denying all wanted induced abortions in the United States would increase pregnancy-related mortality substantially, even if the rate of unsafe abortion did not increase.

Abortion Surveillance - United States, 2019.

Problem/ConditionCDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.Period Covered2019.Description of SystemEach year, CDC requests abortion data from the central health agencies for 50 states, the District of Columbia, and New York City. For 2019, 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2010–2019. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15–44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2018 were assessed as part of CDC’s Pregnancy Mortality Surveillance System (PMSS).ResultsA total of 629,898 abortions for 2019 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2010–2019, in 2019, a total of 625,346 abortions were reported, the abortion rate was 11.4 abortions per 1,000 women aged 15–44 years, and the abortion ratio was 195 abortions per 1,000 live births. From 2018 to 2019, the total number of abortions increased 2% (from 614,820 total abortions), the abortion rate increased 0.9% (from 11.3 abortions per 1,000 women aged 15–44 years), and the abortion ratio increased 3% (from 189 abortions per 1,000 live births). From 2010 to 2019, the total number of reported abortions, abortion rate, and abortion ratio decreased 18% (from 762,755), 21% (from 14.4 abortions per 1,000 women aged 15–44 years), and 13% (from 225 abortions per 1,000 live births), respectively.In 2019, women in their 20s accounted for more than half of abortions (56.9%). Women aged 20–24 and 25–29 years accounted for the highest percentages of abortions (27.6% and 29.3%, respectively) and had the highest abortion rates (19.0 and 18.6 abortions per 1,000 women aged 20–24 and 25–29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.7 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios in 2019 were highest among adolescents (aged ≤19 years) and lowest among women aged 25–39 years. Abortion rates decreased from 2010 to 2019 for all women, regardless of age. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2018 to 2019, abortion rates decreased or did not change among women aged ≤24 years; however, the abortion rate increased among those aged ≥25 years. Abortion ratios also decreased or did not change from 2010 to 2019 for all age groups, except adolescents aged <15 years. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2018 to 2019, abortion ratios increased for all age groups, except adolescents aged <15 years.In 2019, 79.3% of abortions were performed at ≤9 weeks’ gestation, and nearly all (92.7%) were performed at ≤13 weeks’ gestation. During 2010–2019, the percentage of abortions performed at >13 weeks’ gestation remained consistently low (≤9.0%). In 2019, the highest proportion of abortions were performed by surgical abortion at ≤13 weeks’ gestation (49.0%), followed by early medical abortion at ≤9 weeks’ gestation (42.3%), surgical abortion at >13 weeks’ gestation (7.2%), and medical abortion at >9 weeks’ gestation (1.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks’ gestation), 53.7% of abortions were early medical abortions. In 2018, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, two women died as a result of complications from legal induced abortion.InterpretationAmong the 48 areas that reported data continuously during 2010–2019, overall decreases were observed during 2010–2019 in the total number, rate, and ratio of reported abortions; however, from 2018 to 2019, 1%–3% increases were observed across all measures.Public Health ActionAbortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Non-inferiority of low-dose compared to standard high-dose calcium supplementation in pregnancy: study protocol for two randomized, parallel group, non-inferiority trials in India and Tanzania

BackgroundHypertensive disorders of pregnancy are important causes of maternal morbidity and mortality, as well as preterm birth, the leading cause of death for children under 5 years globally. The World Health Organization currently recommends that pregnant women receive high-dose calcium supplementation (1500–2000 mg elemental calcium) for prevention of preeclampsia in populations with low dietary calcium intake. Trials of low-dose calcium supplementation (< 1000 mg elemental calcium/day) during pregnancy have also shown similar reductions in the risk of preeclampsia; however, no trials to date have directly compared low-dose to the standard high-dose calcium supplementation. Our objective is to assess the non-inferiority of low-dose as compared to standard high-dose calcium supplementation in pregnancy.Methods/designWe will conduct two independent trials in Bangalore, India (n = 11,000 pregnancies), and Dar es Salaam, Tanzania (n = 11,000 pregnancies). The trial designs are individually randomized, parallel group, quadruple-blind, non-inferiority trials of low-dose calcium supplementation (500 mg elemental calcium/day) as compared to standard high-dose calcium supplementation (1500 mg elemental calcium/day) among nulliparous pregnant women. Pregnant women will be enrolled in the trial before 20 weeks of gestation and will receive the randomized calcium regimen from randomization until the time of delivery. The co-primary outcomes are (i) preeclampsia and (ii) preterm birth; we will test non-inferiority of the primary outcomes for low-dose as compared to the standard high-dose supplementation regimen in each trial. The trials’ secondary outcomes include gestational hypertension, severe features of preeclampsia, pregnancy-related death, third trimester severe anemia, fetal death, stillbirth, low birthweight, small-for-gestational age birth, and infant death.DiscussionThe trials will provide causal evidence on the non-inferiority of low-dose as compared to the standard high-dose supplementation in India and Tanzania. A single tablet, low-dose calcium supplementation regimen may improve individual-level adherence, reduce programmatic costs, and ultimately expand implementation of routine calcium supplementation in pregnancy in populations with low dietary calcium intake.Trial registrationClinicalTrials.gov identifier: NCT03350516; registered on 22 November 2018. Clinical Trials Registry—India identifier: CTRI/2018/02/012119; registered on 23 February 2018.Tanzania Medicines and Medical Devices Authority Trials Registry identifier: TFDA0018/CTR/0010/5; registered on 20 December 2018.

A content analysis of newspaper coverage of maternal mortality from 2010-2019

ABSTRACT Pregnancy-related death, the death of a woman during or within one year after pregnancy, is between three and four times more likely to occur in Black women than White women. To better understand communication about this public health crisis, we examined features of news coverage on maternal mortality in 155 newspaper articles. Very few articles included a clear definition of the problem, and only about a third mentioned that these deaths are largely preventable. Additionally, 61% referenced the racial disparity, but within those, most did not discuss substantive causes of inequities. In terms of message features, about one third of articles used a patient narrative, with less than 10% referencing a celebrity’s patient experience. Very few (5%) articles included information about the history of mistreatment of Black patients in American health care. Together, the findings suggest current newspaper coverage does not effectively address social determinants of maternal health outcomes.

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020.

BackgroundMaternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions.MethodsWe conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease – 10th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words “maternal mortality”, “maternal death”, “pregnancy-related death”, “reproductive age mortality” and “causes” as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates.ResultsWe identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes.ConclusionsLimitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008-17.

Each year approximately 700 people die in the United States from pregnancy-related complications. We describe the characteristics of pregnancy-related deaths due to mental health conditions, including substance use disorders, and identify opportunities for prevention based on recommendations from fourteen state Maternal Mortality Review Committees (MMRCs) from the period 2008-17. Among 421 pregnancy-related deaths with an MMRC-determined underlying cause of death, 11percent were due to mental health conditions. Pregnancy-related mental health deaths were more likely than deaths from other causes to be determined by an MMRC to be preventable (100percent versus 64percent), to occur among non-Hispanic White people (86percent versus 45percent), and to occur 43-365 days postpartum (63percent versus 18percent). Sixty-three percent of pregnancy-related mental health deaths were by suicide. Nearly three-quarters of people with a pregnancy-related mental health cause of death had a history of depression, and more than two-thirds had past or current substance use. MMRC recommendations can be used to prioritize interventions and can inform strategies to enable screening, care coordination, and continuation of care throughout pregnancy and the year postpartum.