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11 pages, 270 KiB

Open AccessArticle

Knowledge, Propensity and Hesitancy among Pregnant Women in the Post-Pandemic Phase Regarding COVID-19 Vaccination: A Prevalence Survey in Southern Italy

by Cristina Genovese, Carmela Alessia Biondo, Caterina Rizzo, Rosaria Cortese, Isabella La Spina, Paola Tripodi, Bruno Romeo, Vincenza La Fauci, Giuseppe Trimarchi, Vanessa Lo Prete and Raffaele Squeri

Women 2023, 3(3), 374-384; https://doi.org/10.3390/women3030028 - 11 Jul 2023

Viewed by 1398

Abstract

The vaccination of pregnant women against influenza and COVID-19 may reduce the risk of severe illness in both the women of this population and their babies. Although the risks of non-vaccination are more serious than the side effects, maternal immunization is still the [...] Read more.

The vaccination of pregnant women against influenza and COVID-19 may reduce the risk of severe illness in both the women of this population and their babies. Although the risks of non-vaccination are more serious than the side effects, maternal immunization is still the least-used method of prevention due to a lack of information leading to concerns about the safety and efficacy of vaccines, resulting in a low prevalence rate among pregnant individuals. Our study investigates vaccination coverage and the knowledge, attitudes and perceptions of COVID-19 in pregnant women at a university hospital. A questionnaire was created with the following three scores: a vaccination propensity score, a knowledge score and a hesitancy score. The first observation in the results was the very low number of immunized women (only 4.7% received their first dose). The main barrier towards vaccination was found to be fear of adverse events. We noticed a low percentage of influenza and diphtheria tetanus pertussis vaccination compared to other studies. Vaccination propensity was higher when healthcare workers educated their patients. As immunization is a crucial part of public health policy, measuring coverage to identify gaps and monitor trends, especially for individuals considered at high risk, and developing new strategies in order to increase awareness of vaccination during pregnancy is particularly timely and relevant. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

13 pages, 1135 KiB

Open AccessArticle

Clinical Equipment as a Potential Impediment to Optimal Intrapartum Monitoring and Delivery for Pregnant Women in South Africa

by Kgaladi Mpule Mohlala, Livhuwani Muthelo, Mpho Gift Mathebula, Masenyani Oupa Mbombi, Tshepo Albert Ntho and Thabo Arthur Phukubye

Women 2023, 3(2), 335-347; https://doi.org/10.3390/women3020025 - 15 Jun 2023

Viewed by 1136

Abstract

Clinical equipment is essential in a labour unit to assess, monitor, diagnose, and prevent complications during labour. The availability of good working equipment in the labour unit is needed to enhance optimal intrapartum monitoring and delivery for pregnant women. Thus, this paper employed [...] Read more.

Clinical equipment is essential in a labour unit to assess, monitor, diagnose, and prevent complications during labour. The availability of good working equipment in the labour unit is needed to enhance optimal intrapartum monitoring and delivery for pregnant women. Thus, this paper employed a cross-sectional descriptive design using a quantitative research approach to ascertain how equipment impedes optimal intrapartum monitoring and delivery for pregnant women. A total of 59 midwives were recruited to participate in the study. Data collected using an electronic structured questionnaire were analysed with descriptive statistics using Statistical Package for Social Sciences (SPSS) version 25.0. The study reported that most midwives (68%) in labour units experienced barriers to using equipment when administering care to pregnant women. The barriers were perpetuated by various factors, such as bed capacity, in meeting patient demands, including examination lights, overhead radiant warmers, and examination weighing scales for newborns. Incorporating mandatory computerized maintenance management software is recommended to improve the quality of maternity equipment. In addition, there is a need for regular equipment inspections and maintenance by skilled technicians in selected hospitals of Limpopo Province, South Africa. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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15 pages, 610 KiB

Open AccessArticle

Prenatal, Delivery and Postpartum Care Experiences among Black Women in Mississippi during COVID-19 Pandemic 2020–2021

by Praise Ebimaye Tangbe, Mary Shaw-Ridley, Gerri Cannon-Smith, Sheila McKinney, Nelson Atehortua and Russell Bennett

Women 2023, 3(2), 295-309; https://doi.org/10.3390/women3020022 - 24 May 2023

Viewed by 2098

Abstract

The COVID-19 pandemic has presented challenges for countries to maintain high-quality, essential maternal health services, altering pregnancy experiences for women. This qualitative study aims to explore the impact of COVID-19 mitigation strategies on self-reported prenatal, delivery, and postpartum care experiences among Black women [...] Read more.

The COVID-19 pandemic has presented challenges for countries to maintain high-quality, essential maternal health services, altering pregnancy experiences for women. This qualitative study aims to explore the impact of COVID-19 mitigation strategies on self-reported prenatal, delivery, and postpartum care experiences among Black women in Mississippi. Postpartum Black women who gave birth between March 2020 and March 2021 were recruited from a Federally Qualified Health Clinic that serves three Mississippi counties. Using a semi-structured interview guide, 10 postpartum women were interviewed, and their responses were analyzed utilizing the thematic content analysis approach. Major themes identified were stress related to COVID-19, disruption of social life/support, disruption of expected healthcare services, uncertainty and fear about coronavirus, COVID-19 mitigation strategies, and associated poor maternal health outcome. COVID-19 mitigation strategies exacerbated normal maternity-related stress. Postpartum women reported increased anxiety, fear, frustration, emotional stress, and lack of social support resulting in what was described as depression and feelings of loneliness. The results of this qualitative study of 10 Black women who gave birth during COVID-19 suggest the importance of stress-informed care. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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18 pages, 352 KiB

Open AccessArticle

Determinants of Antenatal Education and Breastfeeding Uptake in Refugee-Background and Australian-Born Women

by Tam Anh Nguyen, Mohammed Mohsin, Batool Moussa, Jane Fisher, Nawal Nadar, Fatima Hassoun, Batoul Khalil, Mariam Youssef, Yalini Krishna, Megan Kalucy and Susan Rees

Women 2023, 3(2), 263-280; https://doi.org/10.3390/women3020020 - 11 May 2023

Cited by 1 | Viewed by 1773

Abstract

Despite the well-established benefits of antenatal education (ANE) and breastfeeding for mothers, there is a paucity of evidence about the uptake of ANE and breastfeeding amongst women from refugee backgrounds or its associations with sociodemographic factors. The current study is a cross-sectional survey [...] Read more.

Despite the well-established benefits of antenatal education (ANE) and breastfeeding for mothers, there is a paucity of evidence about the uptake of ANE and breastfeeding amongst women from refugee backgrounds or its associations with sociodemographic factors. The current study is a cross-sectional survey at two time points examining the prevalence of ANE attendance, breastfeeding, and intimate partner violence (IPV) amongst 583 women refugees resettled in Australia and a control group of 528 Australian-born women. Multi-logistic regression was used to explore bivariate associations between ANE attendance, breastfeeding, IPV, and sociodemographic characteristics (parity, maternal employment, and education). Refugee-background women compared to Australian-born women have lower ANE utilization (20.4% vs. 24.1%), higher rates of breastfeeding on hospital discharge (89.3% vs. 81.7%), and more IPV reports (43.4% vs. 25.9%). Factors such as nulliparity, higher level of education, and employment predict higher rates of ANE and breastfeeding adoption. In contrast, IPV is a risk factor for ANE underutilization. Further, of the women from refugee backgrounds who accessed ANE services, 70% attended clinics designed for women from non-English-speaking backgrounds. These findings support the need to ensure effective screening and interventions for IPV during antenatal care and to better understand the role of culture as a protective or risk factor for breastfeeding initiation. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

26 pages, 2407 KiB

Open AccessArticle

Vaccine Hesitancy in Women of Childbearing Age and Occupational Physicians: Results from a Cross-Sectional Study (Italy, 2022)

by Matteo Riccò, Antonio Baldassarre, Milena Pia Cerviere and Federico Marchesi

Women 2023, 3(2), 237-262; https://doi.org/10.3390/women3020019 - 06 May 2023

Cited by 1 | Viewed by 1618

Abstract

Italian occupational physicians (OPs) are instrumental in promoting vaccination practice in occupational settings, and this study aims to characterize their attitudes, knowledge, and practices (collectively, KAP) towards immunization practice in women of childbearing age. A convenience sample of 120 OPs (50.8% males, mean [...] Read more.

Italian occupational physicians (OPs) are instrumental in promoting vaccination practice in occupational settings, and this study aims to characterize their attitudes, knowledge, and practices (collectively, KAP) towards immunization practice in women of childbearing age. A convenience sample of 120 OPs (50.8% males, mean age of 48.2 ± 5.9 years old) completed a structured online questionnaire (potential recipients: 2034; response rate: 5.9%) assessing their understanding of official recommendations, their general knowledge of vaccine practice, their attitudes towards vaccines, and their risk perception about vaccine-preventable infectious diseases. The sampled OPs exhibited a good understanding of official recommendations, and they were largely favorable towards vaccination of pregnant women. Knowledge status was relatively good (potential range 0 to 100%, average score 22 74.5% ± 18.2), while risk perception towards sampled disorders was heterogenous: the greatest was the one for SARS-CoV-2 (52.7% ± 32.9), followed by seasonal influenza (45.3% ± 31.6), and pertussis (37.8% 24 ± 28.2). The main predictors for promoting vaccination were higher knowledge about seasonal influenza vaccine (SIV; adjusted Odds Ratio [aOR] 102.2, 95% Confidence Interval [95%CI] 9.68–1080.26), tetanus-diphtheria-acellular pertussis vaccine (Tdap; aOR 12.34, 95%CI 2.62; 58.22) 27 and SARS-CoV-2 vaccine (aOR 14.76, 95%CI 2.74–79.69). A better attitude towards SIV was positively associated with previous vaccination of the respondent (aOR 4.90, 95%CI 1.19–20.14), while higher risk perception towards SIV was characterized as a negative predictor (aOR 0.04, 95%CI 0.01–0.35), as was working as an OP in healthcare facilities (aOR 0.03, 95%CI 0.01–0.43). Tdap was positively associated with male gender of respondents (aOR 10.22, 95%CI 2.60 to 40.24) and higher risk perception about pertussis (aOR 10.38, 95%CI 1.47 to 73.47). Overall, our data suggest that improving the understanding of OPs about the health burden of frequently encountered pathogens could be instrumental in increasing their involvement in the promotion of vaccine practice. Because of the low rate of response to our survey, our conclusions remain tentative. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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14 pages, 2173 KiB

Open AccessArticle

Differentials in Maternal Mortality Pattern in Sub-Saharan Africa Countries: Evidence from Demographic and Health Survey Data

by Osaretin Christabel Okonji, Chimezie Igwegbe Nzoputam, Michael Ekholuenetale, Emeka Francis Okonji, Anthony Ike Wegbom and Clement Kevin Edet

Women 2023, 3(1), 175-188; https://doi.org/10.3390/women3010014 - 09 Mar 2023

Viewed by 3096

Abstract

Maternal mortality ratios in sub-Saharan Africa remain high and worrisome. Moreover, maternal health indicators have remained poor despite large efforts in the last two decades. This study assesses maternal mortality patterns by age and country. The demographic and health survey data were used [...] Read more.

Maternal mortality ratios in sub-Saharan Africa remain high and worrisome. Moreover, maternal health indicators have remained poor despite large efforts in the last two decades. This study assesses maternal mortality patterns by age and country. The demographic and health survey data were used for the study. Based on the results, countries with the lowest adult female mortality rate include Senegal, Comoros, Rwanda, Mauritania, Sao Tome and Principe, Gambia, and Ethiopia. In addition, Chad (44.7%), Niger (38.7%), the Congo Democratic Republic (34.8%), Nigeria (34.2%), Mauritania (32.0%), Senegal (29.2%), Liberia (28.8%), Benin (27.8%), and Guinea (27.5%), respectively, reported the highest female deaths that are pregnancy-related. Overall, Lesotho (1024; 95% CI: 731–1318), Liberia (913; 95% CI: 638–1189), Chad (860; 95% CI: 728–993), Congo Democratic Republic (846; 95% CI: 690–1003), Sierra Leone (796; 95% CI: 632–960) and Guinea (724; 95% CI: 531–916) had the leading pregnancy-related mortality ratio per 100,000 live births. The study found that the patterns of death vary across different countries. There is a need for concerted efforts to reduce pregnancy-related deaths in sub-Saharan countries. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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11 pages, 261 KiB

Open AccessArticle

Psychosocial Risk Factors and Psychopathological Outcomes: Preliminary Findings in Italian Pregnant Women

by Maria Rita Infurna, Eleonora Bevacqua, Giulia Costanzo, Giorgio Falgares and Francesca Giannone

Women 2023, 3(1), 121-131; https://doi.org/10.3390/women3010010 - 28 Feb 2023

Cited by 2 | Viewed by 1811

Abstract

The perinatal period may represent a particularly challenging time for expecting parents. Previous studies have highlighted an association between several perinatal risk conditions (e.g., childhood maltreatment, poor social support, and stress levels) and the development of psychopathological symptoms in pregnant women, especially depression [...] Read more.

The perinatal period may represent a particularly challenging time for expecting parents. Previous studies have highlighted an association between several perinatal risk conditions (e.g., childhood maltreatment, poor social support, and stress levels) and the development of psychopathological symptoms in pregnant women, especially depression symptoms. The current study examined the effects of psychosocial risk factors (childhood maltreatment, poor social support, and stressful events) on anxiety, depression, perceived stress, irritability/anger, relationship problems, psychosomatic symptoms, specific physiological problems, and addiction/at-risk behaviors. Sixty-one pregnant women (age range = 24–45) participating in a larger study completed questionnaires about childhood maltreatment (CECA Q.), Maternity Social Support Scale (MSSS), questionnaire on stressful events, and the Perinatal Assessment of Maternal Affectivity (PAMA) during their pregnancy. Results from regression analysis indicated that the presence of childhood maltreatment predicted elevated depressive symptoms, elevated irritability and anger, and elevated relationship problems. Further, stressful events in the year prior to pregnancy predicted elevated psychosomatic symptoms during pregnancy. No other significant associations were found. In this study, traumatic childhood events were strongly associated with mental health symptoms during pregnancy. This is an important finding that suggests the importance of screening and targeting psychotherapeutic interventions for vulnerable women during pregnancy. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

12 pages, 403 KiB

Open AccessArticle

Support Needs for Anxiety among Pregnant Women in Japan: A Qualitative Pilot Study

by Ritsuko Shirabe, Tsuyoshi Okuhara, Hiroko Okada, Eiko Goto and Takahiro Kiuchi

Women 2023, 3(1), 95-106; https://doi.org/10.3390/women3010008 - 08 Feb 2023

Viewed by 1774

Abstract

Support needs for pregnancy-related anxiety among low-risk pregnant women remain unclear. This study aimed to clarify the kinds of support for anxiety that women seek during pregnancy in Japan. Data were collected in a semi-structured focus group interview involving five pregnant women who [...] Read more.

Support needs for pregnancy-related anxiety among low-risk pregnant women remain unclear. This study aimed to clarify the kinds of support for anxiety that women seek during pregnancy in Japan. Data were collected in a semi-structured focus group interview involving five pregnant women who were not in specific risk groups, recruited from three facilities in Tokyo. We generated themes using inductive thematic analysis. This paper adhered to the consolidated criteria for reporting qualitative research. From the data on support needs for anxiety during pregnancy, three themes were derived: (1) seeking tailored professional support; (2) seeking continuous support within informal relationships; and (3) seeking others’ success stories in the same situation. These three types of support gave participants a sense of reassurance or raised concern, depending on the situation. We proposed a model comprising the three derived themes using social cognitive theory. We discussed how these three types of support influenced pregnant women’s self-efficacy, which is the core concept of the social cognitive theory. Our findings may help to plan theory-based research and effective interventions to provide support for women’s anxiety during pregnancy using a population approach. Our results also demonstrated the importance of collaboration with pregnant women in developing further research and interventions. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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12 pages, 231 KiB

Open AccessArticle

Knowledge and Perception of Risk in Pregnancy and Childbirth among Women in Low-Income Communities in Accra

by Patricia Anafi and Wisdom Kwadwo Mprah

Women 2022, 2(4), 385-396; https://doi.org/10.3390/women2040035 - 22 Nov 2022

Viewed by 2698

Abstract

Perception and knowledge of risk factors for pregnancy influence health behaviors during pregnancy and childbirth. We used a descriptive qualitative study to examine the perception and knowledge of risk factors in pregnancy and childbirth in low-income urban women in Ghana. Over the course [...] Read more.

Perception and knowledge of risk factors for pregnancy influence health behaviors during pregnancy and childbirth. We used a descriptive qualitative study to examine the perception and knowledge of risk factors in pregnancy and childbirth in low-income urban women in Ghana. Over the course of three-months, 12 focus group discussions and six individual interviews were conducted with 90 participants selected from six communities in the study area. Data were analyzed using inductive-thematic content analysis. Findings revealed that participants had knowledge of some risk factors, although some had superstitious beliefs. Participants viewed pregnancy as an exciting and unique experience, but also challenging, with a host of medical and psychological risks. Pre-existing medical conditions (e.g., diabetes), lack of physical activity, poverty, poor nutrition, and lack of social support were identified as conditions that could lead to negative pregnancy outcomes. Superstitious beliefs such as exposure to “evil eye” during pregnancy, as well as curses and spells, were also identified as risk factors for pregnancy complications. This research has implications for policies and programs to improve pregnancy outcomes for low-income women in Ghana. Thus, we recommend social and economic support programs as well as health education to change misperceptions about pregnancy risk and to support other efforts being made to improve maternal health outcomes. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

19 pages, 833 KiB

Open AccessArticle

Factors Influencing the Utilization of Antenatal Services among Women of Childbearing Age in South Africa

by Putunywa Zandrina Nxiweni, Kelechi Elizabeth Oladimeji, Mirabel Nanjoh, Lucas Banda, Felix Emeka Anyiam, Francis Leonard Mpotte Hyera, Teke R. Apalata, Jabu A. Mbokazi and Olanrewaju Oladimeji

Women 2022, 2(3), 285-303; https://doi.org/10.3390/women2030027 - 10 Sep 2022

Cited by 1 | Viewed by 6440

Abstract

Access to quality care before, during, and after childbirth remains an effective means of reducing maternal and neonatal mortality. Therefore, the study identified factors influencing the utilization of prenatal care services among women of childbearing age in South Africa. This is a retrospective [...] Read more.

Access to quality care before, during, and after childbirth remains an effective means of reducing maternal and neonatal mortality. Therefore, the study identified factors influencing the utilization of prenatal care services among women of childbearing age in South Africa. This is a retrospective study based on secondary data from the South African Demographic Health Survey (DHS) conducted from 1998 to 2016. In South Africa, 21.0% of mothers had used ANC services. Higher odds of seeking prenatal care were found in women aged 35 years and older (cOR = 1.26, 95% CI; 1.08–1.47, p = 0.003), married or cohabiting (cOR = 1.13, 95% CI; 1.004–1.27) observed, p = 0.043), higher level of education (tertiary education: cOR = 0.55, p = 0.001), female residents in urban areas (cOR = 1.35, 95% CI; 1.20–1.52, p = 0.001), higher wealth index (cOR = 1.32, 95% CI; 1.15–1.51, p = 0.001), employed (cOR = 1.48, 95% CI; 1.29–1.70, p = 0.001) and media exposure (cOR = 1.27, 95% CI; 1.12–1.44), p = 0.001). The findings of this study provide insight into the need to make maternal health services more accessible, more widely used, and of a higher quality. This requires effective strategic policies that promote patronage to reduce maternal mortality and improve newborn outcomes in South Africa. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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9 pages, 250 KiB

Open AccessProtocol

Knowledge, Attitudes, Behavior, Acceptance, and Hesitancy in Relation to the COVID-19 Vaccine among Pregnant and Breastfeeding Women: A Systematic Review Protocol

by Vincenza Gianfredi, Alessandro Berti, Marilena D’Amico, Viola De Lorenzo and Silvana Castaldi

Women 2023, 3(1), 73-81; https://doi.org/10.3390/women3010006 - 20 Jan 2023

Cited by 2 | Viewed by 1455

Abstract

A new coronavirus, SARS-CoV-2, was identified at the end of 2019. It swiftly spread all over the world, affecting more than 600 million people and causing over 6 million deaths worldwide. Different COVID-19 vaccines became available by the end of 2020. Healthcare workers [...] Read more.

A new coronavirus, SARS-CoV-2, was identified at the end of 2019. It swiftly spread all over the world, affecting more than 600 million people and causing over 6 million deaths worldwide. Different COVID-19 vaccines became available by the end of 2020. Healthcare workers and more vulnerable people (such as the elderly and those with comorbidities) were initially prioritized, followed by the entire population, including pregnant and breastfeeding women. Despite the safety and efficacy of COVID-19 vaccines, a certain level of skepticism was expressed, including among pregnant and breastfeeding women. There were several reasons for this reluctancy, among them, fear of side-effects for both women and fetuses. Nevertheless, acceptance, as well as hesitancy, were time, country and vaccine specific. This review will collect available evidence assessing knowledge, attitudes, behaviour, practice and acceptance/hesitancy of pregnant/breastfeeding women in relation to the COVID-19 vaccination. The PubMed/MEDLINE, Scopus and EMBASE databases will be consulted. A predefined search strategy that combines both free text and MESH terms will be used. The systematic review will adhere to the PRISMA guidelines and the results will be reported in both narrative and summary tables. A meta-analysis will be conducted if data are available. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

14 pages, 1431 KiB

Open AccessSystematic Review

Respiratory Syncytial Virus in Pregnant Women: Systematic Review and Meta-Analysis

by Matteo Riccò, Pietro Ferraro, Silvia Corrado, Alessandro Zaniboni, Elia Satta and Silvia Ranzieri

Women 2022, 2(2), 147-160; https://doi.org/10.3390/women2020016 - 10 Jun 2022

Cited by 1 | Viewed by 12025

Abstract

Human Respiratory Syncytial Virus (RSV) is a highly contagious viral pathogen. In infants, it is usually listed among the main causes of medical referrals and hospitalizations, particularly among newborns. While waiting for the results of early randomized controlled trials on maternal vaccination against [...] Read more.

Human Respiratory Syncytial Virus (RSV) is a highly contagious viral pathogen. In infants, it is usually listed among the main causes of medical referrals and hospitalizations, particularly among newborns. While waiting for the results of early randomized controlled trials on maternal vaccination against RSV, the present systematic review and meta-analysis aimed to collect available evidence on maternal RSV infections. According to the PRISMA statement, Pubmed, Embase, and pre-print archive medRxiv.og were searched for eligible studies published up to 1 April 2022. Raw data included the incidence of RSV infection among sampled pregnant women, and the occurrence of complications. Data were then pooled in a random-effects model. Heterogeneity was assessed using the I² measure, while reporting bias was assessed by means of funnel plots and regression analysis. A total of 5 studies for 282,918 pregnancies were retrieved, with a pooled prevalence of 0.2 per 100 pregnancies and 2.5 per 100 pregnancies with respiratory tract infections. Neither maternal deaths nor miscarriages were reported. Even though detailed data were available only for 6309 pregnancies and 33 RSV cases, infant outcomes such as low birth weight and preterm delivery were rare (in both cases 0.04%), but up to 9.1% in cases where RSV diagnosis was confirmed. No substantially increased risk for preterm delivery (RR 1.395; 95%CI 0.566 to 3.434) and giving birth to a low-birth-weight infant (RR 0.509; 95%CI 0.134 to 1.924) was eventually identified. Conclusions. Although RSV is uncommonly detected among pregnant women, incident cases were associated with a relatively high share of complications. However, heterogeneous design and the quality of retrieved reports stress the need for specifically designed studies. Full article

(This article belongs to the Special Issue Health and Preventive Strategies in Order to Protect Pregnancy)

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