Complacency over “stillbirth rates”? Wales is in decline but stats are unreliable …

Update 21st Jan 2015: The Times – Inquest rules blamed for stillbirth rate

“Hospitals are failing to bring down the high stillbirth rate because they are allowed to investigate themselves, according to the author of a report into the Morecambe Bay scandal.

Bill Kirkup called for an end to a 1950s law that prevents coroners from opening inquiries unless a baby has drawn a breath.

Dr Kirkup, whose report last year concluded that a “lethal mix” of denial and failure by the NHS led to the deaths of 11 babies and one mother at the trust in Cumbria, said that poor internal investigations were a key reason why Britain’s stillbirth rate remained high.

He said that the death of a baby during labour was often a sign of poor care.

Nicholas Rheinberg, the Cheshire coroner who has been active in investigating baby deaths, wants the law to force staff to report to coroners all deaths after the start of labour.”

How we report facts and figures can be deceiving. We are given the impression that complacency rules, but I expect most Gynaecologists would feel insulted by this. The fact is that we have rationed midwifery training, we have rationed medical students and at undergraduate level so that there is a large gender bias towards women. Women do not wish to do as many pro rata night calls and weekend rotas, because many have child demands, or will have in the future. “The number of stillbirths in England and Wales decreased to 3,254 in 2014 compared with 3,284 in 2013 (a fall of 0.9%). In comparison, the total number of births (both live births and stillbirths) decreased by just 0.5% in 2014. Stillbirths in England decreased by 1.8% from 3,103 in 2013 to 3,047 in 2014. Stillbirths in Wales increased by 15.7% from 153 in 2013 to 177 in 2014. Due to the small number of stillbirths in Wales, small changes in the number of stillbirths in a year can result in large percentage changes.” (ONS)

Chris Smyth reports in the Times 19th Jan 2016: NHS trails Africa in efforts to cut stillbirth numbers

Britain trails the world in improving its stillbirth rate, and fatalism about baby deaths is still widespread among health professionals, a major global study has found.

Progress on reducing stillbirths is slower than in Zambia and the Democratic Republic of Congo. Britain’s annual improvement rate is 1.4 per cent. In the Netherlands, where progress has been fastest, there has been an average annual reduction of 6.8 per cent.

Almost three in every 1,000 babies in this country are born dead. A standardised international measure puts Britain 21st in the world, slipping from 18th place in 2000.

Britain is behind Slovakia; the stillbirth rate here is double that of Iceland, the best performing country.

The Times has repeatedly highlighted NHS complacency over the thousands of babies who die before birth every year. Many could have been saved with basic measures such as consistent measurement of growth in the womb. Yet most deaths are not properly investigated, meaning that the same mistakes are repeated.

A series published in The Lancet today on the world’s 2.6 million annual stillbirths reinforces the message that the matter is not taken as seriously as other child deaths.

Joy Lawn, from the London School of Hygiene & Tropical Medicine, one of the lead authors of the series, said: “There is a common misperception that many of the deaths are inevitable, but our research shows most stillbirths are preventable . . . We already know which existing interventions save lives.

“These babies should not be born in silence, their parents should not be grieving in silence, and the international community must break the silence as they have done for maternal and child deaths,” she added.

Most stillbirths happen in the developing world, with ten countries accounting for two thirds of deaths. There are more than half a million annually in India. Pakistan has the highest rate, at 43 per 1,000 births.

Even in rich countries poor care contributes to up to a third of stillbirths, with most deaths of fullterm babies potentially avoidable, the series says.

Richard Horton, editor of The Lancet, said: “The idea of a child being alive at the beginning of labour and dying for entirely preventable reasons during the next few hours should be a health scandal of international proportions.”

In an international survey of health professionals two thirds thought that few stillbirths could be avoided. The journal warns: “Stigma and fatalism continue to exacerbate trauma for families and impede progress in stillbirth prevention.”

Janet Scott, from the stillbirth charity Sands, said: “We know that 60 per cent of term stillbirths in the UK could potentially be prevented simply by applying the minimum standards of antenatal care and guidance for mothers and babies.”

Jeremy Hunt, the health secretary, has promised to halve stillbirth rates by 2030, with deaths to be investigated more rigorously to highlight where improvements can be made. David Richmond, president of the Royal College of Obstetricians and Gynaecologists, said that the research was a “wake-up call”.

Baby deaths
Stillbirth rates per 1,000 births
1 Iceland 1.3
2 Denmark 1.7
3 Finland 1.8
4 Netherlands 1.8
5 Croatia 2.0
10 Poland 2.3
21 United Kingdom 2.9
25 USA 3.0
44 France 4.7
186 Pakistan 43.1

Source: The Lancet

Birth Scandal The Times leader 19th Jan 2016

Births in England and Wales 2013:

Main points

  • There were 695,233 live births in England and Wales in 2014, a decrease of 0.5% from 698,512 in 2013.
  • In 2014, the total fertility rate (TFR) decreased to 1.83 children per woman, from 1.85 in 2013.
  • In 2014, the stillbirth rate remained at 4.7 per thousand total births, the same as in 2013.
  • The average age of mothers in 2014 increased to 30.2 years, compared with 30.0 years in 2013.
  • Over a quarter (27.0%) of live births in 2014 were to mothers born outside the UK; a small increase compared with 26.5% in 2013.

Summary

This bulletin presents summary statistics of live births and stillbirths in England and Wales in 2014. These statistics include counts of live births and stillbirths, fertility rates by age of mother and by area of usual residence, and the percentage of births to mothers born outside the UK.

This is the first time that the 2014 annual figures for births in England and Wales have been published.

Live births (numbers and rates)

There were 695,233 live births in England and Wales in 2014, compared with 698,512 in 2013 (a fall of 0.5%). The fall in live births in 2014 suggests a continuing downward trend, following on from the large decrease in the number of live births in 2013, which was the largest percentage annual decrease since 1975. This fall represents a change to the increasing numbers of births that had been reported each year from 2001 to 2012, with the exception of a 0.3% fall in 2009. Between 2001 and 2012 the number of live births increased by 23%.

The number of live births and the total fertility rate (TFR) fluctuated throughout the 20th century with a sharp peak at the end of World War II (Figure 1). Live births peaked again in 1964 (875,972 births), but since then lower numbers have been recorded. The lowest annual number of births in the 20th century was 569,259 in 1977. The number of births is dependent on both fertility rates and the size and age structure of the female population.

The TFR for England and Wales (see background note 3) decreased slightly in 2014 to an average of 1.83 children per woman from 1.85 in 2013.

During the 1990s, the TFR fell from 1.80 in 1992 to a record low of 1.63 by 2001. This was largely due to women delaying childbearing to older ages (Jefferies, 2008 (423.9 Kb Pdf) ; Tromans, et al., 2008). The TFR increased steadily between 2002 and 2008 to 1.92, then remained relatively stable between 2009 and 2012 (between 1.90 and 1.94). The fall in TFR from 1.94 in 2012 to 1.85 in 2013 was the largest annual decrease in the fertility rate since 1975.

Figure 1: Number of live births and total fertility rate (TFR), 1944 to 2014

England and Wales

Figure 1: Number of live births and total fertility rate (TFR), 1944 to 2014

Source: Office for National Statistics

Notes:

  1. Based on births occurring in the calendar year.

Download chart

Changes in the TFR can result from changes in the timing of childbearing within women’s lives, as well as any changes in completed family size.

At this stage, it is not possible to determine whether the fall in the TFR and the number of live births in 2013 and 2014 is indicative of an end to the general increasing trend observed since 2001. Despite this recent drop, the number of births and the TFR remain relatively high compared to figures for the last 3 decades.

Reasons for the decreases in fertility in 2014 are likely to vary by age, social status, and number of other children. For example, older women may feel less inclined to delay having children than younger women, while at any age childbearing choices may be affected by parents’ current financial or housing position. Also, women who have already had children and who may be considering having another child will be influenced by different factors to those who have not yet had children. Other factors that could have had an impact on fertility levels in 2014 include:

  • uncertainty about employment and lower career and promotion opportunities (such as temporary, part-time, or zero-hours contracts), which can significantly reduce women’s desire for children (Del Bono E, et al.,2014; Lanzieri G, 2013)
  • reforms by the coalition Government to simplify the welfare system, which have resulted in some significant changes to benefits, may have influenced decisions around childbearing. The changes, announced in 2011 and 2012, included:
    o reduced housing benefit from April 2013 for those living in property deemed to be larger than they need; children under 10 are expected to share a room, as are children under 16 of the same gender
    o removal of child benefit where one parent earns over £50,000 from January 2013 and a 3-year freeze on payments for those eligible from April 2011
    o a cap on the total amount of benefits that working age people can receive from April 2013, so that households on working age benefits can no longer receive more in benefits than the average wage for working families
An article, published in June 2013, ‘Why has the fertility rate risen over the last decade in England and Wales?’ provides information on possible reasons for the rising fertility rates recorded between 2001 and 2012.

Stillbirths

The number of stillbirths in England and Wales decreased to 3,254 in 2014 compared with 3,284 in 2013 (a fall of 0.9%). In comparison, the total number of births (both live births and stillbirths) decreased by just 0.5% in 2014. Stillbirths in England decreased by 1.8% from 3,103 in 2013 to 3,047 in 2014. Stillbirths in Wales increased by 15.7% from 153 in 2013 to 177 in 2014. Due to the small number of stillbirths in Wales, small changes in the number of stillbirths in a year can result in large percentage changes.

The stillbirth rate takes into account the total number of births and so provides a more accurate indication of trends than just analysing the number of stillbirths over time. In 2014, the stillbirth rate for England and Wales remained at 4.7 per thousand total births, the same as in 2013. In 2013, this was the lowest stillbirth rate since 1992 when it was 4.3. In England, the stillbirth rate in 2014 was 4.6 per thousand total births, the same as in 2013. There has been a general downward trend in the stillbirth rate since 2004 with a decrease of 19.3% over the last 10 years (Figure 2). In Wales the stillbirth rate in 2014 was 5.2 per thousand total births, up from 4.5 in 2013 but, has fallen from 5.7 in 2004 (Figure 2).

Figure 2: Stillbirth rates, 2004 to 2014

England, Wales

Figure 2: Stillbirth rates, 2004 to 2014

Source: Office for National Statistics

Notes:

  1. Stillbirths per 1,000 live births and stillbirths.
  2. Based on stillbirths and births occurring in each calendar year.

Download chart

Small fluctuations in the number of stillbirths and the stillbirth rate in England and Wales have occurred during the last decade, with the highest stillbirth rate during the period being 5.7 per thousand total births in 2004. The main risk factors for stillbirths include maternal obesity, smoking, and fetal growth restriction (Gardosi et al., 2013).

Stillbirths and neonatal mortality rates are an indicator within the NHS Outcomes Framework 2014/15 measuring the number of deaths in new born babies younger than 28 days in England. The Department of Health (DH) together with the stillbirth and neonatal death charity (Sands) and a number of important organisations such as NHS England, Public Health England (PHE), the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists are working on an ongoing stillbirth programme. This has included identifying and agreeing the main messages that can be used to raise awareness of the risk factors for stillbirths among pregnant women and health professionals and the actions that can be taken to minimise these risks.

In Wales, a National Stillbirth Working Group was set up within the 1000 Lives Plus programme of work in April 2012, and includes representation of important stakeholders in maternity care. The National Assembly for Wales published a report in 2013 which identified a number of actions to improve the stillbirth rate in Wales. Further information can be found on the 1000 Lives Plus website.

Live births by age of mother

In 2014 fertility decreased in all age groups under 30, while fertility increased in the 30 and over age groups. The largest percentage decrease was seen in women aged under 20, with a decrease of 10.3%. Fertility rates for those aged under 20 have generally declined since 1999. An article looking into international comparisons of teenage births showed that the birth rate to women aged 15 to 19 has been decreasing across Europe since 2004.

Fertility rates for women aged 20 to 24 and 25 to 29 fell by smaller amounts (5.7% and 1.0% respectively). Fertility rates for those aged 20 to 24 have been falling since 2010, while the fertility rate for those aged 25 to 29 is the lowest since 2007.

The largest percentage increase was seen in women aged 35 to 39 with an increase of 2.5%. Fertility rates for women aged 30 to 34 and 40 and over increased by smaller amounts (0.9% and 1.4% respectively). Despite the small decline in 2013, the fertility rate for women aged 40 and over has trebled since 1991 (a rise of 200%) and fertility for women aged 35 to 39 has also nearly trebled over this period (a rise of 197%).

In most developed countries women have been increasingly delaying childbearing to later in life, which has resulted in increases in the mean age at first birth and rising fertility rates among older women. Although fertility rates for women aged 40 and above have generally been rising fast, fertility among women in their 40s is still considerably lower than for women in their 30s. Women aged 30 to 34 currently have the highest fertility of any age group.

Figure 3: Age-specific fertility rates, 1984 to 2014

England and Wales

Figure 3: Age-specific fertility rates, 1984 to 2014

Source: Office for National Statistics

Notes:

  1. Based on births occurring in the calendar year.

Download chart

These changes in age-specific fertility rates have resulted in a continued rise to the average age of mothers reaching 30.2 years in 2014, compared with 30.0 years in 2013 (see background note 6). The average age of mothers has been increasing since 1975, with increasing numbers of women delaying childbearing to later ages. This may be due to a number of factors such as increased participation in higher education (Ní Bhrolcháin, et al., 2012), increased female participation in the labour force, the increasing importance of a career, the rising costs of childbearing, labour market uncertainty, housing factors and instability of partnerships.

The number of births in a given year is dependent on the number of women in the main childbearing ages (15 to 44 years) and on fertility rates in that year. Compared with 2013, the number of live births in 2014 decreased for women aged under 20, 20 to 24 and 40 and over, while there were increases in the number of live births to women aged 25 to 29, 30 to 34 and 35 to 39 in 2014.

  • the decrease in births to women aged under 20 and 20 to 24 in 2014 was caused by falling fertility at this age, alongside a decrease in the estimated number of women at these ages between mid-2013 and mid-2014
  • for women aged 25 to 29 the increase in the number of births was due to an increase in the estimated female population in England and Wales at this age, since fertility levels decreased
  • the rise in births to women aged 30 to 34 and 35 to 39 was caused by an increase in fertility and an increase in the estimated female population in England and Wales at these ages
  • for women aged 40 and over the decrease in the number of births was due to a decrease in the estimated female population in England and Wales at this age, since fertility levels increased

Live births within marriage/civil partnership

In 2014, nearly half of all babies were born outside marriage/civil partnership (47.5%), compared with 47.4% in 2013 and 42.2% in 2004. This continues the long-term rise in the percentage of births outside marriage/civil partnership, which is consistent with increases in the number of couples cohabiting rather than entering into marriage or civil partnership (see Families and Households for further information).

Live births to mothers born outside the UK

The percentage of live births in England and Wales to mothers born outside the UK continued to rise in 2014, reaching 27.0% compared with 26.5% in 2013 and 19.5% in 2004. The proportion of births to mothers born outside the UK has increased every year since 1990 when it was 11.6%. Recent rises in the number of births to non-UK born women can be mainly attributed to the increase in the population of women born outside the UK (ONS, 2012).

In recent years, the proportion of births to women born outside the UK has been higher than the proportion of the female population of childbearing age born outside the UK (ONS, 2012). There are 2 reasons for this:

  • fertility levels are generally higher among foreign-born women
  • the foreign-born and UK-born female populations of reproductive age have different age structures, with a higher proportion of foreign-born women being aged from 25 to 34, where fertility is highest

A report on Childbearing of UK and non-UK born women living in the UK, 2011 Census data, published February 2014, used 2001 and 2011 Census population estimates and annual birth registrations to examine total fertility rates for foreign-born women within England and Wales. Fertility rates for women born in around 150 non-UK countries were analysed. More detailed birth statistics for 2014 by parents’ country of birth will be published in August/September 2015.

Live births by area of usual residence

In 2014, the West Midlands and the East region both had the highest TFR among the regions of England with 1.92 children per woman. London had the lowest TFR (1.71 children per woman).

Among the local authorities in England in 2014, City of London had the lowest TFR with 0.96 children per woman, while Peterborough unitary authority had the highest (2.34 children per woman).

In Wales in 2014, Ceredigion had the lowest TFR, with 1.64 children per woman, while Denbighshire had the highest (2.25 children per woman).

Fertility rates can vary considerably between sub-national areas for a wide variety of reasons. The composition of the population living in each area will vary, and there will be variations in economic, social and cultural factors that may influence fertility rates due to differences in the timing of childbearing, as well as ideals around family size. For example:

  • the presence of a large student population within a local authority often acts to reduce the TFR in that area, as students in higher education tend to have below average fertility
  • the fertility contribution of women born in certain countries such as India, Bangladesh, Pakistan and African countries may be associated with higher fertility in certain areas
  • fertility rates for some local authorities are based on relatively small populations – calculations based on small numbers of events are often subject to random fluctuations and consequently are less robust

An interactive mapping tool for analysing local authority fertility trends (using the TFR) is available. The tool covers the period 2001 to 2014.

Births in the UK

The provisional number of UK births in 2014 was 776,351. This is a fall of 0.3% compared with 2013 when there were 778,805 births.

In Scotland the number of births increased from 56,014 in 2013 to 56,725 in 2014 (provisional figure), a rise of 1.3%. Northern Ireland also recorded an increase in the number of births from 24,279 in 2013 to 24,393, a rise of 0.5%.

Users and uses of birth statistics

The Office for National Statistics uses births data to:

  • produce population estimates and population projections at both national and subnational level
  • quality assure census estimates
  • report on social and demographic trends

The Department of Health (DH) is a main user of birth statistics. Data are used, for example, to plan maternity services, inform policy decisions and monitor child mortality. The Public Health Outcomes Framework sets out the desired outcomes for public health and how these are measured. This includes indicators related to births. Similar indicators are also included within the NHS Outcomes Framework.

Local authorities and other government departments are important users of birth statistics and use the data for planning and resource allocation. For example, local authorities use birth statistics to decide how many school places will be needed in a given area. The Department for Work and Pensions uses detailed birth statistics to feed into statistical models they use for pensions and benefits. The Department of Health uses the data to plan maternity services and inform policy decisions.

Other users include academics, demographers and health researchers, who conduct research into birth trends and characteristics. Lobby groups use birth statistics for their cause, for example, campaigns against school closures or midwife shortages. Special interest groups, such as Birth Choice UK, make the data available to enable comparisons between maternity units to help women choose where they might like to give birth and work closely with health professionals. Charities, such as the Twins and Multiple Births Association provide advice and support to multiple birth parents and use the data to monitor trends. Organisations such as Eurostat and the UN use our birth statistics for international comparison purposes. The media also report on main trends and statistics.

Further information

More data on births in England and Wales in 2014 are available on our website.

Data on deaths in England and Wales in 2014 are available on our website.

A Quality and Methodology Information (257.9 Kb Pdf) document for birth statistics is available on our website. Further information on data quality, legislation and procedures relating to births is available on the ONS website in births metadata (332.6 Kb Pdf) .

Further 2014 birth statistics will be published later in 2015; see the GOV.UK release calendar for more details on releases.

We have published an article on Trends in births and deaths over the last century.

There is a new version of the interactive mapping tool which enables the total fertility rate to be analysed at the local level for the years 2001 to 2014.

For births data for other UK countries please see the latest birth statistics for Northern Ireland and the latest birth statistics for Scotland.

International comparisons of live birth numbers and rates are available in the Vital Statistics: Population and Health Reference Tables.

References

1000 Lives Plus, Transforming Maternity Services- Welsh Initiative for Stillbirth Reduction (WISR) [accessed 29 June 2015]

Del Bono E, Weber A, Winter-Ebmer R (2014). Fertility and economic instability: the role of unemployment and job displacement

Department for Health (2013), Public Health Outcomes Framework

Department for Work and Pensions (2013), Simplifying the welfare system and making sure work pays

Department for Health (2013), NHS Outcomes Framework 2014/15

Gardosi J, Madurasinghe V, Williams M, Malik A and Francis A (2013). Maternal and fetal risk factors for stillbirth: population based study. British Medical Journal, 346:f108

Jefferies J (2008) Fertility Assumptions for the 2006-based national population projections, Population Trends 131 pp 19–27 (423.9 Kb Pdf)

Lanzieri G (2013), Towards a ‘baby recession’ in Europe?

Ni Bhrolcháin M and Beaujouan E (2012), Fertility postponement is largely due to rising educational enrolment, Population Studies: A Journal of Demography

ONS (2014), ‘International comparisons of teenage births

ONS (2013) ‘Why has the fertility rate risen over the last decade in England and Wales

ONS (2012) ‘Childbearing of UK and non-UK born women living in the UK, 2011 Census data

Stillbirth and Neonatal Death charity (Sands), UK stillbirth and neonatal death charity, Sands and the Department of Health progress stillbirth public awareness initiative [accessed 26 June 2015]

Tromans N, Natamba E, Jefferies J and Norman P (2008), Have national trends in fertility between 1986 and 2006 occurred evenly across England and Wales?, Population Trends 133, pp 7–19, autumn 2008 (3.33 Mb Pdf)

Background notes

    1. Birth figures are based on births occurring in the data year, but incorporate a small number of late registrations from births occurring in the previous year.
    2. There is a large degree of comparability in birth statistics between countries within the UK. However, there are some differences, although these are believed to have a negligible impact on the comparability of the statistics. These differences are outlined in Quality and Methodology Information (257.9 Kb Pdf) document for births.
    3. The total fertility rate (TFR) is the average number of live children that a group of women would each have if they experienced the age-specific fertility rates of the calendar year in question throughout their childbearing lives. The TFR provides an up-to-date measure of the current intensity of childbearing. Changes in timing of births may influence the TFR; for example if women are increasingly delaying childbearing to older ages the TFR may underestimate average family size. National TFRs are calculated by summing single-year age-specific fertility rates over all ages within the childbearing years (taken to be ages ‘15 and under’ to ages ‘44 and over’). TFRs for subnational areas (that is regions, counties, unitary authorities and health authorities/boards) are calculated by summing 5-year age-specific fertility rates over all childbearing ages and then multiplying by 5 (this method gives more robust TFRs for areas with smaller populations). The TFRs for 2014 have been calculated using the mid-2014 population estimates.
    4. Stillbirth definition – a baby born after 24 or more weeks completed gestation and which did not, at any time, breathe or show signs of life.
    5. The Human Fertilisation and Embryology Act 2008 contained provisions enabling 2 females in a same sex couple to register a birth from 1 September 2009 onwards. Due to the small numbers of births registered to same sex couples, births registered within a civil partnership are included with births registered within marriage. Births registered by a same sex couple outside of a civil partnership have been included with births registered outside marriage. The impact on 2014 birth statistics is negligible since only 0.1% of live births were registered to same sex couples. In 2014 there were 713 live births registered to same sex couples in a marriage or civil partnership and 277 live births registered to same sex couples outside a marriage or civil partnership.
    6. The standardised mean (average) age of mother is calculated using mid-year population estimates. The standardised mean age of mother is used in order to eliminate the impact of any changes in the distribution of the population by age and therefore enables trends over time to be analysed. Standardised means are calculated using rates per thousand female population by single year of age of mother.
    7. A list of the names of those given pre-publication access to the statistics and written commentary is available in Pre-release Access list for Birth Summary Tables 2014.  The rules and principles which govern pre-release access are featured within the Pre-release Access to Official Statistics Order 2008.
    8. Special extracts and tabulations of births data for England and Wales are available to order (subject to legal frameworks, disclosure control, resources and agreements of costs, where appropriate). Such enquiries should be made to:Vital Statistics Outputs Branch
      Life Events and Population Sources Division
      Office for National Statistics
      Segensworth Road
      Titchfield
      Fareham
      Hampshire
      PO15 5RR
      Tel: +44 (0)1329 444 110+44 (0)1329 444 110
      E-mail: vsob@ons.gsi.gov.uk

 

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This entry was posted in A Personal View, Consultants, Midwives, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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