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. Author manuscript; available in PMC: 2023 Sep 4.
Published in final edited form as: Public Health Nurs. 2022 Jan 17;39(4):744–751. doi: 10.1111/phn.13051

Physical activity changes among non-Hispanic Black pregnant women

Jean W Davis 1, Suzanne Hyer 1, Rui Xie 2, Valerie C Martinez 3, Jenna M Wheeler 1, Dawn P Misra 4, Carmen Giurgescu 5
PMCID: PMC10476508  NIHMSID: NIHMS1926594  PMID: 35037297

Abstract

Objective:

To examine aerobic physical activity (PA) among non-Hispanic Black pregnant women.

Design:

Longitudinal prospective cohort study.

Sample:

A subset of 161 non-Hispanic Black pregnant women from the Midwestern US participating in a larger study completed questionnaires about aerobic physical activity (PA) before pregnancy (reported at 24.46±2.13 weeks gestation), mid-pregnancy (24.46±2.13 weeks gestation), and late pregnancy (31.78±1.95 weeks gestation).

Measurements:

Aerobic PA was measured using the Rapid Assessment of Physical Activity (RAPA).

Results:

Most participants reported being active prior to pregnancy (n = 101, 63%), with 60 (37%) underactive/sedentary. Aerobic RAPA scores were highest pre-pregnancy (3.29±1.11, median = 4, interquartile range [IQR] = 1) compared with mid-pregnancy (3.05±1.26, median = 4, IQR = 2) and late pregnancy (3.05±1.24, median = 4, IQR = 2). Pre-pregnancy scores were significantly higher than mid-pregnancy scores (Wilcoxon test = 1472, p = .008) and late pregnancy scores (Wilcoxon test = 1854, p = .01).

Conclusion:

Most Black pregnant participants reported high levels of aerobic PA both before pregnancy and during pregnancy. However, many were underactive or sedentary. Aerobic PA decreased during pregnancy compared with pre-pregnancy, without the drop in third trimester PA found in other populations. Providers should assess PA across pregnancy and promote adequate PA for maternal and infant health, particularly among Black women.

Keywords: aerobic, African American, physical activity, pregnancy

1 |. INTRODUCTION

National and international guidelines emphasize health benefits of regular physical activity (PA) during pregnancy (American College of Obstetricians and Gynecologists [ACOG], 2020; Bull et al., 2020; Mottola et al., 2018; Piercy et al., 2018). The consensus of these guidelines recommends 150 min per week of moderate-intensity PA throughout pregnancy (ACOG, 2020; Bull et al., 2020; Mottola et al., 2018; Piercy et al., 2018). However, Black pregnant women were less likely to engage in PA compared with White pregnant women (Zhao et al., 2012). Women who are physically active during pregnancy are less likely to experience mild pregnancy side effects, such as backache, mood swings, and sleeping problems (Walasik et al., 2020). Furthermore, regular PA during pregnancy is associated with a decreased risk of excessive gestational weight gain, gestational diabetes, hypertension, pre-eclampsia, and postpartum depression symptoms (Dipietro et al., 2019; Harrison et al., 2016). Evidence suggests that PA during pregnancy may decrease risk for preterm birth, although the evidence is mixed (Orr, James, Garry, Prince, et al., 2006). This is important as preterm birth is a leading cause of infant death (ACOG, 2020; Aune et al., 2017) particularly among Black pregnant women (Misra et al., 1998; Sealy-Jefferson et al., 2014).

Aerobic activity, PA that increases the heart rate and body’s use of oxygen, promotes fitness, maternal health, and birth outcomes (ACOG, 2020). The World Health Organization recommends that pregnant women replace sedentary time with aerobic PA of any intensity, including light intensity PA (Bull et al., 2020). Yet, studies have shown that pregnant women often report decreased aerobic PA during pregnancy compared with pre-pregnancy. Pregnant women in general report significantly lower amounts of aerobic PA as pregnancy progresses (Croy et al., 2015; Evenson & Wen, 2010; Ussery et al., 2020; Walasik et al., 2020). Although aerobic PA among pregnant women has increasingly been studied, there is limited data on aerobic PA among Black pregnant women. Recently, analysis of combined data from the MOnitoring Movement and Health Study (n = 120) and the PRegnancy Activity Monitoring Study (n = 20) revealed higher likelihood of moderate-to-vigorous level aerobic PA among White pregnant women compared with Black pregnant women (Jones et al., 2021). In a large cohort, increased time walking for a purpose was associated with higher gestational age at birth among Black women (N = 1382) (Giurgescu et al., 2017). However, no published studies were found that examined PA changes across gestation in a cohort nor exclusively among Black pregnant women.

1.1 |. Research question and purpose

The purpose of this study was to examine aerobic PA across gestation among non-Hispanic Black pregnant women. The research question was, what PA change occurs across gestation among non-Hispanic Black pregnant women?

1.2 |. Theoretical framework

Transitions theory’s well-being focus during situational transition over time framed this study (Meleis, 2010). In this theory, a change in situation, such as pregnancy, may lead to disconnectedness from usual patterns of behavior, such as routine PA. To support healthy transitions, nurses may provide preventive interventions leading to personal well-being. Our focus was examining the single transition of aerobic PA during the situation transition of pregnancy among Black women.

2 |. METHODS

2.1 |. Design

Longitudinal data were collected prospectively from a sub-sample of pregnant Black women across gestation in a larger study. The ongoing National Institutes of Health supported study is aimed at determining the pathways by which social stressors (e.g., neighborhood disorder) affect preterm birth from a socioecological perspective. Assessment of PA was added to this study as research suggests aerobic PA has a positive effect on stress and wellbeing (Mandolesi et al, 2018; Tartar et al., 2018). Data reported here were collected between March 2018 and March 2020, prior to the declaration of the COVID-19 pandemic.

2.2 |. Sample

Women were enrolled in the larger study from urban prenatal clinics in the Midwestern US Women were included in the study if they self-identified as African American or non-Hispanic Black, were 18–45 years old, had a singleton pregnancy (e.g., no twins), were of any parity, were 8–29 weeks gestation, and were English-speaking. Women enrolled in the study between 8 and 18 weeks gestation (T1). To minimize participant burden, questions on both pre-pregnancy and current PA were not asked until 22–29 weeks gestation (T2). Among the 265 women who provided data on PA at the T2 timepoint, 161 also provided PA data at 30–36 weeks gestation (T3). As our focus was on change in PA, our analytic sample was comprised of the 161 women with PA data at all time points.

2.3 |. Procedures

Institutional Review Board approval at the study universities and clinical sites was obtained prior to the start of the study. Recruitment included flyers and pamphlets about the study posted at the participating prenatal clinics. Research staff approached eligible women in the waiting area in the clinic. In-person recruitment occurred at the clinics before or after provider or ultrasound visits. Research staff explained the study purpose and participation requirements and completed the consenting process with interested women.

Enrollment and retention were monitored and recorded. All women were provided with the study phone line to update contact information as needed. Each subsequent visit appointment was made during the current visit, if possible, otherwise by phone. Data collection occurred primarily during visits for routine prenatal care. Participants received a $30 gift card at each of the data collection points. There has been considerable experience conducting successful studies with Black pregnant women and application of cultural expertise to the development of study materials and research staff training as reported recently (Vaughan et al., 2021). We applied this knowledge to our study.

Participants entered de-identified questionnaire data online using the Qualtrics® Research Suite (Qualtrics, Provo, UT, USA). Qualtrics® is a comprehensive survey platform that allows questionnaire presentation, skip logic to the next appropriate question, flow logic, data collection, secure data storage, and data export. Maternal gestational age reported by questionnaire at each time point was verified through medical record review. The gestational age reported in the medical records was used if maternal report differed from the medical records.

2.4 |. Measures

Physical activity was measured using the Rapid Assessment of Physical Activity (RAPA) (Topolski et al., 2006). The RAPA is a self-report instrument to collect data on the amount (e.g., minutes per day, days per week), intensity (e.g., light, moderate, vigorous), and type (e.g., aerobic, flexibility, strengthening) of PA typically performed by the respondent (Topolski et al., 2006). Graphics are presented in the instrument to align with the PA concepts. The graphics are viewable at https://depts.washington.edu/hprc/wp-content/uploads/2021/02/RAPA-English.pdf. The RAPA was developed, through focus groups, as an easy means of assessing and interpreting physical activity in the clinical setting (Topolski et al., 2006). Criterion validity was established with the CHAMPS long form and also compared to the Behavioral Risk Factor Health Surveillance System (BRFSS) PA questions and the Patient-centered Assessment of Counseling and Exercise (PACE) (Harada et al., 2001; Stewart, Mills, et al., 2001; Stewart, Verboncoeur, et al., 2001; Topolski et al., 2006). The RAPA outperformed all (Harada et al., 2001; Stewart, Mills, et al., 2001; Stewart, Verboncoeur, et al., 2001; Topolski et al., 2006). Comparisons with the CHAMPS were favorable for both moderate caloric expenditure (Spearman’s rho = 0.54, p < .001) and total caloric expenditure (Spearman’s rho = 0.48, p < .001) among a sample of 115 adults ≥50 years (72% female, 18% African American). The sample was recruited through parks and recreation services, clinics, and senior centers in the US state of Washington. Test-retest reliability has since been determined using weighted kappa (K = 0.67, 95% CI [0.52, 0.81]) among adults for the Portuguese RAPA version (Silva et al., 2014).

The RAPA has nine items with seven items for aerobic PA type, intensity, and amount in minutes and days/week (e.g., “I rarely or never do any physical activities”; “I do 30 minutes or more a day of moderate physical activities, 5 or more days a week”). The other 2 RAPA items assess flexibility PA (one item) and strengthening PA (one item). All items use a Yes/No response set. RAPA instrument scoring of the aerobic PA items is achieved by transforming the highest amount of aerobic PA item with a Yes response into the RAPA instrument score using the instrument’s scoring instructions (Topolski et al., 2006). This produces an ordinal score from sedentary to active wherein 0 = sedentary, 1 = under-active, 2 = under-active regular-light activities, 3 = under-active regular activity, and 4 = active. Higher RAPA instrument scores represent more weekly aerobic PA (range 0–4). The RAPA was administered at two timepoints: mid-pregnancy (24.5±2.13 weeks gestation) to assess pre-pregnancy PA (the year before pregnancy) and mid-pregnancy PA (current at time of collection); and in late pregnancy (31.8±1.93 weeks gestation) to assess late-pregnancy PA. Ordinal alpha (Gadermann et al., 2012) was 0.78 for pre-pregnancy, 0.63 for mid-pregnancy, and 0.74 for late pregnancy in this study among Black pregnant women. Although the low number of questions in the scale (7) may result in a low alpha (Tavakol & Dennick, 2011), alphas of 0.60 to 0.70 are considered acceptable, although not ideal (Lance et al., 2006; Taber, 2018; Ursachi et al., 2015).

Maternal demographic characteristics were measured using a self-report questionnaire. Characteristics were derived from literature that conceptually or empirically links them to PA among pregnant women and included maternal age, level of education, marital status/living with father of the baby, employment status, and household income (Evenson et al., 2009; Ussery et al., 2020).

2.5 |. Analytic strategy

Data analysis aligned with the purpose of the study to explore aerobic PA changes across pregnancy among Black pregnant women as self-reported. Statistical analyses were conducted using R version 4.1 with a significance level set at 5%. Descriptive statistics, including means, standard deviations (SD), medians, interquartile ranges (IQR), frequencies, and percentages were calculated. Ordinal alpha was calculated for the RAPA instrument for each time point. Aerobic RAPA scores are not normally distributed, failing the Shapiro-Wilk normality test; these data required use of nonparametric methods. Thus, the paired Wilcoxon signed rank test was used to compare the aerobic RAPA scores between data recalled for pre-pregnancy and mid-pregnancy, mid-pregnancy and late pregnancy, and pre-pregnancy and late pregnancy.

3 |. RESULTS

3.1 |. Sample and demographic descriptive statistics

The 161 participants had a mean age of 27.0±5.4 years and a mean gestational age of 24.5±2.13 weeks gestation at mid-pregnancy and 31.8±1.93 weeks gestation at late pregnancy. Most participants had an annual household income of less than $20,000 (55%), were employed (56%), and reported highest level of education as high school diploma or GED or less (58%). Most participants who chose to respond to the question, are you married to/living with the baby’s father, responded affirmatively (91%). (See Table 1 for sample demographic characteristics.)

TABLE 1.

Sample demographic characteristics

Characteristic Results
Mean ± SD
Age (years) 27.0 ± 5.4
n (%)
Highest Level of Education
 Less than High school 23 (14.3)
 Graduated High School or GED 70 (43.5)
 Technical/ vocational training 16 (9.9)
 Some college 43 (26.7)
 Associate degree   4 (2.5)
 Bachelor’s degree   3 (1.9)
 Graduate program or higher   2 (1.2)
Marital Status
 Married to or living with the baby’s father 58 (36.0)
 Not married to or living with the baby’s father   6 (3.7)
 Preferred not to answer 97 (60)
Employment Status
 Working 90 (55.9)
 Temporarily laid off   7 (4.3)
 Not working 64 (39.8)
Household Income
 less than $10,000 61 (37.9)
 $10,000–$19,999 27 (16.8)
 $20,000–$29,999 35 (21.7)
 $30,000–$39,999 24 (14.9)
 $40,000–$59,999   9 (5.6)
 $60,000–$79,999   2 (1.2)
 more than $80,000   3 (1.9)
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Note. N = 161.

Abbreviation: GED, General Educational Development test.

3.2 |. Physical activity change across pregnancy

We calculated aerobic RAPA scores using the RAPA scoring matrix to determine participants’ activity status at pre-pregnancy, mid-pregnancy, and late pregnancy. Most participants reported being active prior to pregnancy (n = 101, 63%), with 55 participants underactive (34%) and five participants sedentary (3%) prior to pregnancy (See Figure 1). Overall (not a pairwise comparison) there was a lower proportion of active women in the mid-pregnancy period and lower still in the late pregnancy period (See Figure 1).

FIGURE 1.

FIGURE 1

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Aerobic RAPA score categories at pre-pregnancy, mid-pregnancy, and late pregnancy. Note. Bar graph of proportion of 161 participants in each aerobic physical activity category are shown for each time period. Aerobic physical activity category 0 = sedentary, 1 = under-active, 2 = under-active regular-light, 3 = under-active regular, 4 = active; RAPA = Rapid Assessment of Physical Activity

Changes in RAPA category for participants from pre-pregnancy category to mid-pregnancy, and from mid-pregnancy category to late-pregnancy: the numbers of women who were in each category compared to the next are presented in pivot Tables 2 and 3. Qualitatively, it appears that women were less active mid-pregnancy and late pregnancy compared with pre-pregnancy (See Figure 2).

TABLE 2.

Aerobic RAPA activity level changes from baseline (pre-pregnancy) to mid pregnancy

Mid-pregnancy n (%)
Aerobic RAPA RAPA = 0 sedentary (n = 13) =1 under-active (n = 3) =2 under-activelight activities (n = 36) =3 under-active regular (n = 20) =4 active (n = 89)
Pre-pregnancy RAPA = 0 (n = 5) 3 (60%) 0 (0%)   0 (0%)   1 (20%)   1 (20%)
RAPA = 1 (n = 13) 1 (8%) 2 (15%)   8 (62%)   0 (0%)   2 (15%)
RAPA = 2 (n = 13) 0 (0%) 0 (0%)   9 (69%)   1 (8%)   3 (23%)
RAPA = 3 (n = 29) 3 (10%) 0 (0%) 10 (34%)   7 (24%)   9 (31%)
RAPA = 4 (n = 101) 6 (6%) 1 (1%)   9 (9%) 11 (11%) 74 (73%)
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Abbreviation: RAPA, Rapid Assessment of Physical Activity.

TABLE 3.

Aerobic RAPA activity level changes from mid-pregnancy to late pregnancy

Late Pregnancy n (%)
Aerobic RAPA RAPA = 0 sedentary (n = 11) =1 under-active (n = 6) = 2 under-activelight activities (n = 35) = 3 under-active regular (n = 21) =4 Active (n = 88)
Mid-pregnancy RAPA = 0 (n = 13) 6 (46%) 2 (15%)   3 (23%) 1 (8%)   1 (8%)
RAPA = 1 (n = 3) 0 (0%) 0 (0%)   2 (67%) 1 (33%)   0 (0%)
RAPA = 2 (n = 36) 3 (8%) 2 (6%) 14 (39%) 7 (19%) 10 (28%)
RAPA = 3 (n = 20) 1 (5%) 1 (5%)   2 (10%) 4 (20%) 12 (60%)
RAPA = 4 (n = 89) 1 (1%) 1 (1%) 14 (16%) 8 (9%) 65 (73%)
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Abbreviation: RAPA, Rapid Assessment of Physical Activity.

FIGURE 2.

FIGURE 2

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Box Plot of Participants’ RAPA Scores at Pre-pregnancy, Mid-pregnancy, and Late Pregnancy. Note. Box plots of participants’ aerobic Rapid Assessment of Physical Activity (RAPA) scores are shown over time with significance level of indicated above boxes (*p = .01; **p = .08 level; ns = not significant). Aerobic physical activity categories are 0 = sedentary, 1 = under-active, 2 = under-active regular-light, 3 = under-active regular, 4 = active

We next examined changes in aerobic PA among participants by comparing the aerobic RAPA scores for each period and conducting statistical tests for those changes. Mean aerobic RAPA scores were as follows: pre-pregnancy (3.29±1.11, median = 4, IQR = 1, range = 0–4), mid-pregnancy (3.05±1.26, median = 4, IQR = 2, range = 0–4) and late pregnancy (3.05±1.24, median = 4, IQR = 2, range = 0–4). Differences in aerobic RAPA scores for pre-pregnancy, mid-pregnancy, and late pregnancy were compared using the paired Wilcoxon signed rank test. Pre-pregnancy aerobic RAPA scores were significantly higher than both mid-pregnancy scores (Wilcoxon test = 1472, p = .008) and late pregnancy scores (Wilcoxon test = 1854, p = .01). We found no significant changes between mid-pregnancy aerobic RAPA scores and late-pregnancy scores (Wilcoxon test = 1352, p = .41) (See Figure 1).

4 |. DISCUSSION

Our study used a validated instrument to assess aerobic PA across gestation among Black pregnant women (Topolski et al., 2006). Few studies have used validated PA instruments in pregnancy (Harrison et al., 2011; Sattler et al., 2018). Aerobic PA significantly decreased from pre-pregnancy to mid- and late pregnancy, but it did not change from mid-to late pregnancy among participants in our study. This finding among our Black pregnant participants is not consistent with the timewise decline in PA across pregnancy, especially decline in the third trimester, found in studies that did not report by race and ethnicity (Gaston & Cramp, 2011; Pereira et al., 2007; Santo et al., 2017; Ussery et al., 2020). This may be related to the relatively low level of aerobic PA among many of our participants at baseline, with 37% being sedentary or underactive pre-pregnancy. Black women have lower PA in general throughout adulthood and during pregnancy (Williams et al., 2018; Zhao et al., 2012). We see two possible explanations for the lack of decline in aerobic PA from mid- to late pregnancy in our cohort. First, the relatively low level of mid-pregnancy PA leaves little room for decline with late pregnancy. Also, the pre-pregnancy PA level may have dropped at pregnancy to the lowest amount to support lifestyle (e.g., occupational and home task PA) precluding further decline across pregnancy.

Barriers to PA found among pregnant women generally include lack of motivation, social support, and knowledge of recommended and safe PA for pregnant women (Davis et al., 2021; Evenson et al., 2009). Costs of gym membership, exercise sessions, childcare, and transportation and a lack of social support have been identified as barriers to exercise among Black pregnant women (Davis et al., 2021). Neighborhood environment such as walkability, disorder, and perceived crime may inhibit PA since walking is the most common form of leisure time PA in the United States and among pregnant women (Evenson et al., 2009; Laraia et al., 2007). Neighborhood safety may have been a deterrent to PA among our study participants. Our participants were recruited from urban prenatal clinics, thus likely lived in urban areas. Also, most participants had a low level of household income, which may have led to living in a low-income urban neighborhood with unsafe streets to walk on. Future analysis with a larger sample size will be able to examine how neighborhood walkability may relate to our findings. Also reported are associations between increased PA and positive health outcomes such as lower levels of depression and increased active coping among Black pregnant women (Orr et al., 2006). Yet, sparse interventional research has occurred aimed at promotion of PA among Black pregnant women for purposes such as prevention of excessive gestational weight gain (Liu et al., 2015).

Although engaging in guideline-meeting PA is considered a rational choice, biopsychosocial impediments may pose barriers to healthy behaviors, like PA, and require consideration of the context, such as structural impediments and self-efficacy for PA (Short & Mollborn, 2015). The context of PA includes competing demands. Pregnant women may have sedentary work which limits their ability to engage in PA during work hours. Home demands may prevent PA, for instance when no childcare is available. Additional potential impediments to PA include weight gain and physiologic changes of pregnancy such as joint laxity. As the center of gravity changes with pregnancy, affecting balance, fear of falling may result in less leisure time PA. Participants may lack the self-efficacy to perform PA without accessible resources or adequate instructions. Motivational interviewing is a research-based method of improving self-efficacy for PA recommended for use with pregnant women (ACOG, 2009), and group PA programs that include instruction on safe PA during pregnancy are recommended (Davis et al., 2021).

5 |. LIMITATIONS

Physical activity was self-reported from recall which may be inaccurate, particularly as pre-pregnancy PA was measured at mid-pregnancy (mean±SD 24.5±2.13 weeks gestation) with instruction to “Think back to the year before you became pregnant”. However, it should be emphasized that the RAPA has been rigorously validated (see Methods) against multiple other measures. Self-selection bias may have resulted in only 161 of the 265 participants who were asked PA questions providing responses for each time point. People with an affinity for PA may have been more likely to respond to these questions. Thus, influencing our findings of no significant difference in aerobic RAPA scores between mid-and late pregnancy and high proportion of women who scored in the active range throughout pregnancy. Sample size (N = 161) and recruitment area (urban Midwestern US) limit the generalizability of the findings even among Black pregnant women.

6 |. CONCLUSIONS AND PRACTICE IMPLICATIONS

Physical activity plays an important role in the promotion of maternal health and positive birth outcomes. Yet, PA declined from prepregnancy to mid-pregnancy and late pregnancy among our non-Hispanic Black pregnant participants. Our findings of less PA during pregnancy are consistent with other reports for pregnant women in general. However, we did not see the significant third trimester PA decline consistently found in other populations (Gaston & Cramp, 2011; Pereira et al., 2007; Santo et al., 2017; Ussery et al., 2020). Thus, our study adds to the existing body of knowledge surrounding PA among Black pregnant women. This difference may be explained by low PA among Black women in general and the high percentage of our participants reporting pre-pregnancy PA in the underactive or sedentary range (37%). Barriers to PA among Black pregnant women in our prior research include financial, transportation, childcare, and safe exercise space challenges (Davis et al., 2021).

Healthcare providers, including public health nurses, should assess Black pregnant women’s PA and support them to meet ACOG (2020) opinion recommendations for 150 min/week of moderate-intensity PA before, during, and after pregnancy. Providers should use motivational interviewing to improve self-efficacy for PA, set PA goals with Black pregnant women, and instruct on safe PA during pregnancy (ACOG, 2009; Davis et al., 2021). Healthcare providers need to make Black pregnant women aware of the accessible resources in their communities (e.g., low or no cost, accessible by active or public transportation) as needed to support adequate PA during pregnancy. Future research should include objective measurement of PA (e.g., PA tracking devices) before and throughout pregnancy to determine changes. Randomized controlled trials are needed to determine feasible and effective interventions to promote adequate PA throughout pregnancy. More research on barriers to and facilitators of PA among Black pregnant women is needed. Also, interventions to promote and sustain PA among Black pregnant women and research to determine their effects on maternal and infant health are needed. Policy makers should enact policies to create or enhance safe, freely accessible spaces for PA, particularly within geographic areas with maternal morbidity and mortality disparities.

ACKNOWLEDGEMENTS

Carmen Giurgescu and Dawn Misra received funding from the National Institutes of Health, National Institute on Minority Health and Health Disparities, NIH Grant # R01 MD 01157502. We would like to acknowledge all the participants in this study.

Footnotes

CONFLICT OF INTEREST

We have no known conflicts of interest to disclose.

DATA AVAILABILITY STATEMENT

Author elects to not share data

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