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. Author manuscript; available in PMC: 2026 Jun 6.
Published in final edited form as: Disabil Health J. 2026 Feb 14;19(3):102052. doi: 10.1016/j.dhjo.2026.102052

Race, ethnicity, and nativity differences in pregnancy and birth outcomes among Medicaid-enrolled women with disabilities

Alka Dev a,*, Willi Horner-Johnson b, Andrew Schaefer a, Thérèse A Stukel c,d, David C Goodman a, JoAnna K Leyenaar a,e
PMCID: PMC13237495  NIHMSID: NIHMS2178767  PMID: 41714270

Abstract

Background:

Women with disabilities have worse maternal health outcomes than women without disabilities, but we have a limited understanding of other disparities they face.

Objective:

Investigate whether differences in pregnancy and birth outcomes vary by race, ethnicity, and nativity among low-income women with disabilities.

Methods:

We conducted a retrospective cohort study of 24,631 live births to Medicaid-enrolled women with disabilities in Texas. We used linked administrative claims with birth certificate data to examine outcomes, including cesarean delivery, severe maternal morbidity (SMM), preterm birth (PTB), low birthweight (LBW), and small for gestational age (SGA). Modified Poisson regression estimated relative risks (RRs) for associations by race, ethnicity, and nativity.

Results:

Non-Hispanic Black women with disabilities had significantly higher risks compared to non-Hispanic White women for SMM (RR 1.54; 95% CI: 1.25–1.90), PTB (RR 1.21; 95% CI: 1.09–1.34), LBW (RR 1.53; 95% CI: 1.37–1.71), and SGA (RR 1.94; 95% CI: 1.67–2.27). Hispanic women overall did not differ significantly from White women. Foreign-born Hispanic women had lower risks for PTB (RR 0.76; 95% CI: 0.64–0.89), LBW (RR 0.68; 95% CI: 0.56–0.82), and SGA (RR 0.76; 95% CI: 0.59–0.99) than US-born Hispanic women, and were less likely to undergo cesarean delivery (RR 0.89; 95% CI: 0.82–0.96).

Conclusion:

Findings highlight racial disparities in adverse maternal outcomes among women with disabilities and reveal important nativity-based differences within the Hispanic population. These results suggest the need for tailored pregnancy care interventions that address disability status alongside intersecting factors of race, ethnicity, and acculturation.

Keywords: Disability, Preterm birth, Low birthweight, Pregnancy, Interventions

1. Introduction

Approximately 700,000, or one in five births in the U.S., are to someone who has at least one disability.1 Women with disabilities experience disproportionately higher rates of pregnancy complications and adverse birth outcomes compared to those without disabilities, including severe maternal morbidity (SMM), stillbirth, preterm birth (PTB), low birthweight (LBW), and infant mortality.2–4 Estimates of disability prevalence vary depending on the method used to identify disability, but there is consistent evidence that the prevalence is higher among Native American, Black, and Hispanic individuals compared to White individuals and among women compared to men.5–7 Over 20% of Black and American Indian or Alaska Native people in the U.S. report having at least one disability.8 Racial and ethnic inequalities could further compound the risk of adverse pregnancy and birth outcomes among individuals with disabilities, underscoring intersectional challenges to achieving healthy outcomes.9 For example, compared to White individuals without disabilities, racial and ethnic minorities with disabilities are at an elevated risk of unintended pregnancies and preconception health risks, which are associated with adverse maternal and infant health outcomes.10–12.

In a recent cohort study of delivery hospitalizations, Black birthing individuals with physical disabilities had a far higher risk of maternal mortality, compared to White birthing individuals with no disabilities, than those who were only Black or only disabled. In fact, more than half of the risk of maternal mortality among Black birthing individuals with physical disabilities was attributable to the interaction between being Black and being disabled.13 Within disability populations, non-Hispanic Black and Hispanic mothers with intellectual and developmental disabilities (IDD) had 2.5 times the odds of a stillbirth13 and 1.7 times higher odds of PTB11 when compared to their White counterparts with IDD.

While disparities between Hispanic and white populations may appear less pronounced in some contexts, important differences emerge when examining nativity status within Hispanic communities. Research in the general population has shown that foreign-born Hispanic women often experience more favorable birth outcomes compared to their U.S.-born counterparts.14,15 However, it remains unclear whether this protective effect of foreign birth status extends to Hispanic women with disabilities, representing a gap in our understanding of how nativity intersects with disability to influence maternal and birth outcomes.

Building on emerging evidence of intersectional inequities in maternal disability, we examined disparities in pregnancy and birth outcomes among women with disabilities, focusing on race, ethnicity, and nativity. Specifically, we studied differences in cesarean delivery, severe maternal morbidity (SMM), preterm birth, low birth weight (LBW), and neonates small for gestational age (SGA) between non-Hispanic Black, Hispanic, and non-Hispanic White women with disabilities. We also explored whether outcomes differed among pregnant Hispanic women with disabilities by nativity status (U.S.-born vs. foreign-born).

2. Methods

2.1. Study design and population

This is a retrospective cohort study of 24,631 livebirths to women with disabilities who were enrolled in Texas Medicaid from January 2010 to December 2014. The dataset consisted of maternal and infant claims data linked to infant birth certificate data, with 2014 being the most recent year for which linked data are currently available. We identified disability based on either enrollment in a disability managed care program (known as STAR+) or having at least one diagnosis code associated with disability, using the International Classification of Diseases – Ninth Edition (ICD-9), recorded during two prenatal care visits, one emergency room visit, or one hospitalization, as described in previous work.16,17 We excluded births to women without identified disabilities, multiple gestation births, as well as births with more than one race, other race, or unknown race and ethnicity. (Fig. 1).

Fig. 1.

Fig. 1.

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Sample selection.

We included information on maternal eligibility from enrollment files; disability and pregnancy outcomes from maternal claims; infant outcomes from infant claims and birth certificate files; and self-reported maternal race, ethnicity, country of birth, and other demographic characteristics from birth certificate files. We also included the duration of Medicaid enrollment (1–12 months) to understand when people gained coverage in relation to their pregnancy.

The study received approval from the institutional review boards of Dartmouth College, the University of Texas Health Science Center, and the Texas Health and Human Services Commission, with a waiver of informed consent according to 45 CFR 46.116(d). It adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cohort studies.

2.2. Race, ethnicity, and nativity

The independent variable included three mutually exclusive categories for race and ethnicity: with 1) non-Hispanic Black, 2) Hispanic, and 3) non-Hispanic White. Births to Hispanic mothers were further disaggregated by maternal place of birth (U.S. or foreign-born) to assess nativity. Sample sizes were too small to include the country of origin of Hispanic mothers or foreign-born Black or White women as separate categories. Data on race, ethnicity, and maternal place of birth were drawn from infant birth certificate files and reported by the mother or family. We utilized these five groups to capture two separate but related social phenomena in the U.S. First, we used race as a measure of racism, with the understanding that Black individuals experience multiple levels of racism, which impacts their health outcomes.18 Second, nativity status within the Hispanic population is a salient factor for predicting outcomes across many health conditions, potentially driven by multiple overlapping acculturative processes.19 For example, acculturation may lead to the adoption of unhealthy behaviors and erosion of health-promoting community bonds that result in U.S. and foreign-born individuals’ exposure to different risk factors for morbidity and mortality.20 Further, acculturative stress may exacerbate disabling conditions.21

2.3. Outcomes

Outcomes included 1) cesarean delivery, 2) SMM (defined per Centers for Disease Control guidelines) including any one of 21 conditions occurring during the birth hospitalization,22 as reported in maternal professional and facility claims; 3) PTB defined as a birth occurring at less than 37 weeks gestation,23 as reported on the birth certificate; 4) LBW defined as a newborn weighing less than 2500 g at birth,24 as reported on the birth certificate; and 4) SGA defined as a birth weight of less than the 10th percentile for gestational age and sex using the International Fetal and Newborn Growth Consortium for the 21st Century standards and derived from birth certificate data.25 Because receiving only a blood transfusion, without any other accompanying condition and without data on the amount of blood transfused, may lead to an overestimation of severe morbidity, we reported SMM cases both including and excluding those attributed solely to blood transfusion.26,27 Outcomes data were drawn from maternal and infant claims, as well as infant birth certificate files.

2.4. Covariates

We included covariates that could act as confounders when assessing the association of race, ethnicity, or nativity with our chosen outcomes. These included maternal age (15–44 years), education, marital status, parity, smoking status, and severe mental illness, as well as infant’s sex (all obtained from birth certificate data), and rurality based on zip code (obtained from maternal claims).

2.5. Statistical analysis

We calculated means for continuous variables and proportions for categorical variables across the following race and ethnicity groups: non-Hispanic Black, Hispanic, and non-Hispanic White, and separately across two nativity groups: US-born Hispanic and foreign-born Hispanic. We report descriptive statistics with standardized differences, with differences of an absolute value of <0.1 indicating balance across groups.28

Adjusted relative risks (aRRs) and 95% confidence intervals (CIs) for each of the four outcomes were estimated using generalized estimating equation (GEE) Poisson models29 with the individual newborn as the unit of analysis and maternal race or Hispanic ethnicity as the primary independent variables with non-Hispanic White women serving as the reference category. We also produced aRRs for births to foreign-born Hispanic individuals with disabilities, with US-born Hispanic individuals with disabilities as the reference category. We adjusted for any clustering of births within mothers to reduce the genetic or environmental correlation of birth outcomes.30 For SMM, we estimated aRRs for cases that excluded those who only received a blood transfusion but had no other indication. The full regression models are presented in Appendix 1.

3. Results

3.1. Sample characteristics

In our sample of 24,631 births to women with disabilities, a majority (39.5%) were to Hispanic women born in the U.S (Table 1). The most common form of recorded maternal disability was physical across all groups (62.3%), with the largest proportion among White women (74.6%). Standardized differences had an absolute value < 0.1 for most covariates, but some notable differences were observed. Compared to White mothers, Black mothers were more likely to be enrolled in STAR+ (38.8% vs. 15.3%) and have a longer mean duration of Medicaid enrollment in the year preceding delivery (10.5 months vs. 9.4 months). Hispanic mothers had a comparable duration of enrollment in Medicaid preceding delivery compared to White mothers (9.8 months vs. 9.4 months), but further disaggregation by nativity revealed that there was a substantial difference in the duration of enrollment between US-born Hispanic mothers (10.2 months) and foreign-born Hispanic mothers (7.7 months). US-born Hispanic mothers were also more likely to be enrolled in STAR + compared to foreign-born Hispanic mothers (24.2% vs. 13.2%).

Table 1.

Maternal characteristics for births to women with disabilities enrolled in Texas Medicaid, by race, ethnicity, and nativity status (2010 – 2014).

All Births (n = 24,631) All Hispanic Births (n = 11,702)
White, NH Black, NH Std. Difference (ref = White) Hispanic, All Std. Difference (ref = White, NH) Hispanic, US Born Hispanic, Foreign Born Std. Difference (ref = US born)
Number of births (%) 7525 (30.6%) 5404 (21.9%) 11,702 (47.5%) 9735 (39.5%) 1967 (8.0%)
Number of women (%) 6610 (31.3%) 4629 (21.8%) 9996 (47.1%) 8178 (38.5%) 1818 (8.6%)
Enrollment months in year before birth, mean (SD) 9.4 (2.6) 10.5 (2.4) −0.428 9.8 (3) −0.149 10.2 (2.4) 7.7 (4.5) −0.540
Maternal age, mean (SD), years 25.6 (5.5) 25.1 (5.6) 0.077 25.1 (6.1) 0.083 24.4 (5.7) 28.6 (6.5) 0.564
Disability Type
 Physical 5610 (74.6%) 2694 (49.9%) 0.527 7044 (60.2%) 0.310 5784 (59.4%) 1260 (64.1%) −0.096
 Sensory 587 (7.8%) 436 (8.1%) −0.010 1608 (13.7%) −0.193 1242 (12.8%) 366 (18.6%) −0.161
 Intellectual 314 (4.2%) 277 (5.1%) −0.045 797 (6.8%) −0.116 638 (6.6%) 159 (8.1%) −0.059
 STAR + Only 1148 (15.3%) 2096 (38.8%) −0.550 2617 (22.4%) −0.183 2357 (24.2%) 260 (13.2%) 0.285
Maternal education
 < High school 1776 (23.6%) 1649 (30.5%) −0.156 4591 (39.2%) −0.342 3589 (36.9%) 1002 (50.9%) −0.286
 High school 2998 (39.8%) 2176 (40.3%) −0.009 4305 (36.8%) 0.063 3691 (37.9%) 614 (31.2%) 0.141
 College+ 2751 (36.6%) 1579 (29.2%) 0.157 2806 (24%) 0.276 2455 (25.2%) 351 (17.8%) 0.180
 Marital Status (% married) 2805 (37.3%) 838 (15.5%) 0.510 4069 (34.8%) 0.052 3044 (31.3%) 1025 (52.1%) −0.432
Parity
 1 2905 (38.6%) 1960 (36.3%) 0.048 4484 (38.3%) 0.006 3867 (39.7%) 617 (31.4%) 0.175
 2 2180 (29%) 1416 (26.2%) 0.062 2931 (25%) 0.088 2441 (25.1%) 490 (24.9%) 0.004
 >3 2439 (32.4%) 2024 (37.5%) −0.106 4287 (36.6%) −0.089 3427 (35.2%) 860 (43.7%) −0.175
 Severe mental illness 2676 (35.6%) 1822 (33.7%) 0.039 3357 (28.7%) 0.148 2929 (30.1%) 428 (21.8%) 0.191
 Smoked in pregnancy (%) 1844 (24.5%) 452 (8.4%) 0.446 n/a n/a 350 (3.6%) <11 (0%) n/a
 Newborn was female (%) 3625 (48.2%) 2665 (49.3%) −0.023 5689 (48.6%) −0.009 4732 (48.6%) 957 (48.7%) −0.001
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*

Disability types are not mutually exclusive. Multiple disabilities are <2% among Black and White women and <4% among Hispanic women. n/a = not available due to sample size restrictions for Hispanic, Foreign born.

Compared to White mothers, Black mothers were less likely to have a high school education (30.5% vs. 23.6%), be married (15.5% vs. 37.3%), or smoke during pregnancy (8.4% vs. 24.5%). Foreign-born Hispanic mothers were less likely to have completed high school (50.9% vs. 36.9%) and more likely to be married (52.1% vs. 31.3%) and older (mean age of 28.6 years vs. 24.4 years) than their U.S.-born counterparts. Foreign-born women had the lowest rates of severe mental illness.

3.2. Relative risk of adverse birth outcomes

3.2.1. Black, hispanic, and white comparisons

Compared to births to White mothers with disabilities, births to Black mothers had a higher risk of being preterm (aRR = 1.21; 95% CI:1.09–1.34; p < 0.001), low birthweight (aRR = 1.53; 95% CI:1.37–1.71; p < 0.001), or small for gestational age (aRR = 1.94; 95% CI:1.67–2.27; p < 0.01) (Table 2). Births to Black mothers were also more likely to be complicated by severe maternal morbidity, excluding transfusion (aRR = 1.54; 95% CI:1.25–1.90; p < 0.01). There were no differences in the risk of a cesarean delivery among Black mothers compared to White mothers with disabilities. Births to Hispanic mothers carried no additional risks for any outcome when compared to births to White mothers.

Table 2.

Risk of maternal and newborn outcomes by race, ethnicity, and nativity among people with disabilities.

All Births (n = 24,631) All Hispanic Births (n = 11,702)
Non-Hispanic White Non-Hispanic Black Hispanic US-Born Foreign-born
n (%) aRR (95% CI) n (%) aRR (95% CI) n (%) aRR (95% CI) n (%) aRR (95% CI) n (%) aRR (95% CI)
Cesarean delivery 41.6% ref 2174 (40.2%) 1.01 (0.95–1.07) 4861 (41.5%) 1.02 (0.98–1.07) 4106 (42.2%) ref 755 (38.4%) 0.89** (0.82–0.96)
SMM (without transfusion) 36/10,000 ref 296 (5.5%) 1.54*** (1.25–1.90) 425 (3.6%) 1.07 (0.88–1.29) 341 (3.5%) ref 84 (4.3%) 0.92 (0.69–1.23)
SMM (with transfusion) 49/10,000 ref 415 (7.7%) 1.54*** (1.29–1.84) 622 (5.3%) 1.05 (0.89–1.24) 514 (5.3%) ref 108 (5.5%) 0.86 (0.66–1.11)
Preterm birth 15.3% ref 1001 (18.5%) 1.21*** (1.09–1.34) 1787 (15.3%) 0.93 (0.85–1.02) 1543 (15.9%) ref 244 (12.4%) 0.76*** (0.64–0.89)
Low birthweight 960 (12.8%) ref 964 (17.8%) 1.53*** (1.37–1.71) 1442 (12.3%) 0.97 (0.87–1.08) 1263 (13.0%) ref 179 (9.1%) 0.68*** (0.56–0.82)
Small for gestational age 513 (6.8%) ref 581 (10.8%) 1.94*** (1.67–2.27) 732 (6.3%) 1.04 (0.90–1.21) 631 (6.5%) ref 101 (5.1%) 0.76* (0.59–0.99)*
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aRR = adjusted relative risk. 95% confidence interval in parenthesis;

***

p < 0.001,

**

p < 0.01,

*

p < 0.5.

Adjusted for age, education, marital status, parity, smoking, mental illness, infant sex, and rurality. Full models in Appendix 1.

3.2.2. Nativity comparisons

When examining births to Hispanic mothers by nativity, we found that, in comparison to births to US-born mothers, births to foreign-born Hispanic mothers were at lower risk (Table 2). Foreign-born Hispanic mothers had a lower risk of cesarean delivery (aRR = 0.89; 95% CI: 0.82–0.96; p < 0.01), preterm delivery (aRR = 0.76; 95% CI:0.64–0.89; p < 0.01), and having neonates with low birthweight (aRR = 0.68; 95% CI:0.56–0.82; p < 0.01), or SGA (aRR = 0.76; 95% CI:0.59–0.99; p < 0.01). We did not observe statistically significant differences in severe maternal morbidity by Hispanic nativity.

4. Discussion

Few studies have analyzed births to disabled individuals by race and ethnicity, and to our knowledge, none have examined these outcomes by nativity status. We used a unique dataset of linked Medicaid claims and birth certificate files to provide insights into the intersection of disability, race, ethnicity, and nativity in association with pregnancy and birth outcomes among Medicaid-enrolled women with disabilities. Our results show clear racial disparities similar to those documented in the general population, with a higher risk of preterm birth, low birthweight, and SGA among non-Hispanic Black women compared to non-Hispanic White women with disabilities. These findings may be related to differential access to quality prenatal care and the social and economic disadvantages that disproportionately affect Black women, even within a relatively socioeconomically homogenous Medicaid population with disabilities.31 Although Black mothers in our sample had the longest mean duration of enrollment, this may also indicate that they experienced more severe disabilities with significantly worse consequences.

To our knowledge, this is the first study to compare births by Hispanic nativity within the disability population. Foreign-born Hispanic women with disabilities had lower risks of adverse outcomes compared to their U.S.-born counterparts, despite having lower educational attainment and fewer months of enrollment in Medicaid. This finding suggests that protective sociocultural factors, such as stronger community support networks, dietary or behavioral practices, or lower acculturative stress, may mitigate risk among foreign-born women, even in the presence of disability. Supporting this interpretation, the lowest rates of severe mental illness were observed in foreign-born Hispanic women.

Initial evidence from the general population supports this concept, known as the “Latina paradox,” which indicates that foreign-born Hispanic individuals tend to have a lower risk of adverse birth outcomes compared to their White or US-born counterparts.32 For example, national birth records showed that US-born Hispanic women experienced higher rates of preterm birth, low birthweight, and SGA compared to their foreign-born counterparts, with some variation based on country of origin.14 In a cohort from New York City, women from Puerto Rico and Cuba faced higher risks of adverse outcomes like low birthweight and SGA, whereas women from Mexico and South America had lower risks, both in comparison to White women.15 Another study confirmed similar trends, showing that Puerto Rican women had significantly worse outcomes than other Hispanic groups, while foreign-born individuals consistently had lower rates of adverse outcomes than those born in the U.S.33 Although we identified a similar paradox in the disability population, i.e. foreign born Hispanic women had better outcomes than US-born Hispanic women, our sample size was too small to analyze outcomes by the specific country of birth for foreign-born women. It is also possible that our findings reflect a livebirth bias,34 as restricting the analysis to a livebirth cohort would prevent us from capturing potential disparities in the risk of fetal demise between foreign- and U.S.-born Hispanic women. However, to our knowledge, there is currently no evidence suggesting differential risks of fetal demise by nativity among Hispanic women.

Others have reported racial disparities in birth outcomes among women with disabilities, with some notable differences from our study. In linked hospital discharge and vital records from California, Black women with physical disabilities had six times the risk of severe maternal morbidity compared to nondisabled White women, while Hispanic women had 3.7 times the risk.35 While we report a much lower relative risk of severe maternal morbidity by race and no difference in severe maternal morbidity risk by ethnicity, the attenuation of disparities is expected given the change in the reference group. Our analysis holds disability status constant by restricting the cohort to women with disabilities. Consequently, the relative risks reported here are not directly comparable in magnitude to those reported in California. However, our findings demonstrate that racial disparities persist even among women with disabilities, underscoring the independent role of systemic racism beyond disability status alone.

4.1. Limitations

This study had a few limitations. First, some women in our sample may have had disability-related diagnoses that were not reflected in their claims or enrollment files, resulting in their misclassification as not being disabled. In particular, diagnoses may have been less likely to be coded if the disability was not visible or severe, leading to women with less apparent disabilities being excluded from our sample. Second, our analyses were descriptive and were not intended to suggest that race, ethnicity, or nativity causes adverse outcomes. Unfortunately, we could not measure underlying exposures to racial discrimination, nor the degree of acculturation for those born outside the U.S. Third, we lacked sufficient sample sizes to examine country of maternal birth within Hispanic groups, or nativity among non-Hispanic groups, constraining our ability to assess cultural or immigration-related heterogeneity in outcomes. Larger samples would provide deeper insights into the disparities in adverse birth outcomes between individuals with disabilities born in the U.S. and those born in other countries, which would help with informing targeted interventions. Fourth, given that our data only included linkages to live births among those insured by Medicaid, these findings are not generalizable to pregnancies that do not result in a livebirth, and we could not assess outcomes such as stillbirth.

Finally, the data used in this study contain births that occurred over a decade ago. While we used them to understand race and ethnicity trends that we do not expect to change rapidly, it is possible that more recent data could yield different results, particularly in the context of shifting immigration policies. However, our results provide a baseline assessment through which to understand these shifts. Additionally, results may be different in the majority of states that did expand Medicaid, unlike Texas. Nonetheless, our work captures race, ethnicity, and nativity associated patterns in the disability population that have also been observed in the general U.S. population, lending some validity to the findings in line with more current evidence.

5. Conclusion

In conclusion, our study shows that, among women with disabilities, disparities associated with race, ethnicity, and nativity exist in similar ways to those found in the general population. These findings emphasize the need for pregnancy care interventions that are inclusive of disability status and responsive to the intersecting effects of race, ethnicity, and nativity. Women with disabilities deserve culturally tailored, disability-competent prenatal care that addresses systemic barriers and acculturative challenges. Understanding and addressing the full range of risks racially and ethnically diverse disabled women may experience is critical to advancing maternal and infant health in the U.S.

Supplementary Material

Appendix 1

Funding

This study was supported by grants from the National Institute on Minority Health and Health Disparities (grant no. 5K01MD018638 to Dr. Dev), the Eunice Shriver National Institute of Child Health and Human Development (grant no.5R01HD105712 to Dr. Horner-Johnson and grant no. 5R01HD10523 to Dr. Goodman), and the National Institute on Disability, Independent Living, and Rehabilitation Research (grant nos. 90DPHF0011 and 90DPHF0013 to Dr. Horner-Johnson).

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.dhjo.2026.102052.

Footnotes

CRediT authorship contribution statement

Alka Dev: Writing – review & editing, Writing – original draft, Resources, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Willi Horner-Johnson: Writing – review & editing, Methodology, Formal analysis, Conceptualization. Andrew Schaefer: Methodology, Formal analysis, Data curation. Thérèse A. Stukel: Writing – review & editing, Methodology, Formal analysis. David C. Goodman: Writing – review & editing, Methodology, Investigation, Data curation. JoAnna K. Leyenaar: Writing – review & editing, Supervision, Methodology, Conceptualization.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the author(s) used Claude in order to edit for grammar and sentence structure. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Conflict of interest

The authors declare no conflict of interest.

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Appendix 1
NIHMS2178767-supplement-Appendix_1.docx (26.3KB, docx)

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