Abstract
Objective:
To determine if childbirth education conducted over three or more sessions is more effective than courses conducted over one or two sessions.
Methods:
This was a secondary analysis of 2853 participants in a longitudinal study of women recruited during first pregnancy. Data on childbirth education attendance were collected during the one-month postpartum interview. Kruskal-Wallis test for ranks was used for univariate analysis by number of class sessions and logistic regression was used to compare no education to any childbirth education, single session, two session, and three or more session courses. Primary outcomes included induction of labor, cesarean delivery, use of pain medication, and shared decision-making.
Results:
Attending 3 or more education sessions was associated with decreased risk of planned cesarean and increased shared decision-making. Attending any childbirth education was associated with lower odds of using pain medication in labor, reduced odds of planned cesarean, and increased shared decision-making. Childbirth education was not associated with induction of labor.
Conclusion:
Childbirth education can be provided over three or more sessions. This finding can be used to develop evidence-based childbirth education programs.
Keywords: Childbirth education, cesarean delivery, shared decision-making
Precis
Childbirth education courses with three or more sessions are associated with reduced use of planned cesarean and increased shared decision-making.
Introduction
Childbirth education is considered a predictor of patient satisfaction with care and is recommended by most obstetricians and midwives.1–3 In general, providers expect childbirth education courses to cover topics important for achieving population health goals such as birth options, breastfeeding, family planning, and safe infant sleep.2 Several population level studies have found that childbirth education results in reduced use of cesarean delivery, one of the Healthy People 2030 objectives.4–6 These studies are limited to childbirth education as a dichotomous variable and do not address the effectiveness of childbirth education provided over different number of sessions. If the number of sessions in a course alters the outcomes such as cesarean delivery rate, educators can improve their programs by designing a course with the optimum number of sessions.
Studies on childbirth education hypothesize that cesarean delivery can be reduced with either 1) training in comfort measures to reduce pain and the need for intervention or 2) decision counseling to reduce fear and the desire for elective cesarean. Globally, there is wide variation in the number of childbirth education sessions included as part of a study whether the study investigates comfort measures or decision counseling. Some studies examine self-study material, a single education session, or combinations of the two.7–9 These studies report changes in knowledge, fear, or birth planning but do not report delivery outcomes. Most studies test a minimum of 16 hours of content distributed either in two, four, or more sessions.10–15 Some of these report a reduction in cesarean delivery while others do not report delivery outcomes. The lack of consistency in the intervention and reporting of outcomes has resulted in a gap of knowledge about the effect of number of sessions on efficacy of childbirth education as a method to achieve maternal health objectives.
A major limitation of the available literature on childbirth education is the conceptualization of childbirth education attendance as a dichotomous (yes/no) variable. If the number of sessions matters, combining programs with different numbers of sessions can bias results toward no effect. This may be why some studies do not find a relationship between childbirth education and cesarean delivery rates. Studies conducted in individual hospitals test a program with a specific number of sessions but may not account for hospital level characteristics or other changes adopted that contribute to reduction of cesarean. For example, one study of the implementation of a standardized childbirth education program found the change in cesarean rate was not consistent across the participating hospitals.13 There is a need for population level studies examining number of sessions of childbirth education to provide evidence that can be generalized.
This study was designed to test whether the number of sessions of childbirth education is associated with delivery outcomes. The objective was to determine if childbirth education courses conducted over three or more sessions were more effective at meeting quality goals than courses conducted over one or two sessions.
Background
Formal childbirth education began during the natural childbirth movement as a way to train women to use relaxation techniques to give birth without the use of pain medication. Certification for childbirth educators began in the 1960’s with educators operating outside the health care system.16 By the year 2000, 70% of first-time mothers attended formal childbirth education programs, most often at a hospital or medical office.17 Healthy People 2020 included a goal to increase childbirth education attendance.18 The Pregnancy Risk Assessment Monitoring Survey Phase 5 questionnaire tracked states’ progress on childbirth education participation.19 The general expectation was that childbirth education could improve maternal and neonatal health in the United States (US).
Instead, formal childbirth education lost momentum in the US in the new millennium. By 2013, participation in childbirth education declined to 59% of first time mothers.20 Childbirth education courses are now most often conducted in a single session.2,20 Few educators include information on topics relevant to population health goals such as safe infant sleep or family planning.2 These changes are likely due to changing consumer demands that resulted from the introduction of alternative avenues for education such as the internet and doulas.
In the US, multiple options for perinatal education exist, though barriers and limitations to other methods suggest childbirth education remains a valuable tool. Group prenatal care is an effective intervention that integrates education and antenatal services in a single visit, but the space and staffing limitations are barriers to implementation.21–23 Doulas provide one-on-one education, but lack of Medicaid reimbursement creates an economic barrier for many families.24–26 Health education is provided as part of traditional antenatal care visits, though this education is not associated with improvements in the population health objectives tracked through Healthy People.27
In 2016, the World Health Organization included health education in the package for comprehensive antenatal care establishing the importance of this resource.28 Childbirth education remains a trusted intervention among healthcare providers and first time parents and is effective for reducing caesarean rates and increasing breastfeeding rates.5,6 Half of the states include childbirth education in their Medicaid reimbursement package, reducing barriers to implementation.26 These qualities indicate childbirth education is a valuable tool for reaching both facility quality improvement and community population health goals.29
Before childbirth education can be implemented as an evidence-based intervention, the factors associated with its effectiveness must be described. One factor that has not been investigated is the number of sessions. Wide variance exists in this aspect of childbirth education. Single session courses involving fewer hours are typically available through hospital institutions and serve to orient clients to the facility.20 In contrast, mindfulness-based childbirth education programs designed to build comfort skills include between 18–27 hours of instruction over multiple days or weeks.30
Methods
This was a secondary data analysis of data collected as part of the First Birth Study, a longitudinal study of women recruited during their first pregnancy. This project was deemed excluded from review by the University of Nevada, Las Vegas Biomedical IRB because use of the deidentified data did not meet the definition of human subjects research.
Setting
Recruitment for this study was conducted in Pennsylvania between 2009 and 2011. Recruits were eligible for the study if they were between 18 and 35 years of age and pregnant with a single fetus. Recruits were excluded if they had a prior pregnancy of at least 20 weeks gestation, were planning tubal ligation at time of delivery, or if they were planning an out of hospital birth.
Participants
Study participants were eligible for this analysis if they indicated they answered questions about whether or not they attended childbirth education classes. Participants who declined to answer or indicated they did not know were excluded from the analysis. The sample was further restricted to those who delivered at or after 37 weeks gestation because those who delivered prior to 37 weeks may not have attended the full series of their intended childbirth education course.
Variables and Measurement
The independent variable for this study was the number of sessions attended as part of a childbirth education course. This information was provided by respondents during the telephone interview and recoded into an ordinal variable with values indicating no childbirth education, a single session course, a two-session course, or a course with three or more sessions. These groupings were selected to allow comparison of common structures for childbirth education courses.
The primary outcomes for this study were induction of labor, use of pain medication, delivery by cesarean, and shared decision-making. These outcomes were selected because they represent information that providers expect to be covered in childbirth education courses.2,3 Secondary outcomes included use of epidural, use of systemic opioids, delivery by planned cesarean, and delivery by unplanned cesarean.
The delivery outcomes were identified on the postpartum survey and verified by the medical record. Respondents who did not provide an answer for an outcome were excluded from that analysis. Shared decision-making was measured using the Delivery Decision Making Scale (DDMS).31 This scale includes 6 items that focus on the respondents’ perception of involvement and satisfaction with the decision-making process. Item responses are true or false and the instrument is scored based on a scale from 0–6 with higher scores indicating higher levels of shared decision-making. In the original study, this variable was highly skewed (more than half the respondents had the highest score possible), so the variable was dichotomized to indicate a score of six or a score less than six.33
Control of Bias
Control variables were selected based on statistically significant differences in attendance at childbirth education in these data. These variables included maternal age, pre-pregnancy BMI, maternal education level, pregnancy intention, insurance source, and maternal race and ethnicity. Due to low proportions of participants who identified themselves in underrepresented race or ethnic groups in some course structures, maternal race and ethnicity data were collapsed into two groups as White non-Hispanic or other race or ethnicity.
Two additional variables were included in the models for induction and cesarean delivery to control for any differences in medical indication for these procedures not accounted for in other variables. The variable for indication of induction included ICD-9-CM codes that identified hypertension, diabetes, other medical conditions, premature rupture of membranes, fetal compromise, hydramnios or oligohydramnios, and post-date pregnancy. The variable for indication of cesarean included ICD-9 codes that identified malpresentation, macrosomia, cephalopelvic disproportion, antepartum bleeding or placental conditions, abnormalities of the pelvis, nonreassuring fetal status, hypertension, diabetes, post-term pregnancy, umbilical cord complications, hydraminos, oligohydramios, prolonged rupture of membranes and fetal abnormalities.32 The exact ICD codes used can be found in Supplement 1.
Statistical Methods
Multiple imputation calculations provided values for any missing data. Descriptive analysis was conducted using the Kruskal-Wallis test by ranks to compare distribution of each characteristic by number of childbirth education sessions attended.
Two multivariate logistic regression models were created for each outcome. The first model included childbirth education as a dichotomous predictor variable to calculate the odds of any childbirth education compared to no childbirth education. The second model included childbirth education as an ordinal variable with no childbirth education set as the reference. This compared each category of number of sessions to taking no childbirth education. All models used backward selection and included all variables that had potential to be associated with the number of sessions and the primary outcomes. Backward selection allows the model to keep only the control variables that are significant when predicting outcome and is therefore the most parsimonious model possible with these data. In these models, variables remained in the model as long as they had a p value less than 0.10. This method was selected because there was a paucity of existing literature to identify variables to control for confounding based on number of class sessions.
Because odds ratios can overstate the risk for outcomes with incidence greater than 10%, the odds ratios from the logistic regression models were converted to approximated risk ratios using the method described by Zhang and Yu.33
Results
Participants
The full sample included 3006 participants. After removing 120 participants who gave birth prior to 37 completed weeks and 2 participants who did not answer the question about prenatal education, 2884 respondents were eligible for this analysis. Of those, 890 (30.9%) did not attend childbirth education, 333 (11.4%) attended a single session course, 320 (11.1%) attended a two session course, 1336 (46.8%) attended a course that was three or more sessions, and 5 participants did not provide the number of sessions attended. Full description of sample characteristics can be found in Table 1.
Table 1:
Description of sample by number of sessions in the childbirth education course
| Characteristic | Did Not Attend N=870 |
1 Session N=332 |
2 Sessions N=315 |
≥3 Sessions N=1336 |
|---|---|---|---|---|
|
| ||||
| Maternal Agea | ||||
| 18–24 | 428 (47.8%) | 71 (21.3%) | 48 (15%) | 242 (18.1%) |
| 25–29 | 272 (30.4%) | 142 (42.6%) | 133 (41.6%) | 598 (44.8%) |
| 30+ | 195 (21.8%) | 120 (36.0%) | 139 (43.4%) | 496 (37.1%) |
| Pre-Pregnancy BMIb | ||||
| ≤ 24.9 | 483 (54.0%) | 184 (55.4%) | 193 (60.5%) | 783 (58.6%) |
| Overweight | 193 (21.6%) | 82 (24.7%) | 75 (23.5%) | 290 (21.7%) |
| Obese | 219 (24.5%) | 66 (19.9%) | 75 (16.0%) | 263(19.7%) |
| Maternal Education Levela | ||||
| ≤ High School | 292 (32.6%) | 44 (13.2%) | 21 (6.6%) | 125 (9.4%) |
| Some College | 288 (32.2%) | 91 (27.3%) | 71 (22.2%) | 328 (24.6%) |
| College | 315 (32.2%) | 198 (29.5%) | 228 (71.3%) | 883 (66.1%) |
| Pregnancy Intentiona | ||||
| Not Intended | 420 (47.6%) | 95 (28.8%) | 69 (21.7%) | 331 (25.0%) |
| Intended | 462 (52.4%) | 235 (71.2%) | 249 (78.3%) | 995 (75.0%) |
| Rural Residencea | ||||
| Yes | 89 (9.9%) | 45 (13.5%) | 17 (5.3%) | 98 (7.34%) |
| No | 806 (90.1%) | 288 (86.4%) | 303 (94.7%) | 1238 (92.7%) |
| Maternal Race/Ethnicityb | ||||
| White non-Hispanic | 617 (25.7%) | 298 (12.4%) | 283 (11.8%) | 1203 (50.1%) |
| Black non-Hispanic | 152 (68.8%) | 18 (8.1%) | 11 (5.0%) | 40 (18.1%) |
| Hispanic | 86 (51.8%) | 12 (7.2%) | 17 (10.2%) | 51 (30.7%) |
| Other | 51 (44.0%) | 7 (6.0%) | 12 (10.3%) | 46 (39.7%) |
| Insurance Sourceb | ||||
| Public Insurance | 384 (57.4%) | 62 (9.3%) | 40 (6.0%) | 183 (27.4%) |
| Private Insurance | 510 (23.1%) | 271 (12.3%) | 280 (12.7%) | 1152 (52.1%) |
| Induction Indication | ||||
| No | 422 (47.2%) | 167 (50.2%) | 139 (43.4%) | 656 (49.1%) |
| Yes | 473 (52.%) | 166 (49.9%) | 181 (56.5%) | 680 (40.9%) |
| Cesarean Indication | ||||
| No | 210 (23.5%) | 75 (22.5%) | 69 (21.6%) | 270 (20.2%) |
| Yes | 685 (76.5%) | 258 (77.5%) | 251 (78.4%) | 1066 (79.8%) |
p<.05
p<.001
Descriptive Data
The Kruskal-Wallis test for ranks identified differences in number of sessions of childbirth education for all participant characteristics except indications for induction or cesarean. The Kruskal-Wallis test for ranks identified differences based on sessions of childbirth education for three of the primary outcomes; use of any pain medication (p<.05), use of epidural, (p<.05), and high shared decision-making score (p<.001). Mode of delivery was not associated with number of sessions. Full description of outcomes by number of class sessions can be found in Table 2.
Table 2:
Description of Outcomes by number of sessions in the childbirth education course
| Outcome | Did Not Attend N=870 |
1 Session N=332 |
2 Sessions N=315 |
≥3 Sessions N=1336 |
|---|---|---|---|---|
|
| ||||
| Induction of Labor | ||||
| Yes | 323 (36.1%) | 120 (36.0%) | 112 (35.0%) | 421 (31.5%) |
| No | 572 (63.9%) | 213 (64.0%) | 208 (65.0%) | 915 (68.5%) |
| Any Pain Medication | ||||
| Yes | 849 (95%) | 303 (91.0%) | 292 (91.3%) | 1184 (92.4%) |
| No | 45 (5.0%) | 30 (9.0%) | 28 (8.6%) | 98 (7.6%) |
| Epidurala | ||||
| Yes | 761 (85.0%) | 261 (78.4%) | 266 (83.1%) | 1081 (80.9%) |
| No | 134 (15%) | 72 (21.6%) | 54 (16.9%) | 255 (19.1%) |
| Systemic Opioidsa | ||||
| Yes | 238 (27.4%) | 103 (31.0%) | 52 (16.5%) | 380 (28.9%) |
| No | 632 (72.6%) | 229 (69.0%) | 263 (83.5%) | 937 (71.15%) |
| Mode of Delivery | ||||
| Vaginal | 634 (70.8%) | 243 (73.0%) | 231 (72.2%) | 952 (71.3%) |
| Cesarean | 261 (29.2%) | 90 (27.0%) | 89 (27.8%) | 384 (28.7%) |
| Planned | 53 (5.9%) | 15 (4.5%) | 16 (5%) | 68 (5.1%) |
| Unplanned | 208 (23.2%) | 75 (22.5%) | 73 (22.8%) | 316 (23.7%) |
| Decision Makinga | ||||
| Score 6 | 489 (56.3%) | 214 (66.5%) | 206 (65.0%) | 892 (67.9%) |
| Less than 6 | 380 (43.7%) | 108 (33.5%) | 111 (35.0%) | 421 (32.1%) |
p<.05
Main Results
Attendance at any childbirth education was associated with reduced use of pain medication during labor (ARR 0.94 95% CI 0.88 – 0.98), including a reduced use of epidural (ARR 0.94 95% CI 0.90 – 0.99). The use of opioids increased for those attending childbirth education (ARR 1.22 95% CI 1.06 – 1.39). Attending childbirth education was not associated with overall cesarean use, but was associated with reduced use of planned cesarean (ARR 0.65 95% CI 0.46 – 0.92). Attending childbirth education was associated with increased shared decision-making (ARR 1.07 95% CI 1.01 – 1.12.) Full results are available in Table 3.
Table 3:
Approximated risk ratios for outcomes with childbirth education by number of sessions in the course
| Any Childbirth Education ARR (95% CI) |
Analysis by Structure of Childbirth Education | |||
|---|---|---|---|---|
| Single Session ARR (95% CI) |
2 Session Course ARR (95% CI) |
≥3 Sessions ARR (95% CI) |
||
|
| ||||
| Induction of Labor | 0.97 (0.84 – 1.11) | 1.10 (0.91 – 1.32) | 0.99 (0.80 – 1.21) | 0.93 (0.79 – 1.08) |
| Any Pain Medication | 0.94 (0.88– 0.98) | 0.93 (0.84 –0.99) | 0.94 (0.87 – 1.00) | 0.95 (0.91 – 0.99) |
| Use of Epidural | 0.94 (0.90–0.99) | 0.90 (0.80 – 0.98) | 0.98 (0.91 – 1.04) | 0.95 (0.90 – 1.00) |
| Use of Opioids | 1.22 (1.06 – 1.39) | 1.28 (1.06 – 1.51) | 0.75 (0.55 – 1.02) | 1.28 (1.12 – 1.46) |
| Any Cesarean | 0.92 (0.79 – 1.06) | 0.88 (0.69 – 1.10) | 0.87 (0.69 – 1.11) | 0.97 (0.90 – 1.03) |
| Planned Cesarean | 0.65 (0.46 – 0.92) | 0.62 (0.34 – 1.10) | 0.66 (0.37 – 1.17) | 0.74 (0.53 – 0.99) |
| Unplanned Cesarean | 1.02 (0.87 – 1.19) | 0.98 (0.76 – 1.24) | 0.98 (0.75 – 1.25) | 1.04 (0.85 – 1.28) |
| Decision Making | 1.07 (1.01 – 1.12) | 1.07 (0.98 – 1.16) | 1.04 (0.94 – 1.13) | 1.20 (1.04 – 1.37) |
Attending childbirth education conducted over three or more sessions was associated with reduced use of pain medication (ARR 1.28 95% CI 1.12 – 1.46), reduced use of planned cesarean (0.74 95% CI 0.53 – 0.99), and increased shared decision making (ARR 1.20 95% CI 1.04–1.37). In contrast, attending childbirth education conducted as a single session or two sessions was only associated with reduced use of pain medication. No association was identified between childbirth education and use of induction of labor.
Discussion
The key finding of this study is that childbirth education conducted over three or more sessions is more effect at achieving population health objectives and facility quality goals than courses conducted as one or two sessions. This information can be used by nurses to design childbirth education interventions that help meet specific facility or population health goals. Additionally, pregnant people can use this information to help select the best childbirth education course for their needs. Finally, the number of sessions of childbirth education can be used as a marker for the quality of perinatal programs.
Though participants in any childbirth education course had reduced odds of using pain medication, only participants in courses conducted as three or more sessions had increased decision making and reduced use of cesarean delivery. This may be due to a difference in the learning that can be achieved between single or multiple session courses. Courses conducted over multiple weeks take advantage of distributive practice. Distributive practice is an evidence-based strategy that results in improved learning compared to concentrated learning in a single session.34 The findings of this study demonstrate that childbirth education courses are more effective when designed using distributive practice. Knowing this, the number of sessions can be considered one measure of the quality of the childbirth education, especially when implemented to achive population health or facility quality improvement goals.
The reduced use of planned cesarean with childbirth education agrees with prior research.5,6,29 There are two mechanisms by which childbirth education conducted over 3 sessions may reduce cesarean rates. First, the distributive practice that results from three session courses likely results in increased knowledge and development of comfort skills. Increased knowledge about birth options is associated with favorable views about vaginal delivery.4 The second potential mechanism is by reducing fear of childbirth. Fear of childbirth is associated with a preference for cesarean, but is reduced with education.35 Longer courses may be able to include more information and result in larger reductions in fear of childbirth. Wide variations in the content of childbirth education, training of the educator, and duration of class sessions are reported in the US and in other high income countries.2,36,38–40 Future research should investigate which of these characteristics are related to number of sessions and which could be used as additional measures for childbirth education quality.
Participation in childbirth education was associated with reduced use of pain medication for all categories of number of sessions of childbirth education tested. It is possible that participants enrolled in childbirth education as a strategy to give birth without medication. This is unlikely because childbirth education was associated with an increase in use of opioids for pain relief. This study was not able to control for intention to use medication during labor. Prior research found that training in comfort measures for labor is associated with changing plans for pain management in labor, suggesting that this finding may be due to the education provided rather than a selection bias for those attending childbirth education courses.41
There are several reasons childbirth education may not be associated with induction of labor. First, there is an ongoing transition in scientific understanding of the risks of non-medically indicated induction of labor.42 Additionally, prior evidence that decisions about induction of labor do not follow established standards of shared decision-making suggests childbirth education may have no impact on this outcome.43 Finally, the participants in this study were mostly non-Hispanic white, a population subgroup with the highest rate of non-medically indicated induction of labor.44
The finding of an association between shared decision making and attending childbirth education of at least three sessions provides a foundation for understanding how childbirth education affects maternal health outcomes. Though shared decision making is demonstrated to improve patient outcomes in other medical fields, it is uncommon in maternity care.43,45 Shared decision making has limited effect when it begins during a hospitalization, and the time constraints of the labor and delivery experience are a barrier to pregnant people examining options and values as they might for other health care services.46 One factor that increases the use of shared decision making is patient education.47 Childbirth education conducted over three or more sessions provides pregnant people with the time needed to review what they have learned and may function similarly to enhanced decision support from a trained health coach.
The findings from this study provide evidence of the need to further study childbirth education as a strategy for achieving population health objectives. The current body of evidence for childbirth education indicates improvements in maternal health across a wide variation in course content and distribution of the content across sessions. However, not every study finds a reduction in cesarean delivery with childbirth education interventions. Research is needed to identify which childbirth education characteristics are associated with improved maternal outcomes.
The findings of this study do not support prior findings from this time period that a single session childbirth education course was the most commonly attended.20 Instead, the most commonly attended course was conducted over three or more sessions. The sample for this study was consistent with samples from prior retrospective studies of childbirth education in the United States that suggest that maternal age, race and ethnicity, education level, and income are associated with attendance at childbirth education.3,5 These social determinants of health are also associated with access to care, pregnancy-related morbidity, and maternal health disparities. It is possible the sample for this analysis had fewer barriers to attending multi-session childbirth education. Program implementation may be improved by research investigating the barriers and facilitators for attending three or more sessions of childbirth education.
Strengths and Limitations
A particular strength of this study is that the data provided the education course subject, which allowed exclusion of individuals who attended breastfeeding or newborn care classes. Another strength was the validation of participant reports of cesarean delivery with the participant’s medical record. Finally, inclusion of participants who attended childbirth education at multiple locations and gave birth in hospitals across the state strengthen the generalizability of these findings.
This study was limited by comparison of the number of childbirth education sessions without information about the specific content or function. There is wide variation in the content of childbirth education courses, and this variation could not be controlled in this study.36,37 This limitation was considered acceptable because this was the first examination of the effect of the number of sessions of childbirth education, and it is likely that the content provided in a course varies by the number of sessions. This study was further limited by the use of data from a single state. State variations, such as Medicaid reimbursement for childbirth education, alter access to childbirth education and therefore may alter the reasons pregnant people participate in childbirth education. This study was limited by use of data from 2009–2011, a time when participation in childbirth education was decreasing. The participation rates from this study should not be generalized to current participation.
Practice Implications
Childbirth education conducted over three or more sessions can be considered an effective intervention for meeting population health or facility quality improvement goals. When evaluating a childbirth education program, the number of sessions can be evaluated as an indicator of the quality of the intervention. Nurses working to implement new childbirth education programs can improve the effectiveness by designing a course that is conducted over three or more sessions. Future research should investigate the barriers to implementing childbirth education of at least three sessions to improve implementation of evidence-based childbirth education.
Conclusions
This study found that childbirth education conducted in three or more sessions is associated with decreased use of planned cesarean and increased shared decision-making. Implementing childbirth education programs with three or more session can be used to achieve population health or facility quality goals.
Supplementary Material
Contributor Information
Jennifer Vanderlaan, University of Nevada Las Vegas School of Nursing, 4505 S. Maryland Parkway, Box 453018, Las Vegas, Nevada 89154-3018.
Christen Sadler, University of St. Thomas School of Nursing, Houston, TX.
Kristen Kjerulff, Penn State College of Medicine Department of Public Health Sciences, Hershey, PA.
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