Abstract
Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States.
Methods. We used 2016–2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence.
Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened.
Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297–305. https://doi.org/10.2105/10.2105/AJPH.2022.307195)
Maternal morbidity and mortality are increasing in the United States, with some individuals and communities experiencing disproportionate risk, including Black or American Indian/Alaska Native people, low-income individuals, and rural residents.1–4 Many recent public health efforts addressing maternal mortality have focused on clinical risk factors and the quality of hospital-based care, but maternal safety outside the clinical setting, including in homes and communities, is equally important.5,6
Intimate partner violence (IPV) is a leading nonobstetric cause of maternal morbidity and mortality.7–11 IPV includes physical, emotional, and sexual violence and comprises patterns of behavior to gain or maintain power and control.12 Although physical violence is a commonly recognized form of IPV, emotional and sexual violence are also harmful and prevalent. Examples of emotional violence are verbal insults, humiliation, isolation from friends and family, threats of harm, controlling finances, and monitoring communication or location. Examples of sexual violence are forcing or attempting to force a partner to take part in a sex act, sexual touching, and nonphysical sexual events (e.g., sexting) when the partner does not or cannot consent.13,14 Maternal experiences of IPV are associated with higher rates of preterm birth, lower birth weights, and lower rates of breastfeeding.11,15 Risk of the most severe outcome, homicide perpetrated by an intimate partner, is heightened around the time of pregnancy and childbirth.7,8,16–18 Approximately 60% of homicides that occur around the time of pregnancy are related to IPV.7
People who give birth frequently interact with clinicians before, during, and after pregnancy, making health care a crucial setting for IPV screening and intervention. Since 2012, the American College of Obstetricians and Gynecologists has recommended regular IPV screening during pregnancy and postpartum, and in 2018, the US Preventive Services Task Force upgraded their recommendation for IPV screening for reproductive-aged individuals from I (insufficient evidence) to B (recommended), supporting universal screening nationally.19,20 Screening and referral to treatment may attenuate maternal and infant health inequities that are exacerbated by experiences of violence.21 Still, IPV screening is not consistently provided for all reproductive age patients in either primary care or maternity services.19,22,23
Understanding the extent to which birthing people experience physical violence and whether they are screened for IPV before, during, and after pregnancy will provide critical insight for public health services and policy. We measured IPV screening during the perinatal period among those experiencing physical violence in a large representative sample of US residents who gave birth, and we discuss strategies to reduce the inequities identified.
METHODS
We used 2016–2019 data from 42 states and 2 jurisdictions (i.e., New York City and Washington, DC) from the Pregnancy Risk Assessment Monitoring System (PRAMS), conducted by the Centers for Disease Control and Prevention (CDC) in collaboration with state and city health departments.24 We used PRAMS data from phase 8 surveys, which survey postpartum individuals between 2 and 6 months after childbirth. For each survey year, the CDC releases data that meet a minimum response rate threshold (55% in 2016–2017; 50% in 2018–2019).24 Inclusion and exclusion criteria are described in Figure A (available as a supplement to the online version of this article at http://www.ajph.org).
Measures
Key outcome variables were (1) experiencing physical violence by a current or former intimate partner, and (2) screening for IPV at health care visits among those reporting physical violence.
The PRAMS survey asked whether a husband or partner or ex-husband or ex-partner pushed, hit, slapped, kicked, choked, or physically hurt the respondent in any other way. This outcome was coded as a dichotomous variable indicating whether the respondent reported experiencing physical violence, either before or during pregnancy.
Respondents were asked whether they had health care visits during the preconception period (12 months before pregnancy), prenatal care visits (during pregnancy), or any health care visits postpartum. If they reported a health care visit, they were asked whether a health care worker asked if someone was hurting them emotionally or physically. Although IPV comprises 3 types of violence (physical, emotional, and sexual), we described this as IPV screening, recognizing that respondents were asked about only 2 of the 3 potential aspects of IPV. Survey questions about screening were asked of individuals only about each respective period (preconception, pregnancy, postpartum) when they reported a health care visit, and we created a dichotomous indicator for screening for each of these periods among those reporting physical violence.
We selected the covariates included in our analyses a priori. Core sociodemographic variables were rural versus urban residency (based on National Center for Health Statistics Urban–Rural Classification Scheme for Counties),25 race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic [English-speaking and Spanish-speaking], American Indian/Alaska Native, Asian/Pacific Islander, and multiple/other), and health insurance status at childbirth (private insurance, Medicaid, and no insurance). Other sociodemographic variables were age (< 24, 25–34, and ≥ 35 years), education (< high school, high school, > high school), marital status (married and not married). We obtained the core and other sociodemographic variables from the linked birth certificate data. Clinical variables included parity, prepregnancy comorbidities (diabetes, high blood pressure/hypertension, depression, and smoking), and prepregnancy obesity, and we included them to account for the probability of greater health care interaction. We obtained parity from the birth certificate record, and all other clinical variables were reported in the PRAMS questionnaire.
Analysis
To describe characteristics of respondents who reported experiencing physical violence, we present survey-weighted proportions with 95% confidence intervals (CIs) using PRAMS weights, which account for the complex stratified survey design, and tested for distributional differences across characteristics by using the Rao–Scott χ2 test.
Among respondents who reported physical violence, we used multivariate logistic regression to calculate adjusted predicted probabilities and percentage point risk differences (RDs). We calculated RDs using postestimation techniques available in Stata’s margins command standardized to the distribution of covariates in the data. We calculated predicted probabilities and RDs of not attending a health care visit before, during, or after pregnancy—and thus not having an opportunity to be screened for IPV in the health care setting. Among those attending visits, we also calculated adjusted predicted probabilities and percentage point RDs for the lack of screening in each pregnancy period.
For each pregnancy period and each reason for not being screened, we calculated RDs across the core sociodemographic variables of rural versus urban residence, race and ethnicity, and health insurance status, comparing each to its reference category (i.e., urban, non-Hispanic White, and privately insured, respectively). We conducted several sensitivity analyses examining differences between respondents who did and those who did not report experiencing physical violence, predictors of not being screened among all birthing people, and predictors of not being screened prenatally across Kotelchuck Index levels of prenatal care adequacy to examine whether the number of prenatal visits could be associated with screening probability.26
We used Stata version 17.0 (StataCorp LLC, College Station, TX) and Stata’s margins command in conducting analyses.
RESULTS
Physical violence before or during pregnancy was reported by 3.5% of this sample of US residents who gave birth between 2016 and 2019 (unweighted n = 6259/158 338; Table A, available as a supplement to the online version of this article at http://www.ajph.org). Compared with respondents who did not report physical violence, higher proportions of those who experienced physical violence were rural residents, identified as non-Hispanic Black or American Indian/Alaska Native, were younger, were less educated, were unmarried, were insured by Medicaid at childbirth, had a pregnancy that was unintended, and had higher proportions of clinical comorbidities (P < .05 for all comparisons described; Table A).
Table 1 shows the proportion of respondents with health care visits and IPV screening at visits for each pregnancy period among those who reported physical violence. During the 12 months before pregnancy, more than half of individuals who reported violence were not screened for IPV (58.7%; n = 3555/6259), either because they did not have a health care visit (32.9%; n = 2103/6259) or because they attended a visit but were not asked about abuse (38.4% of those experiencing physical violence who attended any visit; n = 1452/4156).
TABLE 1—
Health Care Visits and Intimate Partner Violence (IPV) Screening Among Patients Reporting Physical Violence: United States, Pregnancy Risk Assessment Monitoring System, 2016–2019
| Unweighted No. (Weighted %) | 95% CI | |
| Preconception | ||
| Health care visit in the 12 mo before pregnancy | ||
| No | 2103 (32.9) | 31.0, 34.9 |
| Yes | 4156 (67.1) | 65.1, 69.1 |
| If yes, received IPV screening | ||
| No | 1452 (38.4) | 35.9, 41.0 |
| Yes | 2704 (61.6) | 59.1, 64.1 |
| Not screened (no visit or visit without screening) | 3555 (58.7) | 56.6, 60.7 |
| Pregnancy | ||
| Prenatal care visit | ||
| No | 135 (1.9) | 1.4, 2.5 |
| Yes | 6124 (98.2) | 97.5, 98.6 |
| If yes, received IPV screening | ||
| No | 1326 (25.5) | 23.6, 27.5 |
| Yes | 4798 (74.5) | 72.5, 76.4 |
| Not screened (no visit or visit without screening) | 1461 (26.9) | 25.0, 28.8 |
| Postpartum | ||
| Postpartum health care visit | ||
| No | 1196 (17.0) | 15.6, 18.6 |
| Yes | 5063 (83.0) | 81.4, 84.5 |
| If yes, received IPV screening | ||
| No | 1714 (37.6) | 35.4, 40.0 |
| Yes | 3349 (62.4) | 60.0, 64.6 |
| Not screened (no visit or visit without screening) | 2910 (48.3) | 46.2, 50.4 |
Note. CI = confidence interval. Sample size was n = 6259. Sample excludes 790 people who were younger than 18 years and not asked about violence/IPV and 3430 who had births in Vermont (which does not report race/ethnicity).
During pregnancy, almost all (98.2%; n = 6124) respondents who experienced physical violence reported having a prenatal care visit, so very few were not screened because of no prenatal care. However, 25.5% (n = 1326/6124) of those reporting prenatal care visits were not screened for IPV during any prenatal visit. As a result, 26.9% (n = 1461/6259) of those who experienced violence did not get screened at all during pregnancy.
Of respondents who experienced physical violence, 17% (n = 1196/6259) did not attend a postpartum health care visit. Of those who did, 62.4% (n = 3349/5063) were screened for IPV. As a result, 48.3% (n = 2910/6259) of postpartum people with a history of experiencing physical violence had no IPV screening after childbirth.
Among all birthing people, 65.7% were not screened for IPV before pregnancy, 29.7% were not screened during pregnancy, and 48.0% did not get screened during the postpartum period (Table B, available as a supplement to the online version of this article at http://www.ajph.org).
We examined associations between sociodemographic characteristics and IPV screening among respondents who reported physical violence, distinguishing between those who were not screened because they did not have a health care visit and those who were not screened at the visits they attended. Adjusted RDs for core characteristics (rural vs urban residency, race and ethnicity, and health insurance coverage at childbirth) are shown in Figures 1, 2, and 3, with specific percentage point differences reported in Table C (available as a supplement to the online version of this article at http://www.ajph.org). Table D (available as a supplement to the online version of this article at http://www.ajph.org) shows adjusted predicted probabilities of not receiving IPV screening by reason (i.e., no visit or not screened) overall and for each period (i.e., preconception, prenatal, and postpartum) among individuals who experienced physical violence with different sociodemographic characteristics.
FIGURE 1—
Adjusted Differences in Characteristics of Patients Not Receiving Intimate Partner Violence Screening in the Preconception Period Among Patients Reporting Physical Violence Who (a) Were Not Screened Because of No Visit, and (b) Visited but Were Not Screened: United States, Pregnancy Risk Assessment Monitoring System, 2016–2019
Note. CI = confidence interval. The sample size was n = 6259. Model also adjusted for maternal age, education, marital status, parity, and prepregnancy conditions (obesity, diabetes, high blood pressure/hypertension, smoking, or depression). Percentage point difference estimates were based on multivariable logistic regression results. Values for percentage point differences are provided in Table C (available as a supplement to the online version of this article at http://www.ajph.org). Adjusted predicted probability values from which differences were calculated are provided in Table D (available as a supplement to the online version of this article at http://www.ajph.org).
FIGURE 2—
Adjusted Differences in Characteristics of Patients Not Receiving Intimate Partner Violence Screening During Pregnancy Among Patients Reporting Physical Violence Who (a) Were Not Screened Because of No Visit, and (b) Visited but Were Not Screened: United States, Pregnancy Risk Assessment Monitoring System, 2016–2019
Note. CI = confidence interval. The sample size was n = 6259. The model also adjusted for maternal age, education, marital status, parity, and prepregnancy conditions (obesity, diabetes, high blood pressure/hypertension, smoking, or depression). Percentage point difference estimates were based on multivariable logistic regression results. Values for percentage point differences are provided in Table C (available as a supplement to the online version of this article at http://www.ajph.org). Adjusted predicted probability values from which differences were calculated are provided in Table D (available as a supplement to the online version of this article at http://www.ajph.org).
FIGURE 3—
Adjusted Differences in Characteristics of Patients Not Receiving Intimate Partner Violence Screening in the Postpartum Period Among Patients Reporting Physical Violence Who (a) Were Not Screened Because of No Visit, and (b) Visited but Were Not Screened: United States, Pregnancy Risk Assessment Monitoring System, 2016–2019
Note. CI = confidence interval. The sample size was n = 6259. The model also adjusted for maternal age, education, marital status, parity, and prepregnancy conditions (obesity, diabetes, high blood pressure/hypertension, smoking, or depression). Percentage point difference estimates were based on multivariable logistic regression results. Values for percentage point differences are provided in Table C (available as a supplement to the online version of this article at http://www.ajph.org). Adjusted predicted probability values from which differences were calculated are provided in Table D (available as a supplement to the online version of this article at http://www.ajph.org).
Figure 1 shows adjusted differences in characteristics of those not screened for IPV in the preconception period by reason (i.e., no visit or not screened) among respondents who experienced physical violence. There were statistically significant differences by race and ethnicity, with a greater predicted proportion of Spanish-speaking Hispanic people who experienced physical violence (56.5%; Table D) not being screened because they lacked a health care visit in the 12 months before pregnancy compared with non-Hispanic White people (30.8%; Table D), with an adjusted difference of 25.7 percentage points (95% CI = 16.0, 35.3; Table C). By contrast, non-Hispanic White people reporting physical violence who were not screened at the preconception visits they attended (40.9%; Table D) constituted a higher predicted proportion compared with English-speaking Hispanic people (32.3%; an 8.5 percentage point difference; 95% CI = 0.8, 16.3; Tables C and D). People insured by Medicaid at childbirth and those without health insurance at childbirth, respectively, had a 9.6 (95% CI = 5.1, 14.2) and 22.6 (95% CI = 9.3, 35.9; Table C) percentage point higher probability of not having a health visit in the year before pregnancy compared with privately insured people (predicted proportions = 34.7%, 47.7%, and 25.1%, respectively; Table D). However, people with private insurance at childbirth had a 6.9 percentage point (95% CI = 0.7, 13.1; Table C) higher probability of not being screened for IPV at the visits they attended compared with those with Medicaid coverage (43.0% and 36.1%, respectively; Table D).
Figure 2 focuses on pregnancy and shows adjusted differences in characteristics of those who experienced physical violence and did not receive IPV screening, either because they did not have a prenatal care visit or because they were not screened at the visits they attended. More than 90% of respondents reporting physical violence attended at least 1 prenatal visit, so differences were concentrated among those who attended a visit but were not screened for abuse.
Groups at increased risk for not being screened included rural residents and privately insured people, with adjusted differences of 7.2 percentage points (rural vs urban; 95% CI = 2.1, 12.4) and 7.8 percentage points (private insurance vs Medicaid; 95% CI = 3.1, 12.6; Table C). Additionally, adjusted RDs for screening among non-Hispanic Black and American Indian/Alaska Native survivors were 6.1 percentage points (95% CI = 1.0, 11.3) and 10.0 percentage points (95% CI = 2.0, 18.0) higher, respectively, than rates for non-Hispanic White people who experienced physical violence (Table C). Among people experiencing physical violence who were rural residents, non-Hispanic White, or privately insured, the predicted proportions not screened during prenatal care were 31.0%, 27.4%, and 31.0%, respectively (Table D). Differences in screening by the adequacy of prenatal care were inconsistent across sociodemographic characteristics examined, as shown in Table E (available as a supplement to the online version of this article at http://www.ajph.org).
IPV screening in the postpartum period is the focus in Figure 3. Among those who experienced physical violence, there were large differences by race and ethnicity and by insurance status in lacking postpartum visits, with American Indian/Alaska Native people 14.2 percentage points (95% CI = 6.1, 22.3; Table C) more likely than non-Hispanic White people to not have a postpartum visit where screening could occur (30.1% and 15.9%, respectively; Table D). Additionally, people with Medicaid coverage at childbirth (17.5%) and those without insurance at childbirth (28.1%) experiencing physical violence were at elevated risk for not having postpartum care compared with those with private insurance (12.3%; percentage point differences = 5.1; 95% CI = 1.5, 8.8 and 15.8; 95% CI = 5.0, 26.6; Table C).
Among those reporting physical violence who did have a visit postpartum, non-Hispanic White people and privately insured people had elevated predicted proportions not screened for IPV at postpartum visits (41.5% and 42.4%, respectively; Table D). Although a higher proportion of American Indian/Alaska Native (vs non-Hispanic White) people did not have a postpartum visit, those that did receive care after childbirth had a 17.0 percentage point (95% CI = 25.4, 8.5; Table C) higher probability than did non-Hispanic White people of being screened for abuse at the visit they attended.
DISCUSSION
IPV is a risk factor for maternal morbidity and mortality, and homicide is a leading cause of death during pregnancy and postpartum.10 Our analysis indicated that 3.5% of birthing people in this study reported physical violence in the context of IPV. This equates to approximately 280 000 people who gave birth between 2016 and 2019 in 42 states and 2 US jurisdictions who reported being pushed, hit, slapped, kicked, choked, or otherwise physically hurt by current or former intimate partners. Of these, we found that more than half (58.7%) were not screened for IPV before pregnancy, more than a quarter (26.9%) lacked screening during pregnancy, and nearly half (48.3%) were not screened postpartum, either because they did not have a health care visit during these periods or because they attended a visit but were not asked whether someone had hurt them physically or emotionally. These individuals are a critically at-risk population for whom targeted clinical and policy interventions may be important and impactful.
Our analysis revealed 2 distinct reasons that people experiencing IPV around the time of pregnancy were not screened. The first reason is lack of perinatal health care visits. Spanish-speaking Hispanic people, American Indian/Alaska Native people, those with Medicaid at childbirth, and people without insurance at childbirth were less likely than were non-Hispanic White and privately insured people to attend preconception and postpartum visits at which IPV screening could occur. Focusing on access to care in these populations may increase opportunities for IPV screening.
The second reason is lack of screening at health care visits attended by respondents. Among those experiencing physical violence and attending health care visits, rural (vs urban) residents, non-Hispanic White (vs racialized) people, and those with private insurance (vs Medicaid or no insurance) were less likely to be screened during their encounters with the health care system. Those overlooked for screening may reflect clinicians’ perceptions about who is at risk for physical, emotional, or sexual violence. Additionally, health care systems and practices caring for more advantaged individuals (e.g., non-Hispanic White, privately insured) are less likely to include IPV screening in routinized care.27
Non-Hispanic Black and American Indian/Alaska Native individuals experience the highest rates of IPV-associated homicide compared with other racial groups,4 and pregnancy exacerbates this racialized pattern of harm.28 Our analysis indicated risks of potential underdetection among Spanish-speaking Hispanic people (before pregnancy) and American Indian/Alaska Native people (during the postpartum period) who reported physical violence by a current or former intimate partner.
Clinical and Policy Implications
Clinical and policy organizations recommend universal IPV screening and referral to support services to increase the safety of survivors and their families and to address health risks.29 These findings indicate that the US health care system falls short on universal IPV screening during a critical period in the life course. Efforts to improve screening rates could include changes to reimbursement or financing for IPV screening, such as requiring managed care organizations or hospitals that contract with state Medicaid programs or that receive matching federal funds to implement routine screening as a condition of payment. Similar financial policy interventions have been successful in reducing rates of early elective delivery at the time of childbirth and improving maternity care quality generally.30,31
Improving access to perinatal health care visits, including assessing how visit attendance may be affected by IPV, is an important area for research and policy intervention. We found that people experiencing physical abuse who had Medicaid coverage at childbirth as well as those who were uninsured when they gave birth had higher risks than did privately insured people of not receiving a health care visit in the year before pregnancy or having a postpartum follow-up visit. Access to care influences service use and screening in the perinatal period, and efforts to improve access to care through Medicaid expansion and postpartum insurance eligibility extensions could improve IPV screening in the perinatal period.32,33
Improving the frequency and efficacy of screening may require investment in trauma-informed, evidence-based training for clinicians who interact with patients around the time of pregnancy. These include a variety of health professions—obstetricians, family physicians, midwives, psychologists, psychiatrists, licensed family and marriage therapists, social workers, substance abuse and addiction specialists, nurses, nurse practitioners, physician assistants, pediatricians, maternal–fetal medicine specialists, neonatologists, and emergency physicians—as well as nonclinical staff. IPV takes many forms and is not limited to physical violence, yet clinician training and understanding of the multiple complex facets of IPV are often limited.34 Our findings highlight the importance of ensuring universal screening among those attending health care visits and addressing potential clinician bias about who is at risk for experiencing IPV.
Additionally, efforts to ensure the availability of referral and treatment of patients who screen positive for IPV, as well as providing support to both clinicians and patients who interact with systems outside health care in the context of IPV, are essential to promote patient safety and well-being.
Limitations
This study has several important limitations. Respondents were not asked about experiences of emotional or sexual violence, likely resulting in an underestimate of the true prevalence of IPV, as study respondents were asked only about experiences of physical violence. Similarly, the question about screening for IPV did not encompass sexual violence. Survey questions in the PRAMS data and other surveillance efforts could be improved to better measure IPV. Self-reported physical violence and IPV screening are both subject to potential biases. Physical violence is underdetected and underreported, generally because of social desirability bias, and may be differentially underreported by characteristics of interest, including race and ethnicity, rural versus urban residency, and health insurance status.21 Additionally, in the PRAMS data, experiences of violence are not asked about during the postpartum period. Self-reports of screening may be affected by recall bias (i.e., whether a respondent remembers being screened), which could be related to the results of the screening.15
The generalizability of this study is limited, as results do not represent the experiences of people who gave birth in 7 US states (i.e., Arizona, California, Idaho, Nevada, Ohio, South Carolina, and Texas). The postpartum visit rate of PRAMS respondents is higher than the national average, and response rates are higher among non-Hispanic White and socioeconomically advantaged groups, so estimates of physical violence and IPV screening may be differentially conservative based on patient characteristics.24,35
Conclusions
As rates of US maternal morbidity and mortality increase, the role of IPV has become increasingly clear. Approximately half of birthing people who reported physical violence before or during pregnancy were not screened because they did not have a health care visit in the year before pregnancy or postpartum or because they were not screened for IPV at the visits they attended. Among those who experienced IPV, we found that Spanish-speaking Hispanic and American Indian/Alaska Native people and those with Medicaid coverage or no health insurance at childbirth were at greater risk for being unscreened than were non-Hispanic White and privately insured people because of lack of visits.
Additionally, some birthing people experiencing physical violence—including those who were non-Hispanic White rural residents and those who were privately insured at childbirth—were at higher risk for not being screened at the visits they attended than were racialized, urban, or uninsured people or those with Medicaid who experienced violence and attended visits. These findings imply a critical need for increased health care access and better screening to identify and support people experiencing violence by an intimate partner. More broadly, clinical and policy efforts to improve maternal health in the United States should address IPV as a public health policy issue.
ACKNOWLEDGMENTS
This research was supported in part by the National Institutes of Health (NIH), National Center for Advancing Translational Sciences (grant UL1TR002494). L. Admon is supported by the Agency for Healthcare Research and Quality (grant K08HS027640) and the NIH (grants R01MH120124 and R01MD014958).
The authors gratefully acknowledge all Pregnancy Risk Surveillance and Monitoring System (PRAMS) study participants and members of the PRAMS Working Group at the Centers for Disease Control and Prevention. The authors also thank Alyssa H. Fritz, MPH, RD, for helpful input on the article.
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the NIH.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
Data were de-identified, and this study was designated exempt from review by the University of Michigan’s and the University of Minnesota’s institutional review boards.
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