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Barriers to Rural Induced Abortion Services in Canada : Findings of the British Columbia Abortion Providers.. Norman, Wendy V.; Soon, Judith Alice; Maughn, Nanamma; Dressler, Jennifer Jun 28, 2013

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Barriers to Rural Induced Abortion Services in Canada:Findings of the British Columbia Abortion ProvidersSurvey (BCAPS)Wendy V. Norman1,2*, Judith A. Soon1,2,3, Nanamma Maughn2, Jennifer Dressler21Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada, 2Women’s Health Research Institute, British Columbia Women’sHospital, Provincial Health Services Authority, Vancouver, Canada, 3 Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, CanadaAbstractBackground: Rural induced abortion service has declined in Canada. Factors influencing abortion provision by ruralphysicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urbanabortion providers in the Canadian province of British Columbia (BC).Methods: We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed apreviously-published questionnaire and conducted semi-structured interviews.Results: Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural andurban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of totalreported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive agewomen reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortionsannually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, oftenusing general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using localanaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urbanproviders reported occasional anonymous harassment and violence.Conclusions: Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the decliningaccessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatorycare settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.Citation: Norman WV, Soon JA, Maughn N, Dressler J (2013) Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia AbortionProviders Survey (BCAPS). PLoS ONE 8(6): e67023. doi:10.1371/journal.pone.0067023Editor: Virginia J. Vitzthum, Indiana University, United States of AmericaReceived January 20, 2013; Accepted May 14, 2013; Published June 28, 2013Copyright:  2013 Norman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Funding: This study was supported by the Women’s Health Research Institute of British Columbia Women’s Hospital. During this study Dr. Norman wassupported by the Canadian Institutes of Health Research as a Fellow in interdisciplinary primary healthcare research (TUTOR-PHC), and during manuscriptpreparation as a Scholar of the Micheal Smith Foundation for Health Research. None of these funders had a role in the study design, data collection, analysis,decision to publish, or preparation of the manuscript.Competing Interests: The authors have declared that no competing interests exist.* E-mail: wendy.norman@ubc.caIntroductionInduced abortion is a common procedure with 95,876 reportedin Canada, [1] and 43.8 million globally, [2]for 2008. Nearly athird (31%) of Canadian women have at least one inducedabortion during their reproductive lifespan [3]. We define inducedabortion, and will use the term ‘‘abortion’’, with the CanadianInstitute for Health Information definition: ‘‘Induced abortion isdefined as the medical termination of pregnancy’’ [1]. Availabilityof abortion service in rural areas is a growing problem in Canada[4–8]. Abortion is increasingly available only at purpose-specificclinics (‘‘abortion clinics’’). In Canada abortion clinics are locatedexclusively in the largest urban centers [4–8]. Statistics Canadareports a steady downward trend from 91% of abortionsperformed in hospitals in 1988 (when the provision of abortionsat non-hospital clinics became legally available in Canada) to 43%in 2010 [1,9,10]. Due to the absence of abortion clinics in ruralareas of Canada, surgical abortion in rural areas is available onlywithin hospitals. As such, and given that the overall number ofabortions performed has been stable over this interval, [1,9,10] thedecline in the proportion of all abortions that are performed inhospitals represents at least a 58% decline in the number ofabortions performed in rural areas.British Columbia (BC) is a large Canadian province of about 4million people, with an area aproximately the size of France andGermany combined. BC maintains a comprehensive provincialreferral system for abortions, the Pregnancy Options Service(POS) [11]. The POS system offers a unique opportunity to studyfactors influencing abortion availability and distribution. POSrecords indicate that the number of rural abortion providers, aswell as the number of communities where abortion service isoffered, have declined more than 60% over the decade prior toPLOS ONE | www.plosone.org 1 June 2013 | Volume 8 | Issue 6 | e670232010 [12]. With declining rural access to surgical abortion,abortion induced using medication (‘‘medical abortion’’) could bean available alternative. However several sources currentlyestimate medical abortions are fewer than 4% of all Canadianabortions [6,10,13].No published studies have examined experiences and practiceamong rural Canadian physicians providing abortion. In Canadaonly physicians are licensed to provide abortions. Experiences andpractice among urban abortion providers who are voluntarymembers of a professional association in Canada, the USA andAustralia have been previously reported [14–16]. These studiesdemonstrate adherence to evidence-based guidelines and a largedegree of uniformity of practice among urban abortion providersin all three jurisdictions. All BC urban abortion clinics weremembers of this association in 2001 and participated in the mostrecently published survey: none of the rural abortion providers inBC participated in the previous surveys.Thus, rural abortion services are disappearing in Canadaalthough we know little about the experiences of abortionproviders and factors related to their provision of rural services.Understanding the distribution, services provided and conditionsexperienced by rural abortion provider physicians is a first step todetermine appropriate health policy. Determination of factors thatcould address the remarkable shift away from abortion services inrural areas has the potential to improve closer-to-home access toreproductive health care for rural and remote Canadians.MethodsEthicsEthics board approval was obtained from the University ofBritish Columbia Children’s and Women’s Hospital ResearchEthics Board (H11-00766) prior to commencement of the study.All participants submitted written completed surveys, including astatement that submission of the survey would imply consent toparticipation. Participants had the option to provide self-identifi-cation at the beginning of the survey, with the assurance that nodata would be published that would allow individual identification.This mixed methods study explored practices and experiencesof rural compared to urban abortion providers in BC. Self-administered questionnaires were distributed to BC abortionproviders in 2011. Questionnaire respondents were invited toparticipate in a semi-structured individual interview. (See quali-tative findings in the companion article: ‘‘The perspective of ruralphysicians providing abortion in Canada: qualitative findings ofthe BC Abortion Providers Survey (BCAPS)’’).QuestionnaireThe questionnaire was kindly provided by Drs. Lichtenberg,O’Connell White, Paul and Jones as developed for their previouslypublished studies [14–16]. We adapted their instrument to removequestions or options inappropriate for the Canadian context or thepurpose of this study, and to add options pertinent to Canada,creating the ‘‘BC Abortion Providers Survey’’ (BCAPS). Respon-dents selected among coded responses for all questions, and wereencouraged to write-in comments. This report presents theanalysis of abortion provider demographics and distribution; basicservices; and reported stigma or harassment. The companionarticle in this issue: ‘‘The perspective of rural physicians providing abortionin Canada: qualitative findings of the BC Abortion Providers Survey(BCAPS)’’, explores qualitative findings on attitudes, perceivedbarriers and facilitators related to abortion provision.Sampling TechniqueWe distributed the BCAPS between April 15th and September15th, 2011 to all abortion providers on the POS roster. We defined‘‘urban’’ participants as those providing services within a CensusMetropolitan Area (CMA). Statistics Canada defines a CMA asbeing ‘‘formed by one or more adjacent municipalities centred ona large urban area (known as the urban core). The censuspopulation count of the urban core is at least 100,000 to form acensus metropolitan area. To be included in the CMA, otheradjacent municipalities must have a high degree of integrationwith the central urban area, as measured by commuting flowsderived from census place of work data.’’ [17,18] All otherparticipants were defined as rural providers.Statistical AnalysisWe analyzed questions referring to individuals using theindividual clinician as the unit of analysis. We used the facility(either an urban abortion clinic, or a rural hospital or ruralcommunity as appropriate) as the unit of analysis for questionsregarding facilities. In some cases it was appropriate to use thehealth authority region, i.e., the administrative division for deliveryof health services within BC, which we will refer to as the‘‘region’’, [19] as the unit of analysis. Only physicians are licensedto provide abortion service in Canada, thus all responders arelicensed physicians. We performed all analyses using the softwareprogram R [20]. Where appropriate, we used the students’ t-test(comparing age of providers), Chi-square test of independence(comparing gender and location, and years in practice andlocation), Fischer’s exact test (comparing specialty mix andlocation)and a Wilcoxon rank sum test (comparing proportion ofpractice devoted to family planning).ResultsEighty-five percent (39/46) of current surgical abortionproviders in BC returned surveys.(Fig. 1) Two additional ruralphysicians returned surveys. Although each of these had formerlyprovided abortion service and were still working as physicians intheir communities, both had recently discontinued providingabortions. This analysis presents responses from current providersfor all services questions, and considers both current and pastproviders in presentation of questions regarding harassment andstigma.Demographics of Abortion ProvidersRural providers were more likely to have been providingabortions for less than 15 years (12/22, 54.5%), although of asimilar average age, and proportion of oldest physicians, thanurban providers (3/17, 17.6%, p= 0.044) (Table 1).Respondents indicated an overall average of 30.7% (SD 30.1%)of their practice was devoted to family planning, although 5/17(29.4%) urban providers reported that they practice exclusively inthis area. Among urban providers, 7/17 (41%) indicated familyplanning as 30% or less of their practice. Among rural providers21/22 (95%) indicated family planning as 30% or less of theirpractice, and none practice exclusively in family planning.Number of AbortionsResponding providers reported an estimated 15,953 inducedabortions performed in 2010 in BC, including 2349 (14.7%)medical abortions. The average number of reported abortionsperformed by each rural provider was 76 (SD 52) including 35 (SD30) medical abortions. The urban facilities provided 90.2% of allreported abortions by any method.Rural Abortion Services-CanadaPLOS ONE | www.plosone.org 2 June 2013 | Volume 8 | Issue 6 | e67023Figure 1. Survey Distribution and Response. Notes: CMA=Census Metropolitan Area.doi:10.1371/journal.pone.0067023.g001Table 1. Characteristics of rural compared to urban current abortion provider participants.Overalln = 39Rural Providersn=22Urban Providersn=17Significance(rural vs. urban)Average Age (SD) in years 51.8 (10.7) 50.7 (10.7) 53.1 (11.1) p = 0.50Current age over 59 years 11 (28%) 6 (27%) 5 (29%)Female Providers 21 (54%) 11 (50%) 10(59%) p = 0.82Specialty (%) p= 0.58Obstetrician-gynecologist1 21 (54%) 12 (55%) 9 (53%)Family Physician2 18 (46%) 10 (45%) 8 (47%)Years as an abortion provider,15 years 15 (38%) 12(55%)* 3 (18%)* p = 0.043.15–25 years 12 (31%) 5 (23%) 7 (41%).25 years 12 (31%) 5 (23%) 7 (41%)% Practice in Family Planning 30.7(SD30.1) 15.0(SD11.2)* 51.0 (SD35.9)* p,0.001Notes:*Significant differences.1Including those with Canadian and Non-Canadian certification.2Including general practitioners.3Siginificant when Rural vs Urban for ,15 years is compared to 15 or more years.doi:10.1371/journal.pone.0067023.t001Rural Abortion Services-CanadaPLOS ONE | www.plosone.org 3 June 2013 | Volume 8 | Issue 6 | e67023Distribution of Abortion ServicesUrban providers work within seven facilities: six abortion clinics(15/17, 88.3%), and one urban hospital (2/17, 11.8%). Ruralproviders identified 16 distinct communities in which theypractice. One rural provider identified only the region of practice.For analysis purposes this provider was assumed to represent adistinct 17th community, an assumption supported by the variationin facility and service descriptors between this responder and thoseof other responders in the same region.Abortion services were reported in four of the five geographichealth authority regions. (Table 2) No sources available were ableto identify provision of induced abortion in one large region,including in the encompassed CMA. Three quarters of ruralcommunities (13/17, 76.5%) do not offer induced abortionbeyond the first trimester (Table 3). Only 1.7% of second trimestersurgical abortions reported occurred in rural communities. Bycontrast, medical abortions in the first trimester of pregnancy arerelatively accessible with 12/17 (70.6%) of reporting ruralcommunities offering this service compared to 2/7 (28.6%) urbanfacilities.Knowledge of the location and the mode of anaesthesiaavailable for the provision of surgical abortion are relevant inorder to understand the barriers and facilitators experienced byproviders. All rural providers performed surgical abortions withina hospital operating room, although three indicated availability ofhospital outpatient clinic space where they performed a portion oftheir cases. Among urban respondents, four of the seven facilitiesperformed some or all procedures within a hospital, but only oneexclusively used an operating room, with the others predominantlyusing outpatient based clinic space. Two of these clinics alsooffered procedures within an operating room for exceptionalindications.With respect to the anaesthesia and analgesia methods offeredby facilities providing surgical abortions: all urban clinics (7/7,100%), and 6/17 (35.3%) rural facilities, offered local anaesthesiaplus intravenous sedation as the predominant modality foranaesthesia. This approach was utilized for over 90% of surgicalabortions. Examination of physician practice indicates that amongrural providers 16/22 (72.7%) offer general anaesthesia as anoption and 10/22 (45.5%) use general anaesthesia exclusively ornearly exclusively.Stigma, Harassment and Logistical BarriersNearly half (8/17, 47.1%) of rural communities reported aproportion of operating room nurses or anaesthesiologists whowould not accept an assignment to the abortion cases. Operatingroom scheduling issues were noted as a significant source of stressand/or conflict by rural abortion provider respondents, nearly allof whom wrote-in extensive additional notes. For example: ‘‘I havesuffered threats and have had both (sic) anesthetists, [ultrasound]technologists, and [operating room] nurses refuse to cooperate intreatment or have had patients suffer insults’’. No such barrierswere reported from providers in the urban facilities whoconversely reported supportive facility environments. In addition,7/22 (31.8%) of rural providers indicated their community hadexperienced resignations from physicians or nurses due tounwillingness to endure harassment or stigma experienced as aresult of involvement in abortion provision. No such resignationswere reported from urban facilities or providers. The only reportsTable 2. Location of facilities where participants provide surgical abortion services.Health Authority Region% of BC females age15–441Rural2n=17Urban3n=7Totaln =24Provincial Health Services4 n/a 1 1Fraser Health 36.5% 0 0 0Interior Health 14.1% 4 1 5Northern Health 6.3% 7 n/a5 7Vancouver Coastal Health 28.1% 1 4 5Vancouver Island Health 15.1% 5 1 6Notes:1BCStats. Population Estimates by Standard Age Groups. [37].2The unit of reporting is by rural community which in this case is equivalent to facility.3The unit of reporting is by urban facility.4Provincial Health Services Authority (PHSA) facilities are located in Vancouver and have a provincial service mandate. ‘‘(The PHSA’s) primary role is to ensure that BCresidents have access to a coordinated network of high-quality specialized health care services.’’ [38].5Northern Health Authority does not have a Census Metropolitan Area (see definition of urban in text); Fraser, Interior, Vancouver-Coastal and Vancouver-Island eachhave one.doi:10.1371/journal.pone.0067023.t002Table 3. Rural compared to urban induced abortion serviceavailability reported for BC.ServiceRural1n (%)Urban2n (%)Surgical Induced Abortion 17 (100) 7 (100)Upper limit of gestational age(weeks)12 or less 8 (47.1) 1 (14.3).12 up to 14 5 (29.4) 2 (28.6).14 up to 18 4 (23.5) 1 (14.3)Over 18 0 3 (42.9)Medical Abortion (First trimester)12 (70.6) 2 (28.6)Medical Abortion (Secondtrimester)103 (58.8) 2 (28.6)Notes:1The unit of reporting is by rural community.2The unit of reporting is by urban facility.3Although not specifically elicited, about half of rural facilities volunteeredinformation on restricted criteria for medically induced second trimesterabortions, such as restriction to fetal indications.doi:10.1371/journal.pone.0067023.t003Rural Abortion Services-CanadaPLOS ONE | www.plosone.org 4 June 2013 | Volume 8 | Issue 6 | e67023of sporadic anonymous personal harassment or violence wereamong urban providers, and were in the categories: ‘‘threats toyou or your family’’ (2/17, 11.8%); ‘‘property vandalism’’(4/17,23.5%); and ‘‘trespassers at your home’’(2/17, 11.8%).We asked all respondents to consider 12 possible categories ofrelationships (e.g., siblings, parents, children, colleagues, andfriends) and report which were aware of their work as an abortionprovider. No differences were seen between rural and urbanphysicians overall or among any specific categories.DiscussionBC’s current abortion providers are about half specialists andhalf family physicians, and about half are female, both overall andin each jurisdiction. Rural abortion service was reported asavailable in 17 hospitals outside of large urban areas in BC. Urbanservice was reported as available at seven facilities in three of thefour largest urban areas. Our finding that 15% of all abortions aremedical abortions is higher than previously reported in Canada.Rural physicians perform an average of 76 (SD 52) abortionsannually, about half of which are medical abortions. Ruralphysicians report stigma and operational barriers within theirfacility and among their colleagues with particular conflict arisingin operating room scheduling. Urban physicians report excellentsupport from their facilities and colleagues, but occasionalexperiences of anonymous harassment and violence.Demographics of Abortion ProvidersThe mean age of BC abortion providers at 51.8 (SD 10.7) yearsis not significantly different than that reported for physiciansoverall in BC at 49.5 years (p = 0.50), with an equivalentproportion (28%) over age 60 [21]. A significantly greaterproportion of rural compared to urban providers have beenproviding abortion service for less than 15 years. Data on thenumber of years in practice were not collected, thus we wereunable to determine if the fewer years providing abortions amongrural physicians represented attrition after a certain number ofyears of rural abortion service provision, or that rural physiciansbegan providing abortions later in their careers, or was due tosome other etiology. Further study of this phenomenon iswarranted.Number of Abortions Performed in BCThe report of 15,953 induced abortions in 2010, is comparableto Canadian Institutes of Health Information (CIHI) report of12,149 in the same year, as CIHI notes data from BC clinics to beincomplete [10]. The overall number of abortions is consistentwith that reported by CIHI for BC in 2007 (15,770) and for 2011(14,341), years for which complete data are reported [22,23].Urban case numbers reported per facility are thought to beaccurate, however, rural physician self-reported ‘number of cases’did exhibit rounding in some cases. As rural physicians contrib-uted less than 10% of total BC abortions, the impact of roundingamong individual physicians on the total number of reportedabortions is likely to be minimal. Our respondents reportedproviding medical abortions as 15% of all abortions. This issignificantly higher than analyses of administrative databases,which estimate fewer than 4% of abortions in Canada are medicalabortions [6,10,13]. As medical abortion provision is difficult tocapture through administrative database analysis for a number ofreasons, our findings may represent a more accurate reflection ofthe provision of medical abortion in Canada.Distribution of Abortion ServicesWe found a mismatch between where abortion service isavailable, and where reproductive age women reside in BC. Over90% of abortions reported for BC are offered in three of the fourlarge urban areas(CMAs) in this province although only 57% ofBC reproductive age women live in the regions associated withthese areas [24,25]. No urban or rural abortion services weredetected within one regional health authority, although this regionprovides health care for 36.5% of all reproductive age women inBC [26,27]. Abortion service in BC is provided in only 17/67(25.4%) hospitals [28] outside of the large urban areas. A 2006analysis [8] found 29/90 (32%) of all BC hospitals (i.e., both urbanand rural) offered abortion service. However, four years later wehave found abortion service offered at only 21/97 (22%) of allhospitals in BC. Both figures include abortion services at foururban hospitals. Adjusting for urban hospital-based services, thistranslates to a one-third decline (from 25 to 17 hospitals) in ruralabortion service over 4 years.Stigma, Harassment and Logistical BarriersPhysicians providing abortions in rural areas are more likelythan their urban counterparts to perform abortions in anoperating room (100%), and to use general anaesthesia (73%include this method as an option while overall 46% use thismethod always). Rural providers, including responses from twoformer abortion providers who continue as practicing physicians intheir community, report stigma and operational barriers withinprofessional relationships and at their hospitals. This may suggest arole for frustration and early burn-out as an etiology for thepreviously noted marked rural abortion provider attrition. (Seecompanion article ‘‘The perspective of rural physicians providingabortion in Canada: qualitative findings of the BC AbortionProviders Survey (BCAPS)’’ for related experiential findings fromrural abortion providers.).Although rural providers report prevalent use of generalanaesthesia for abortion care, guidelines of expert organizationsin Canada and globally [29–32] currently suggest local anaesthesiawith or without sedation as preferred over general anaesthesia.We found rural abortions are provided predominantly inhospital operating room settings, which physicians identified as afactor in both limitation to services and contributing to theirexperience of conflict, harassment and stigma. Urban hospital-based abortions are provided predominantly in non-operatingroom settings, similar to those for out-patient procedures such ascolposcopy or colonoscopy. Health system advantages such ascost-effectiveness (for surgical abortion management withoutgeneral anaesthesia), and a reduction in post-operative complica-tions among services delivered in ambulatory care settings, havebeen documented for Canada and similar countries. [33–36].LimitationsThe largest limitation to our understanding of the decline inrural physicians offering abortion service in BC is the inability toidentify and sample most of the rural physicians who are no longerproviding abortions. To partially address this, we plan toiteratively follow current and new providers over time to betterunderstand challenges and facilitators. As POS has foundproviders offering only medical, and not surgical, abortion areless likely to participate in their register, we were unable to locateand survey all providers of medical abortions. Thus the numberand proportion of actual medical abortions in the province may behigher than we report. POS uses a number of methods to ensureaccurate information on current surgical abortion providers in theprovince of BC, aided by their role to distribute appropriateRural Abortion Services-CanadaPLOS ONE | www.plosone.org 5 June 2013 | Volume 8 | Issue 6 | e67023security updates and support for BC abortion providers on behalfof BC Women’s Hospital and the BC Ministry of Health. It isthought the POS register of surgical abortion providers iscomprehensive. Self-reported estimates of procedures by ruralphysicians, although a small contribution to the total number ofabortions in the province, may not correlate with the exactnumber of abortions performed. In contrast, the number ofabortions provided by urban facilities is thought to be accurate.ConclusionAttrition of rural abortion providers is an important problemthroughout Canada. This study offers a first look at possibleetiologies and potentially addressable issues. Rural inducedabortion services in BC have limited accessibility, with sub-optimal alignment between where reproductive age women liveand where services are available. Rural abortion service is nearlyexclusively operating room based and usually under generalanaesthesia, despite national and international recommendationsfor safe provision using local anaesthesia. Most rural abortionproviders identified addressable barriers to service provision, inparticular highlighting both stigma and service delivery conflictswhere abortion service is limited to the hospital operating room.Moving surgical abortions out of operating rooms and into localambulatory care facilities has the potential to lower costs whileimproving service availability in rural areas.AcknowledgmentsThe authors wish to thank Drs. E. Steve Lichtenberg, Maureen Paul,Katharine O’Connell White and Heidi Jones for their permission to usetheir survey instrument for the purpose of this study.Author ContributionsConceived and designed the experiments: WN. Performed the experi-ments: WN JD NM. Analyzed the data: WN JS JD NM. Contributedreagents/materials/analysis tools: WN JS. Wrote the paper: WN. Allauthors contributed to revisions of the manuscript and all have reviewedand accepted the final submission.References1. Canadian Institutes for Health Information (2011) Induced abortions performedin Canada in 2009. Canadian Institutes of Health Information. Available:h t t p : / /www . c i h i . c a /C IH I - e x t - p o r t a l / p d f / i n t e r n e t /TA_0 9 _ALLDATATABLES20111028_EN Accessed: 25 Mar 2013.2. Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, et al. (2012) Inducedabortion: incidence and trends worldwide from 1995 to 2008.Lancet Feb18;379(9816): 625–32. doi: 10.1016/S0140-6736(11)61786-8.3. 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