Open Journal of Obstetrics and Gynecology, 2012, 2, 255-261 OJOG Published Online September 2012 (
Trends in cesarean section rates at a large East African
referral hospital from 2005-2010
Ayaba Worjoloh1,2,3*, Rachel Manongi4, Olola Oneko5, Cathrine Hoyo2, Anne Kjersti Daltveit6,7,
Daniel Westreich2,8
1Hubert-Yeargan Center for Global Health, Duke University, Durham, USA
2Department of Obstetrics and Gynecology, Duke University, Durham, USA
3Fogarty International Clinical Research Fellowship, Duke Global Health Institute, Duke University, Durham, USA
4Department of Community Health, Kilimanjaro Christian Medical Center, Moshi, Tanzania
5Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Center, Moshi, Tanzania
6Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
7Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
8Duke Global Health Institute, Duke University, Durham, USA
Email: *
Received 9 May 2012; revised 13 June 2012; accepted 30 June 2012
Between 2005 to 2010 in a Tanzanian referral hospi-
tal, the cesarean section rate ranged from 29.9% to
35.5%. The leading indication was previous cesar-
ean section.
Keywords: Cesarean Delivery; Maternal Health; Africa;
Birth Registry; Tanzania; Trends
Emergency obstetric care is crucial to reducing maternal
morbidity and mortality from direct causes such as hem-
orrhage, infection, hypertensive disorders of pregnancy
and obstructed labor and reaching Millennium Develop-
ment Goal 5. [1,2] In the developing world, access to
cesarean section (CS) is one hallmark of emergency ob-
stetric services [3]. The World Health Organization
(WHO) and Pan American Health Organization suggest
the ideal CS rate for a country is 5% - 15% [2,4,5]. This
range represents assumptions about the effective use of
CS as an essential intervention, maximizing access to
care while minimizing adverse outcomes. Adverse ef-
fects of CS compared to vaginal delivery include higher
costs of surgery [6], slower recovery for the woman, in-
creased risk of adverse events in subsequent pregnancies,
and increased complication rates such as infections, in-
jury to nearby organs, and increased complication rates
such as infections, blood transfusion and death [7], espe-
cially given the high prevalence of HIV infection.
According to the WHO Global Survey on Maternal
and Perinatal Health, which recently collected CS data in
24 countries around the world [8-10], the average fre-
quency of CS in Africa is 9% [11]. Previous studies
documenting CS rates among African countries cite a
range of 0.6% - 18.0% [3,4,12]. The leading indications
for CS in Sub-Saharan Africa (SSA) is labor dystocia
followed by previous CS [4,11]. Looking closely at fa-
cilities, those with higher CS rates also have higher ma-
ternal and neonatal morbidity and mortality. Therefore,
examination of individual facilities driving the average
as evidenced by a privately owned facility in Kenya with
a 35% CS rate and a public-owned facility in Angola
with a 1.1% CS rate [11]. It remains unknown whether
these higher facility rates represent overuse of CS as an
intervention, or whether they reflect systematic differ-
ences in populations (e.g., higher HIV prevalence) such
that higher rates of CS are appropriate.
There are almost no studies of time-trends in CS rates
conducted in and published from SSA since 2005. Ex-
amination of local trends in CS is needed to assess the
data gaps and explore ways for improvements because of
suboptimal representation of how CS rates can be much
higher at select hospitals. To our knowledge this is the
third study in the past decade performed in SSA to ex-
amine hospital-specific trends in frequency of CS [13,14].
Our study adds to this literature by evaluating the trend
in CS rates and indications from 2005-2010 at a referral
institution for a large region of Tanzania.
2.1. Study Area
The Kilimanjaro Christian Medical Center (KCMC) is a
large, University-referral hospital in northern Tanzania.
The hospital is located in the Kilimanjaro region, and is
*Corresponding author.
A. Worjoloh et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 255-261
one of four referral hospitals in a country of over 42 mil-
lion [2]. The region itself includes over 1.4 million in-
habitants [15], yet the obstetric patients served by the
hospital include seven regions in Tanzania as well as
districts in Kenya just beyond the border. The hospital
conducts over 3300 deliveries per year.
Monitoring of labor at KCMC is done using the parto-
graph, palpation of contractions and fetoscope. Cardio-
tocography, intrauterine pressure catheter, and fetal scalp
electrodes are not used. In emergency situations, moni-
toring is supplemented by ultrasound. Pregnant women
in active labor are monitored in the inpatient obstetrics
unit and then transferred to the labor ward just prior to
delivery. The labor ward has 4 beds partitioned along a
sterile room, and overflow occurs in the sterile corridor.
There are two operating theaters designated for CS in
addition to five main operating rooms used for other sur-
geries. The hospital has 3 full-time specialist obstetric-
cian-gynecologist and is a training site for obstetrics and
gynecology specialists.
The birth registry at KCMC was initiated by public
health practitioners through the Center for International
Health at the University of Bergen, Norway [16]. Since
1999, births from women admitted to labor and delivery
have been recorded by specially trained nurse-midwives.
Within 24 hours of delivery, or as soon as mothers had
recovered in cases of complicated deliveries, mothers
were visited by a birth registry nurse-midwife who re-
quested verbal consent to have personal information and
birth information recorded. The nurse-midwife recorded
the information through a specially designed question-
naire. There is complete coverage of births on a daily
basis, including weekends and holidays. Information col-
lected includes women’s and their spouses’ sociode-
mographic characteristics, maternal diseases and com-
plications before and during pregnancy, complications
during delivery, and information on the newborn [17]. In
2005 the first written instruction manual for the Registry
was produced which led to improved quality of the data.
Therefore we included births from January 1st 2005 to
December 31st 2010.
2.2. Study Population
We analyzed singleton gestations. Our unit of observa-
tion was the pregnancy, and for the 3339 women who
delivered at the facility more than once during the 6-year
period, each pregnancy was counted as a separate obser-
2.3. Description of Select Variables
The variables for analysis were chosen because they are
associated with CS rates in other studies and are com-
monly accepted indications for CS. The following vari-
ables are composites coded from listed variables in the
birth registry. Induction of labor is defined as an inter-
vention used either to begin or augment the labor process.
These interventions include amniotomy, intravenous oxy-
tocin administration, and/or vaginal prostaglandin place-
ment. Labor dystocia includes poor progress of labor,
obstructed labor, cervical dystocia, prolonged labor,
cephalopelvic disproportion, persistent occiput posterior,
deep transverse arrest, contracted pelvis, big baby, and
borderline pelvis. Malpresentation includes breech and
other abnormal presentations including face, arm, shoul-
der, and footling presentation as well as transverse and
oblique lie. Nonreassuring fetal status includes listed
indications of fetal distress, cord prolapse, and severe
intrauterine growth restriction, low biophysical profile.
Antepartum bleeding includes antepartum hemorrhage,
placenta previa, placenta abruption, and uterine rupture.
Previous uterine scar includes previous CS and previous
2.4. Statistical Analysis
The CS proportion was defined as the number of CS in
the year divided by the total number of births at KCMC
in that same year. We used frequencies to describe the
maternal characteristics, pregnancy history, delivery his-
tory and indications for CS per year. All data were from
the birth registry.
Linear test of trends were used to assess changes by
year. A p value 0.05 was considered statistically sig-
nificant for the linear test of trends. All analysis were
performed for each year from 2005-2010. Analytical
tests were carried out using STATA/IC (version 11, Col-
lege Station, TX).
2.5. Ethical Consideration
The overall registry study was approved by the KCMC
Ethics Committee and the Ministry of Health in Tanzania.
The protocol for the current analyses was approved by
the KCMC Ethics Committee and the Duke University
Medical Center Institutional Review Board.
3.1. Demographics
Overall there were 19,088 singleton deliveries in the
six-year study period at KCMC. As seen in Tab l e 1 the
frequency of CS was between 29.9 to 35.5 percent with
the peak in year 2005 and nadir in year 2007. There were
no statistically significant trends in the frequency of CS,
although each year had lower CS than the peak reference
year of 2005. The median maternal age ranged from 27.5
to 27.8 years, and overall, approximately 86% of the
births occurred in married wmen. The majority of births o
Copyright © 2012 SciRes. OPEN ACCESS
A. Worjoloh et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 255-261
Copyright © 2012 SciRes.
change per year (95%
Ta bl e 1. Percentages of cesarean section, sociodemographic characteristics and pregnancy history of women delivering at Kiliman-
jaro Christian Medical Center.
(N = 2771)
n (%)
(N = 2857)
n (%)
(N = 3132)
n (%)
(N = 3509)
n (%)
(N = 3475)
n (%)
(N = 3344)
n (%)
Cesarean section 984 (35.5) 911 (32.0) 937 (29.9) 1107 (31.6) 1082 (31.1) 1121 (33.5) 0.2% (0.6, 0.2)
Marital status
Married 2438 (88.0) 2549 (89.2) 2798 (89.3) 3091 (88.1) 3030 (87.2) 2897 (86.6) 0.7% (0.9, 0.4)
Unmarried 302 (10.9) 263 (9.2) 325 (10.4) 414 (11.8) 438 (12.6) 444 (13.3)
Missing 31 (1.1) 45 (1.6) 9 (0.3) 4 (0.1) 7 (0.2) 3 (0.1)
Age mean, SD (range) 27.6, 6.2
(14 - 50)
27.5, 5.9
(13 - 49)
27.6, 5.9
(13 - 47)
27.5, 6.0
(13 - 48)
27.6, 5.9
(14 - 46)
27.8, 5.9
(14 - 48) 3.6% (1.5, 8.7)
Age NA
16 yrs or less 26 (1.0) 27 (1.0) 22 (0.7) 32 (0.9) 30 (0.9) 31 (0.9)
17 - 25 1091 (39.4) 1100 (38.5) 1224 (39.1) 1395 (39.8) 1350 (38.8) 1235 (36.9)
26 - 34 1224 (44.2) 1355 (47.4) 1470 (47.0) 1595 (45.5) 1622 (46.7) 1568 (46.9)
35 and older 424 (15.3) 368 (12.9) 410 (13.1) 483 (13.8) 472 (13.6) 507 (15.2)
Missing 6 (0.2) 7 (0.3) 6 (0.2) 4 (0.1) 1 (0.0) 3 (0.1)
Highest education level NA
None 51 (1.8) 56 (2.0) 54 (1.7) 66 (1.9) 60 (1.7) 50 (1.5)
Primary (1 - 7 y) 1765 (63.7) 1743 (61.0) 1875 (59.9) 2015 (57.4) 1906 (54.9) 1811 (54.2)
Secondary (8 - 12 y) 133 (4.8) 130 (4.6) 137 (4.4) 187 (5.3) 172 (5.0) 177 (5.3)
Beyond secondary (>12 y) 813 (29.3) 921 (32.2) 1060 (33.8) 1237 (35.3) 1327 (38.2) 1303 (39.0)
Missing 9 (0.3) 7 (0.3) 6 (0.2) 4 (0.1) 10 (0.3) 3 (0.1)
Tribe NA
Chagga 1610 (58.1) 1596 (55.9) 1664 (53.1) 1902 (54.2) 1872 (53.9) 1826 (54.6)
Pare 377 (13.6) 351 (12.3) 409 (13.1) 454 (12.9) 417 (12.0) 403 (12.1)
Other 773 (27.9) 895 (31.3) 1048 (33.5) 1144 (32.6) 1158 (33.3) 1089 (32.6)
Missing 11 (0.4) 15 (0.5) 11 (0.4) 9 (0.3) 28 (0.8) 26 (0.8)
Percentages may not add up to 100% because rounding.
occurred among women who had attended 7 or fewer
years of school, which corresponds to the end of primary
school in Tanzania. Other critical demographic charac-
teristics are summarized in Table 1.
3.2. Pregnancy and Delivery Characteristics
Table 2 shows the proportion of births to women with
previous CS decreased from 2005-2010 with a frequency
of 26.3 percent in 2005 and 17.1 percent in 2010 (esti-
mated change of 1.3% per year [95% CI 1.7%, 0.9%]
over six years). The frequencies of pre-eclampsia, ecla-
mpsia, malpresentation, and antepartum bleeding re-
mained similar over the observation period. Births from
women attending more than 4 antenatal visits have de-
creased from 69.0 to 58.8 percent (estimated change of
2.6% per year [95% CI 3.0%, 2.2%]). There has also
been a decrease among births from post term pregnancies.
Over the study period the referral rate for births has in-
creased from 20.1% in 2005 to 23.3% in 2010 (estimated
change of 0.9% per year, [95% CI 0.6%, 1.3%]) and
while the frequency of labor induction has decreased
from 33.1 to 10.8 percent (estimated change of 5.9%
per year, [95% CI 6.2%, 5.5%]).
Figure 1 shows that the percent of referrals receiving
A. Worjoloh et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 255-261
Table 2. Characteristics of pregnancy and delivery for Births at Kilimanjaro Christian Medical Center.
(N = 2771)
n (%)
(N = 2857)
n (%)
(N = 3132)
n (%)
(N = 3509)
n (%)
(N = 3475)
n (%)
(N = 3344)
n (%)
Change per Year
(95% CI)
Current Pregnancy
Primigravidas 1095 (39.5) 1130 (39.6)1299 (41.5)1558 (44.4)1494 (43.0)954 (28.5) 0.5% (0.1, 0.9)
Previous Cesarean 743 (26.8) 758 (26.5) 744 (23.8) 692 (19.7) 681 (19.6) 570 (17.1) 1.3% (1.7, 0.9)
Pre-Eclampsia 125 (4.5) 153 (5.4) 104 (3.3) 126 (3.6) 175 (5.0) 174 (5.2) 0.1% (0.1, 0.3)
Eclampsia 22 (0.8) 20 (0.7) 22 (0.7) 19 (0.5) 16 (0.5) 22 (0.7) 0.0% (0.1, 0.0)
Antepartum Bleedinga 41 (1.5) 33 (1.2) 51 (1.6) 38 (1.1) 38 (1.1) 50 ( 1.5) 0.0% (0.1,0.1)
Malpresentationb 44 (1.6) 41 (1.4) 40 (1.3) 52 (1.5) 45 (1.3) 60 (1.8) 0.0% (0.1, 0.1)
>4 Prenatal Visits 1913 (69.0) 1973 (69.1)1993 (63.6)2050 (58.4)2011 (57.9)1966 (58.8) 2.6% (3.0, 2.2)
PROMc 94 (3.4) 70 (2.5) 46 (1.5) 74 (2.1) 40 (1.2) 40 (1.2) 0.3% (0.5, 0.2)
Known HIVd Seropositivity 136 (4.9) 148 (5.2) 170 (5.4) 186 (5.3) 159 (4.6) 159 (4.8) 0.4% (0.6, 0.2)
Post Term (>42 weeks) 49 (1.8) 19 (0.7) 19 (0.6) 13 (0.4) 7 (0.2) 6 (0.2) 0.2% (0.2, 0.1)
Referral (any) 556 (20.1) 586 (20.5) 721 (23.0) 896 (25.5) 878 (25.3) 779 (23.3) 0.9% (0.6, 1.3)
Induction of Labor 918 (33.1) 921 (32.2) 975 (31.3) 581 (16.6) 261 (7.5) 362 (10.8) 5.9% (6.2, 5.5)
aAntepartum bleeding-refers to vaginal bleeding second half of pregnancy; bMalpresentation-includes breech and transverse; cPROM-Premature rupture of
membranes; dHIV-Human immunodeficiency virus; Percentages do not lead to expected result because of missing values.
Figure 1. Proportion of cesarean sections at Kilimanjaro Christian Medical Center according to referral status. aEstimated change per
ear (95% CI): 1.5% (2.4, 0.6); bEstimated change per year (95% CI): 0.1% (0.5, 0.3). y
Copyright © 2012 SciRes. OPEN ACCESS
A. Worjoloh et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 255-261 259
cesarean deliveries decreased from 52% in 2005 to 44%
in 2010 (estimated change of 1.4% per year, [95% CI
2.4, 0.6]) while the proportion of CS among the non-
referrals has remained relatively constant.
3.3. Indications for Cesarean Deliveries
Among women with CS the most likely indication was
previous uterine scar (Table 3). Of these previous uterine
scars 1.1 percent was prior myomectomy. The indica-
tion of previous uterine scar, has decreased in frequency
from 2005-2010. The next most common indication was
labor dystocia. Nonreassuring fetal status, antepartum
bleeding, and known HIV seropositivity have remained
constant in their contribution to CS. Pre-eclampsia/ecla-
mpsia showed a statistically significant increasing trend
as an indication for CS, with percentages in 2005 of
6.6% and 10.5% in 2010 (an estimated per year in-
crease of 0.7%, [95% CI 0.3%, 1.1%]). We also analyzed
trends of CS rate within in each indication, however
there were no clear time trends (data not shown). No
indication was listed for 3.6% of women.
While the worldwide debate about the rise in CS conti-
nues, there has been to date little focus on sub-Saharan
Africa. Given the persistently high perinatal mortality
rates, it is important to examine trends and indications of
CS in this region. In this hospital-based study there has
been little change in the frequency of CS from 2005 to
2010. With percentages ranging between 29.9% and
35.5%, this is significantly higher than Tanzania’s coun-
try rate of 3.0% to 4.5% and Kilimanjaro region’s rate of
7.2% to 11% seen in the 2005 and 2010 Demographic
and Health Surveys (DHS) [18,19]. The leading indica-
tion for CS is previous uterine scar and that has shown a
significant decrease over the study time period. At the
same time, other indications for CS such as pre-eclamp-
sia/eclampsia, and labor dystocia have shown a marginal
The frequency of CS at KCMC does not mirror the
rise in CS seen across many other countries [20,21], nor
does it reflect the low prevalence of CS in Tanzania and
other SSA countries [3,11,22]. It does however compare
to the stability in CS rates found in countries like Finland,
Norway and the Netherlands [23]. While we know that
referral hospital based CS rates do not reflect the coun-
try’s CS rate, it does raise the question: is the observed
CS prevalence and trend appropriate for a referral hospi-
tal in Tanzania or sub-Saharan Africa generally?
According to the 2005 and 2010 Tanzania DHS, the
CS rate in the Kilimanjaro region has trended up from
7.5% to 11% [18,19]. These estimates suggest that either
the high frequency of CS at KCMC reflect few CS being
performed in other health facilities in the region (and
cases needing CS being referred to KCMC); women
present to KCMC too late in their labor course for vagi-
nal delivery to be a viable mode of delivery; or unindi-
cated CS are occurring at KCMC.
Our study showed that 33% of CS occur among
women referred from other health facilities. These refer-
rals likely represent indicated CS that the referring faci-
lity is unable to perform. A recent study using the birth
registry shows that women who are referred for delivery
have a higher likelihood of CS than women who are self-
referred [15]. Although the reason for referral is not ex-
plicitly stated, the study states the main admitting diag-
nosis, which may act as a proxy for referral reason. The
Ta b le 3 . Proportions of individual indications for cesarean sections at Kilimanjaro Christian Medical Center among women under-
going cesarean section.
(N = 984)
n (%)
(N = 911)
n (%)
(N = 937)
n (%)
(N = 1107)
n (%)
(N = 1082)
n (%)
(N = 1121)
n (%)
Change per Year
(95% CI)
Previous Uterine Scar 509 (51.7) 500 (54.9) 472 (50.4) 484 (43.7) 442 (40.9) 387 (34.5) 2.3% (3.1, 1.6)
Labor Dystociaa 207 (21.0) 227 (24.9) 215 (23.0) 296 (26.7) 269 (24.9) 285 (25.4) 0.8% (0.2, 1.5)
Nonreassuring Fetal Statusb 121 (12.3) 104 (11.4) 116 (12.4) 125 (11.3) 137 (12.7) 128 (11.4) 0.1% (0.5, 0.8)
Malpresentationc 26 (2.6) 32 (3.5) 32 (3.4) 42 (3.8) 37 (3.4) 45 (4.0) 0.2% (0.0, 0.5)
Pre-Eclampsia/Eclampsia 65 (6.6) 77 (8.5) 49 (5.2) 66 (6.0) 107 (9.9) 118 (10.5) 0.7% (0.3, 1.1)
Antepartum Bleedingd 26 (2.6) 22 (2.4) 32 (3.4) 17 (1.5) 22 (2.0) 37 (3.3) 0.0% (0.3, 0.2)
Known HIVe Seropositivity 52 (5.3) 45 (4.9) 45 (4.8) 69 (6.2) 59 (5.5) 70 (6.2) 0.1% (0.5, 0.3)
aIncludes poor progress of labor, obstructed labor, cervical dystocia, prolonged labor, cephalopelvic disproportion, persistent occiput posterior, deep transverse
arrest, contracted pelvis, big baby, and borderline pelvis; bIncludes fetal distress, cord prolapse, and severe intrauterine growth restriction, low biophysical
profile; cIncludes breech and other abnormal presentations such as face, arm, shoulder, and footling presentation as well as transverse and oblique lie; dIncludes
antepartum hemorrhage, placenta previa, placenta abruption, and uterine rupture; eHIV-Human Immunodeficiency Virus; Does not add up to the expected N
ecause of missing indications, indications for CS listed in Registry that do not fit into these categories, and some indications are not mutually exclusive. b
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A. Worjoloh et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 255-261
study found that the main admitting diagnosis is previous
CS and this corresponds with our study’s finding that the
leading indication for CS is previous uterine scar. The
next most common indications for CS found in our study
are labor dystocia and fetal distress. The reasons for re-
ferral deserve further exploration, starting with a focus
on facilities that refer to KCMC. Expansion of the birth
registry to these centers or implementation of a similar
birth surveillance system could help answer this question.
It also has potential to supplement our knowledge about
the quality of decision making around management of
labor and mode of delivery.
The quality of labor management is linked to the ex-
planation that women present to KCMC too late in their
labor course for vaginal delivery to be a viable mode of
delivery. An unpublished Master’s Thesis from the Uni-
versity of Copenhagen done in the Kagera region of
Tanzania revealed 10% of labor dystocia diagnoses did
not receive oxytocin or amniotomy for augmentation and
20% of CS were not indicated based on internationally
agreed medical indications for CS [24]. It is likely that
diagnoses such as labor dystocia are not acted upon ap-
propriately in the periphery and therefore when the
woman presents to the referral facility the mother or fe-
tus is in distress. Therefore a CS must be performed.
More audits such as those from Kagera could be used as
a metric to assess if a woman receives appropriate inter-
vention before she is referred. This could improve labor
management and potentially result in decreased CS rate.
The question of unindicated CS is difficult to disen-
tangle in retrospective data. Worldwide, an increasingly
pervasive and often unsafe reason for CS is the unindi-
cated CS or CS by maternal request [7]. An unindicated
CS in one setting may be indicated in another setting.
One can use the example of vaginal birth after CS
(VBAC). In this study the leading indication for CS is
prior CS. Studies in SSA have shown that VBAC is safe
and feasible [25]. In health facilities which allow VBAC,
a provider must have the resources for proper monitoring,
emergency intervention and knowledge about managing
the labor of women with previous CS. It is possible that a
proportion of women who should VBAC, may not be
given the option. It is beyond the scope of this study to
delve deeper into which CS should be considered unin-
There are inherent limitations in any hospital based
data collection because those who do not deliver in the
hospital are not included in these analyses. The 2010
DHS indicates that almost 12 percent of deliveries in the
Kilimanjaro region occur at home. Another limitation of
this retrospective analysis using registry data is that the
indications for CS are largely subjective. One provider
may interpret and diagnose labor dystocia different from
Despite these limitations, this registry based study of
trends in CS rates in a SSA facility shows that the CS
rate is higher than recommended by WHO. The rate has
been stable over many years, although it does not ap-
proximate the countrywide CS rate. Furthermore, the
primary indication for CS is different from most other
studies in SSA. Understanding reasons for a high CS rate
is a critical next step in assessing the observed rate. A
facility-based audit at referral and referring centers would
assist in understanding the decision making around labor
and mode of delivery by health care providers, women
and their families in Africa, a place often overlooked in
evaluation of rising CS rates. A reasonable starting point
for examination is referral centers because they perform
the majority of CS.
The Kilimanjaro Christian Medical Center Birth Registry is funded by
the Center for International Health at the University of Bergen, Norway.
We are grateful to all the postpartum women, providers and nurses who
gave their time and talents to make it successful. We declare that we
have no conflicts of interest.
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