NPM 3 - Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
ESM 3.1 - Percent of delivering hospitals convened at a meeting to share data and discuss the Alabama Perinatal Regionalization System Guidelines
ESM 3.2 - Number of steps of the CDC's Level of Care Assessment Tool (LOCATe) process completed in order to design and align the Alabama Perinatal Regionalization System Guidelines with the national criteria for the maternal levels of care
Very low birth weight infants (‹1,500 grams or 3.25 pounds) are the most fragile newborns with a risk of death over 40 times higher than that of normal birth weight infants (>=2,500 grams or 5.5 pounds). In Alabama, although they represented less than 1.8 percent of all births in 2021, VLBW infants accounted for 181 deaths out of total of 443 infant deaths, or 40.8 percent of all infant deaths. VLBW infants are significantly more likely to survive and thrive when born in a facility with a Level-III neonatal intensive care unit, a subspecialty facility equipped to handle high-risk neonates. In 2021, there were 847 VLBW infants born in a hospital with a Level III or above NICU out of total of 1092 VLBW births in Alabama. That was 77.6 percent of the VLBW births delivered in Level III or above NICUs in Alabama, and a 3.5 percent increase in the rate from 74.1 percent in 2020.
ADPH has renewed its collaboration with AlaHA to focus on high-risk pregnant women and infants delivering at the appropriate level of care. A workgroup was formed with staff from representative delivering hospitals and AlaHA to explore how the Alabama Perinatal Regionalization System Guidelines are used by hospitals and what challenges they had encountered. As a result of recommendations from this workgroup, LOCATe, from the CDC, was introduced to delivering hospitals in a virtual statewide meeting in April 2021. AlaHA encouraged hospitals to complete the survey on a voluntary basis. Over half of delivering hospitals participated and most completed an assessment of both their neonatal care and maternal care levels. Each hospital received its own results. Aggregated results were shared with ADPH and all delivering hospitals.
The results from LOCATe are used to guide the perinatal regionalization workgroup’s discussions about QI opportunities. Representatives from the Alabama Chapter of the American Academy of Pediatrics, the Alabama Section of the American College of Obstetricians and Gynecologists, and staff from the Alabama Perinatal Quality Collaborative (ALPQC) have been added to the workgroup.
NPM 5 - Percent of infants placed to sleep on their backs
ESM 5.2 - Number of sleep-related infant deaths
ESM 5.3 - Number of trainings facilitated to assist healthcare professionals and first responders, who interact with expecting and new mothers, with being trained on safe sleep recommendations
The three commonly reported types of SUID include sudden infant death syndrome (SIDS), unknown cause, and accidental suffocation and strangulation in bed. These deaths often occur during sleep or in the infant’s sleep area. In 2021, there were 101 SUIDs out of 443 total infant deaths. That was 22.8 percent of the total infant deaths in Alabama, which was a 2.4 percent decrease in SUID from 25.2 percent in 2020. ADPH continues to address SUID through safe sleep education, training of medical personnel and community workers, and distribution of cribs to families without a safe sleep environment.
In September 2022, our partners with the Child Death Review (CDR) organized two trainings on SUID investigations geared towards law enforcement, but open to all relevant professionals, including FIMR staff. FIMR staff participated and assisted in promoting the trainings.
The ADPH Perinatal Health Division also worked to bring attention to the tragedy of sleep-related deaths through a satellite training in August titled, “Talking with Parents and Caregivers about Safe Sleep.” Continuing education credits were awarded to both social workers and nurses. The recording can be accessed on-demand from the Alabama Public Health Training Network webpage on the ADPH website and has been viewed online by approximately 500 individuals.
The division has helped promote the availability of free portable cribs to a variety of family services providers, including maternity care coordinators at the ACHNs, Blue Cross Blue Shield of Alabama’s Baby Yourself® program nurses, labor and delivery nurse managers, and hospital case managers. New initiatives to reach expectant families at car seat clinics and select community events in Montgomery and Macon Counties have also started. In FY 2022, over 300 cribs were distributed to families statewide who lacked a safe place for their infant to sleep.
An ADPH press release highlighting updates to the American Academy of Pediatrics’ “Recommendations for Reducing Infant Deaths in the Sleep Environment” was shared by local news networks in Montgomery, Mobile, and Huntsville. The new guidelines added details with more focus on the baby’s sleep surface, which should be firm, flat, and should not be shared with others. Based on the updated recommendations, the Baby Box Initiative has been changed to use Baby Boxes only as a temporary, emergency sleep place as a stop-gap until the family can be provided with a pack n’ play or other more permanent solution.
Ongoing activities in Alabama to improve birth outcomes and reduce morbidity and mortality:
Fetal/Infant Mortality Review (FIMR)
Regional perinatal nurses continue to present de-identified case summaries to our Regional Perinatal Advisory Committee (RPAC) case review teams for discussion. These teams are made up of regional professionals from law enforcement, medical providers, social workers, coroners, DHR, and Medicaid. The teams discuss the cases, the contributing factors, and make recommendations to prevent similar tragedies in the future. The region-specific recommendations are brought to the cross-sector Community Action Teams (CATs) for implementation.
State Perinatal Advisory Committee (SPAC)
SPAC brings together professionals from across sectors in the perinatal domain statewide at quarterly meetings where guest speakers provide information related to perinatal topics, relevant state agencies give updates regarding services to pregnant women and infants, and one perinatal region is spotlighted to give updates on trends they are seeing in fetal/infant deaths and the implementation of CAT initiatives.
Breastfeeding
WIC breastfeeding staff and Perinatal Health Division staff work closely with community partners to identify resources that support breastfeeding families and to find new ways for connecting families with those resources. In close collaboration with the Alabama Breastfeeding Committee and The Wellness Coalition, resource lists have been published and shared in statewide and local formats. This aligns with the priority need, “Lack of or inadequate access to breastfeeding supports.”
There is also much work surrounding the public support for and visibility of breastfeeding. The Wellness Coalition, based in central Alabama, continues its “Breastfeeding is Normal” campaign with life-size cutouts of women of color breastfeeding their children, often along with a support person. Stickers proclaiming, “I Support Breastfeeding” and window decals declaring “Breastfeeding Welcome Here” have been widely distributed by The Wellness Coalition.
Collaborating Partners and Initiatives for the MCH Populations
Count the Kicks
Healthy Birth Day, Inc. is the non-profit organization that created Count the Kicks. Their mission is to improve birth outcomes through programming, advocacy, and support while reducing racial disparities that persist. Count the Kicks helps save babies from preventable stillbirth, prevents preterm births, and improves outcomes for moms. CDC lists a change in a baby’s movements as one of its 15 urgent maternal warning signs. Count the Kicks educates expectant parents on the importance of tracking their babies’ movements in the third trimester of pregnancy and notifying a medical provider if they notice a change. In Iowa, where the program began, there has been a 32 percent decrease in the stillbirth rate and a 39 percent decrease in the stillbirth rate among African American women. This is the type of decrease we want to see happen in Alabama and is why ADPH has partnered with Count the Kicks, to bring their evidence-based materials and resources to our state.
The hallmark tool of Count the Kicks is a free kick-counting app. This free app is in 16 languages and is for expectant mothers in their third trimester of pregnancy. Count the Kicks provides evidence-based tools and resources for free to anyone in the state that works directly with expectant parents. Visit www.CountTheKicks.org to learn more and order free materials today.
From October 1st, 2021, through September 30th, 2022, 151 healthcare professionals placed orders for Count the Kicks educational resources. There were 75,745 Count the Kicks educational resources such as brochures, app reminder cards, and posters mailed out to 642 expectant parents who downloaded the app. These numbers continue to grow as healthcare professionals share this resource with more Alabamians.
Alabama Perinatal Quality Collaborative (ALPQC)
ALPQC has been working closely with providers and hospitals to implement AIM Patient Safety Bundles on Hypertension in Pregnancy and Neonatal Opioid Withdrawal Syndrome. The Perinatal Health Division staff serve on the steering committee of ALPQC and staff from ALPQC serve on various workgroups and committees led by ADPH.
March of Dimes
The Perinatal Health Division director is a participant in the March of Dimes workgroups on policy, services, and support related to substance abuse disorders for pregnant women and new mothers. The workgroups meet regularly to strategize methods to reduce barriers to treatment and increase advocacy for pregnant women and new mothers with substance use disorders.
State of Alabama Infant Mortality Reduction Plan
Many activities of the SAIMRP have been integrated into the above report. Below is a summary of activities not reported elsewhere.
Safe Sleep
DHR began a new digital ad campaign in January 2022 with the launch of a new safe sleep website: www.safesleepalabama.com and targeted digital ads on Google and Facebook that direct to the website. The ads have reached a wide audience in Macon, Montgomery, and Russell Counties, totaling 1,806,744 views resulting in 22,988 clicks on the ad for more information.
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
SBIRT is a comprehensive, integrated public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. This strategy involves training healthcare providers and care coordinators in implementing SBIRT and the associated tools to aid in identifying and providing referrals for women who may be experiencing substance abuse, domestic violence, and/or depression. Screening maternity patients and identifying risky use patterns and/or potential mental health issues allows risky behaviors to be addressed before the behaviors worsen, which increases positive health outcomes for moms and babies in Alabama.
This strategy came out of repeated recommendations from MMRC and aligns with the education portion of the need priority “lack of or inadequate substance abuse treatment and prevention education, including detox, addiction, and rehabilitation/recovery services.”
First Teachers
The Department of Early Childhood Education (DECE) offers evidence-based home visiting programs via the Nurse-Family Partnership (NFP) and Parents as Teachers (PAT) models in over half of the counties in the state. This collection of projects funded by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program and other sources, aligns with several priority needs including access to health resources, access to breastfeeding support, and support for pregnant and parenting teens and young/new parents. Through the SAIMRP, NFP programs were funded in Macon, Montgomery, and Russell Counties, and a PAT program was funded in Russell County.
Prematurity Prevention
With the discontinuation of the strategy to promote the hormone treatment 17P, a new strategy to prevent preterm birth had to be found. After consulting research from academic sources as well as policy sources, and exploring several possible strategies to address prematurity, group prenatal care was selected as the new prematurity strategy. A strong team of cross-sector stakeholders was gathered to form a strategy workgroup. Due to its lack of maternity care providers in the county, Macon County was chosen as the pilot location for the strategy. This strategy aligns with the priority need, “inequitable access to health resources based on race/ethnicity, socioeconomic status, geographic location, and education.”
ALL Babies
This ADPH program, which aligns with the priority need, “Lack of or inadequate comprehensive, affordable health and dental insurance,” was designed to improve the health of mothers and babies by providing low-cost, comprehensive healthcare coverage for unborn children through the Children’s Health Insurance Program (CHIP). This program currently operates in Montgomery, Macon, and Russell Counties. There are no premiums for coverage, and eligibility criteria are broad, allowing more eligible mothers to enroll. Mothers who meet the eligibility criteria are offered a wide range of benefits, including but not limited to, mental health and substance use disorder services. Benefits are all-inclusive healthcare services which include, maternity, preventive, hospital, pharmacy, dental, etc. Benefits can begin on the date an application is received by CHIP or Medicaid and continue through 60 days postpartum. Care coordination services provided by social workers provide easy navigation of all aforementioned services to promote the health of both mother and baby.
Noteworthy accomplishments:
- From January 2020 through September 2022, 1,179 women were enrolled in the program
- From October 1, 2021, through September 30, 2022, 349 babies were delivered
- Beginning October 2021, enrollees received continuous health messaging such as information about WIC, Baby Yourself®, Count the Kicks, and more including ALL Babies educational awareness materials and phone contact from ALL Babies staff
ADPH Public Health District Initiative
ADPH, JCDH, and MCHD coordinators submitted MCH FY 2022 project proposals to address needs within the Perinatal/Infant Health Domain. These projects focused on infant mortality and injury prevention and below is a summary of those efforts.
East Central Public Health District
In addition to the community outreach, the district MCH coordinator formed partnerships with several community agencies, including the Gift of Life Foundation, Inc. and the Wellness Coalition. The partnership with the Wellness Coalition has allowed the creation/placement of lactation rooms on the campus of Tuskegee University, at the Montgomery CHD, and at local churches throughout the East Central District. The coordinator also partners with the Coalition to host monthly baby depots in Macon and Montgomery Counties. The depots are a one-stop place where parents and caregivers receive information on healthy babies and healthy moms.
Jefferson County Department of Health
JCDH operates the From Day One (FDO) Program, with the goal of improving pregnancy and birth outcomes for the women and infants in Jefferson County. FDO is a comprehensive patient-centered program designed to educate and support expectant mothers from the first trimester of pregnancy through their child’s first year of life. FDO promotes early access to prenatal care and connects families to beneficial community resources. The patients served by FDO consist of high-risk pregnant women, their infants, and maternal partners. Emphasis is placed on low-resource, low income, under-insured, uninsured, and minority patient populations. FDO works with Connection Health to provide community health workers (CHWs) to achieve the program goals. Connection Health CHWs provide the day-to-day monitoring of each participant in the program. In previous studies, it was shown that the western area of Jefferson County accounted for 66 percent of burn injuries, 55 percent of bicycle injuries, and 57 percent of poisonings admitted to the COA. With the use of zip code mapping, it was determined that the majority of FDO participants live in western Jefferson County.
FDO program participants receive a baby safety shower in their third trimester of pregnancy. The goal of the Baby Safety Shower is to increase client knowledge on infant safety, thereby reducing the number of childhood injuries and improving infant mortality. Each shower is planned as a special event for the program participant, one supportive person, and all children under age 5 in the household. Baby Safety Showers are held quarterly at JCDH and last approximately two and a half hours. During the Baby Safety Shower, JCDH staff, community partners, and first responders deliver presentations covering a variety of infant health, injury prevention, and safety topics. Participants receive education on safe sleep, breastfeeding, fire safety, gun safety, personal safety, car seat safety, stress reduction, and oral health. Also, at the conclusion of the shower, participants take home safety-related items.
At enrollment, FDO participants complete a demographic questionnaire that includes questions about infant and childhood injury risk factors currently in their homes. Also, before entering the Baby Safety Shower, participants complete a pre-test to determine baseline knowledge of injury prevention and childhood safety. When showers are held in person, simultaneous interpretation is utilized for participants with limited English proficiency. Printed information is also provided in Spanish.
Due to COVID-19, the format for the Baby Safety Showers was temporarily changed to a virtual presentation and touchless distribution model. Break-out rooms were utilized when the FDO showers were held via Zoom. Break-out rooms allowed the participants with limited English proficiency to participate with interpreters in those rooms. Preparation for the virtual showers included a participant survey to assess Wi-Fi access.
In the year 2022, there were a total of 4 showers and 78 maternity clients participated. Since July 2018, when the first Baby Safety Shower was held, there have been a total of 19 baby safety showers with a total of 239 maternity clients and 161 family members participating.
The touchless distribution drive-up was held at the local health department in order for the participants to receive the “in-kind” gifts. The safety items distributed in 2022 were Dreambaby® Household Safety Kits, diapers, safety tubs, and Graco® Pack ‘n Play playards. The Graco® playards were donated by the IMPACT Family Counseling Cribs for Kids Program. IMPACT also provided safe sleep information and demonstration during the shower. Diapers were provided by the local diaper bank and feminine products were provided by the Junior League of Birmingham.
One month after the Baby Safety Shower each participant completes a post-test to evaluate knowledge and retention of safety education provided at the shower. In 2022, the pre-test score range for each question was 69 to 94 percent, and after the shower, the post-test score range was between 94 and 100 percent.
Finally, CHWs make a third trimester home visit to verify or help with the installation of the safety-related items. In 2022, due to COVID-19, the third trimester home visits were completed virtually. In May 2022, the visits returned to in-person, and in December 2022 the showers returned to in-person events. When a participant has completed the full 18-month FDO program, a face-to-face evaluation is done in the home that includes questions about the of use of safety-related items and safety knowledge received at the baby safety shower. A 6-month post-graduation phone interview and evaluation are completed to ensure sustained safety adherence. This evaluation assesses safety knowledge and collects data on any preventable injuries sustained at home since safety shower participation.
Mobile County Health Department
The infant mortality rate is significant in Alabama. According to ADPH reports, in 2021, the rate increased to 12.1 from the 2020 rate of 10.9. The infant mortality rate for White mothers was 5.8, an increase from 5.2 in 2020. The infant mortality rate declined among Hispanic mothers from 7.2 (37 infant deaths) in 2020 to 5.2 (29 infant deaths) in 2021. The infant and maternal mortality rates among Black infants and mothers remain disparaging with poverty, a lack of education, and the lack of resources to receive quality maternal care among the key factors.
In December 2021, Royce V. Smith was hired by MCHD as its new Maternal and Child Health Program coordinator. She swiftly jumped into her new role within the division, completing the Safe Sleep Certification training with the Safe Sleep Academy and working to prepare information to teach academy participants and community members about reducing infant mortality rates through safe sleep education. Throughout the year, the MCH coordinator attended various community meetings and met certified consultants in order to gain knowledge about Count the Kicks, health disparities, FIMR, perinatal safety, and lactation. This knowledge allows her to educate program participants and promote resources that positively impact perinatal and infant health. The MCH coordinator participated in several webinars to learn more about maternal and child health and become better educated on topics such as breastfeeding, health disparities, immunizations, and maternal mental health.
With the lingering effects of the Covid-19 pandemic, MCH education and community outreach participation resumed for FY 2022 in the month of October under limited restrictions. Safe sleep classes continued with the participants of the Family Support/Home Visitation program. MCH program staff participated in numerous community outreach events disseminating educational materials on breastfeeding, car seat safety, and safe sleep. There were 23 safe sleep classes held during FY 2022 and all were held virtually due to ongoing safety concerns related to the COVID-19 pandemic. There was one class taught with the assistance of a Spanish translator. Each class participant received a portable Pack ‘n Play playards for their baby and printed certificates for completing the class.
In addition to the community events and group connect activities, MCH program staff promoted many health observances such as International Prenatal Prevention Month, Maternal Mental Health, and the Maternal and Child Stillbirth Prevention Act which promoted awareness of infections transmitted from mother to baby during pregnancy or the delivery process. The coordinator also collaborated with the Lead Poisoning Prevention coordinator and traveled to several local daycare centers and pediatric doctor’s offices throughout the county distributing over 500 flyers on MCH services, including breastfeeding. The coordinators also partnered to record a Wellness Wednesday segment highlighting the effects of lead in breastmilk that was aired on the agency’s YouTube channel with the information presented on other agency social media platforms such as Facebook and Twitter.
Southeastern Public Health District
Infant health continues to be an issue in the Southeastern Public Health District. According to the 2022 Robert Wood Johnson County Health Rankings report, Barbour County saw an increase of 1 percent in low-birth-weight deliveries, now at 12 percent. Henry County experienced the same increase and the percentage of low-birth-weight deliveries was reported as 11 percent.
As reported in the 2020 ADPH infant mortality report, the district had an infant mortality rate of 7.6 for all 10 Counties. Every county within the district experienced at least 1 infant death in 2020, with a total loss of 37 infants. According to the ADPH Center for Health Statics, Henry County had an alarming rate of 12.4 per 1,000 live births, the highest in the district. Houston County was second at a staggering 11. 2 per 1,000 live births. Barbour County followed at 10.8 per 1,000 live births. Eight of the 10 Southeastern District counties were listed as having an infant mortality rate higher than the national average.
During FY 2022 the district collaborated with the regional perinatal coordinator to create the Safe Bama Baby Safe Sleep Survey. The survey and consent form were approved by the Internal Review Board (IRB). The consent form will be presented to the expecting parent to gain permission to conduct the Safe Bama Baby Safe Sleep Survey. The plan was to implement this survey in the three district counties with the highest infant mortality rates. District staff certified as Safe Sleep Ambassadors through Cribs for Kids® will identify and meet with pregnant WIC recipients and gift them a tote bag with safe sleep educational materials and related items. If the expecting parent provides consent, the survey is completed during the third trimester of pregnancy. The survey will help to craft individualized education and identify the lack of a safe sleep space for the expected infant. If a safe sleep space is needed, the Safe Sleep Ambassador will assist with a referral for a Cribs for Kids® pack ‘n play from FHS. The incentive item for completing the survey will include a “Snoozzzette” zip-able blanket from Cribs for Kids®. The zip-able blanket reinforces safe sleep practices.
Other ADPH Perinatal/Infant Health Programs
Pregnancy Risk Assessment Monitoring System (PRAMS)
ADPH has been collecting data on mothers and their newborns through the PRAMS Program since 1993. Surveys are mailed to the mother’s home address to be completed. If a survey is not completed and returned to ADPH, contracted staff phone the mothers to complete the survey. Incentive items are given to the mothers when the surveys are completed. The data collected from mothers in Alabama regarding their health, maternal attitudes, and experiences before, during, and shortly after pregnancy can help identify ongoing and emerging issues and assist in developing policies and initiatives moving forward.
Of the 1,399 women who received PRAMS surveys in 2022, 785 completed the surveys, which is a return rate of 56.1 percent. This reporting year, data from PRAMS surveys were presented to the regional perinatal nurses through the FIMR Program and shared with their CATs. The data was a tool to assist CATs with developing initiatives in their communities to address maternal and infant health. Additionally, the PRAMS data was presented to members of the OWH Steering Committee at a quarterly meeting in 2022. The steering committee membership consists of volunteers throughout the state with an interest in women’s health, including health providers, educators, and community workers. The PRAMS data will be useful in their work promoting health for women.
In 2023, the MCH Epi Branch will collaborate with staff from the Well Woman Program and the Maternal Mortality Review Program to strengthen health services provided to women and develop recommendations for maternal health based on the data analysis.
Alabama Newborn Screening Program
The Alabama Newborn Screening Follow-up Division is part of the BCL. It is a coordinated system encompassing newborn screening, care coordination, evaluation, diagnosis, intervention, and management of conditions. The newborn screen includes the bloodspot screen, newborn hearing screen, and pulse oximetry screen to detect critical congenital heart defects. The goal of newborn screening is to identify certain genetic and congenital disorders early to reduce infant morbidity, death, intellectual disability, and other developmental disabilities.
Newborn screening allows treatment to be initiated within the first few weeks of life, preventing some of the complications associated with disorders. Early diagnosis may reduce morbidity, mortality, intellectual disability, and other developmental disabilities. The program works in partnership with pediatric subspecialists throughout the state to ensure all babies identified with presumptive positive results receive appropriate diagnostic evaluation and treatment. The program’s subspecialists participate in provider education webinars and on the Alabama Newborn Screening Advisory Committee. Additionally, six community-based sickle cell organizations provide counseling services and follow-up for children identified with sickle cell disease or trait.
Newborn screening is mandated by public health law and is a collaborative effort between the BCL and FHS. The BCL performs blood analysis of approximately 150,000 specimens each year for 33 core conditions, and over 50 conditions including secondary disorders that may be found inadvertently when screening for a core condition. In addition, the BCL manages a web-based system, Secure Remote Viewer, which allows medical providers to access newborn screening results online. During 2022, the BCL received approximately 789 presumptive positive lab referrals, 2,855 did not pass hearing screenings, and identified 206 infants with a newborn screening condition (see table below).
2022 Core Conditions Confirmed
The Alabama Early Hearing Detection and Intervention (EHDI) Program, Alabama’s Listening, ensures that all infants receive a hearing screening prior to hospital discharge and that they are referred for further testing and intervention if they do not pass the inpatient newborn hearing screen. The Alabama EHDI Program is federally funded through a grant from the Health Resource and Services Administration (HRSA) and the CDC. The goal of the program is to follow the Joint Committee on Infant Hearing Guidelines, which is screening by 1 month of age, diagnostic hearing evaluation by 3 months of age, and referral to early intervention by 6 months of age to ensure optimal language acquisition, academic achievement, and social and emotional development. The Alabama EHDI Program continues to undergo many challenges with following these guidelines as diagnostic facilities return post-COVID-19 pandemic to normal business hours and scheduling families for follow-up. Additionally, the Alabama EHDI Program will have federal grant funding terminating in 2024.
There have been some important changes to the Alabama Newborn Screening Program (NSP)
- Testing began for Spinal Muscular Atrophy (SMA) – February 14, 2022.
- The NSP was administratively reassigned from the FHS to the BCL effective April 16, 2022, with case management continuing to be administered and monitored by FHS.
- In 2023, there are plans to include the addition of three conditions to the Alabama Newborn Screening Panel including X-linked adrenoleukodystrophy (X-ALD), Pompe disease, and Mucopolysaccharidosis type I (MPS I).
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