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Original Article
Institutional Delivery in the Philippines: Does a Minimum of 8 Antenatal Care Visits Matter?
Felly Philipus Seneweorcid, Agung Dwi Laksonoorcid, Roy Glenn Albert Massieorcid, Leny Latifahorcid, Syarifah Nurainicorresp_iconorcid, Rozana Ika Agustiyaorcid, Jane Kartika Propianaorcid, Wahyu Pudji Nugraheniorcid
Journal of Preventive Medicine and Public Health 2025;58(1):44-51.
DOI: https://doi.org/10.3961/jpmph.24.245
Published online: January 31, 2025
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Research Center of Public Health and Nutrition, National Research and Innovation Agency Republic of Indonesia, Bogor, Indonesia

Corresponding author: Syarifah Nuraini, Research Center of Public Health and Nutrition, National Research and Innovation Agency Republic of Indonesia, Bogor 16911, Indonesia, E-mail: syar021@brin.go.id
• Received: May 15, 2024   • Revised: September 6, 2024   • Accepted: September 20, 2024

Copyright © 2025 The Korean Society for Preventive Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objectives
    This cross-sectional study investigated the association between the utilization of 8 antenatal care (ANC) visits and delivery in a healthcare institution in the Philippines, using data from the 2022 National Demographic and Health Survey.
  • Methods
    A sample of women who had given birth within the past 3 years was selected for analysis (n=4452). The association between ANC utilization and institutional delivery was assessed using logistic regression models, covariates by relevant socio-demographic factors, and childbirth history.
  • Results
    We found that 97.2% of respondents who completed ANC opted for institutional delivery. A higher proportion of rural residents did not undergo institutional delivery than urban residents (12.9 vs. 6.9%). The group aged 20–24 years had the highest coverage (92.8%), and the group aged 40–44 years had the lowest. Higher education levels, employment, and greater wealth were associated with higher institutional delivery rates. Divorced or widowed mothers (85.1%) and grand multiparous mothers had lower rates than other groups. Multivariable logistic regression analysis showed a significant positive association between ANC utilization and institutional deliveries after adjusting for covariates (adjusted odds ratio, 2.486; 95% confidence interval, 2.485 to 2.487; p<0.001).
  • Conclusions
    ANC visits were associated with deliveries in institutions in the Philippines. Policymakers should promote ANC by ensuring 8 World Health Organization-recommended visits, strengthening programs, conducting community outreach, addressing access barriers, and integrating maternal health services to increase institutional births and improve maternal and infant health.
Institutional delivery, which occurs in hospitals, clinics, and health centers, is crucial to the prevention and management of childbirth complications [1]. Delivering in a health facility is linked to improved maternal and child health outcomes, reduced stillbirths, and enhanced newborn survival. Skilled health workers in supportive environments are essential to avoiding preventable maternal and newborn deaths [2,3].
To address obstetric complications promptly, it is vital to promote deliveries in health facilities [1]. Many countries prioritize the goal of 100% institutional deliveries to reduce maternal mortality [4]. In 2018, a study across 224 countries showed significant progress in expanding delivery care services for adolescents, with 24 out of 54 low-income and middle-income countries achieving 80% coverage with institutional deliveries and skilled birth attendance [5]. Policies and programs should be tailored to national trends, with a focus on older women and adolescents who face higher risks of maternal mortality and adverse obstetric outcomes [6].
In the Philippines, the Department of Health has enforced a “no home-birthing policy” since 2008 to promote institutional childbirth services [7]. However, as of 2017, utilization of these services remained inadequate, especially in rural areas. Improving healthcare solutions and services is crucial for encouraging deliveries in healthcare institutions.
To promote institutional deliveries, understanding the factors that influence a woman’s choice of delivery place is essential [8,9]. Factors such as place of residence, education, age, employment status, adherence to antenatal care (ANC), and pregnancy complications influence a woman’s decision to seek institutional care [3,10].
The World Health Organization (WHO) introduced a new ANC model in 2016, recommending at least 8 ANC visits to improve the quality of care and reduce stillbirths and complications [11]. Our study in the Philippines explored the factors influencing institutional delivery, including ANC adherence. Promoting maternal health services is crucial to compliance with the WHO-recommended 8 ANC visits during pregnancy. We hypothesized that adherence to these guidelines would also increase the likelihood of institutional delivery in the Philippines.
Study Design
We analyzed data from the 2022 National Demographic and Health Survey (NDHS) conducted by the Philippine Statistics Authority and the NDHS program. This seventh survey in the Philippines, part of a series since 1968, was conducted from May 2, 2022 to June 22, 2022, involving over 30 000 households and approximately 28 000 women aged 15–49 years. Funded by the United States Agency for International Development and facilitated by the Inner-City Fund (ICF), the program supports global population and health surveys. The 2022 NDHS included household and individual questionnaires that covered household and family health information, women’s reproductive health, family planning, maternal and child health, health behaviors, nutrition, and HIV/AIDS.
The survey employed a 2-stage stratified sampling design based on the 2010 and 2015 censuses, ensuring national, urban, rural, and regional representation. In the first stage, 1247 primary sampling units (PSUs) were selected, followed by 22 housing or 29 housing units per PSU in the second stage. Interviews were conducted with 1–3 members in all households (3 members in larger households) without altering the preselected units to avoid bias. Survey weights ensured representative estimates at regional and national levels. From 27 821 respondents, the study included 4452 women (98% of eligible women) aged 15–49 years who had given birth within 3 years of the interview.
Outcome Variable
Institutional delivery was used as an outcome variable in the study and was defined as delivery in a health facility under the supervision of skilled birth attendants [12]. Institutional delivery included government and private hospitals, health centers, and clinics.
Exposure Variable
Completed ANC status was the primary exposure variable in the study. We divided the completed ANC category into “yes” (at least 8 visits during pregnancy) and “no” (fewer than 8 visits). The WHO guidelines stipulate that completed ANC requires a minimum of 8 visits throughout pregnancy, as cited in a Bangladeshi study assessing completed ANC [11].
Covariates
This study examined 7 covariates: type of residence, age group, education level, marital status, employment status, socioeconomic status, and parity. The residence types were divided into urban and rural areas. The age categories were 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49 years. Education levels included informal only, primary, secondary, or higher. Marital status was divided into 3 categories: never married, married, and divorced/widowed. Employment status was divided into employed and unemployed. Socioeconomic status was divided into poorest, poorer, middle, wealthier, and richest. Parity was determined by the number of live births. The 3 types of parity were primiparous (≤1), multiparous (2 to 4), and grand multiparous (>4). These variables were chosen because a relationship between the mother’s socioeconomic background and childbirth history and the mother’s choice of birthplace had previously been shown [13,14].
Statistical Analysis
This study utilized descriptive and inferential analysis. The chi-square test was used to obtain a descriptive picture of the patterns, differences, and determinants of institutional delivery according to ANC status and socio-demographic characteristics. Next, a collinearity test was conducted to assess correlations among the independent variables. Lastly, binary logistic regression was used to analyze the institutional delivery status because the dependent variable was dichotomous. We included the dependent and independent variables and 7 covariates in the regression analysis. The adjusted odds ratio (aOR) with a 95% confidence interval (CI) was used to express the coefficients obtained from the model equation. The aORs compared the risks between 2 groups of individuals with different characteristics. Significance was set at a p-value <0.001.
Ethics Statement
The 2022 NDHS protocol underwent a comprehensive evaluation by the ICF’s Institutional Review Board, which diligently followed the Protection of Human Subjects regulations (45 CFR 46) established by the United States Department of Health and Human Services.
The descriptive statistics of institutional delivery in the Philippines are presented in Table 1. The data indicated that almost all respondents who completed ANC examinations also opted for institutional delivery (97.2%). Urban residents showed a higher rate of institutional delivery than rural residents, with 12.9% of rural respondents not undergoing institutional delivery. The 20–24 years age group had the highest rate of institutional delivery (92.8%), while the 40–44 year age group had the lowest. Mothers with higher education levels were more likely to choose institutional delivery. Divorced or widowed mothers had the lowest proportion of institutional delivery when compared to never-married and married or cohabiting mothers (85.1%). Employed mothers had a higher institutional delivery rate than unemployed mothers (87.9%), and the wealth of the mother was related to the percentage of institutional delivery. Grand multiparous mothers had a lower institutional delivery rate than primiparous and multiparous mothers.
The results of a binary logistic regression analysis of institutional delivery in the Philippines are shown in Table 2. The findings highlight the significant factors influencing a mother’s choice of institutional delivery. Mothers who completed ANC were 2.486 times more likely to opt for institutional delivery than those who do not complete ANC (aOR, 2.486; 95% CI, 2.485 to 2.487). Moreover, residence location also played a role, with mothers in rural areas being 1.108 times more likely to choose institutional delivery than their urban counterparts (aOR, 1.108; 95% CI, 1.108 to 1.108).
Age emerged as a significant factor, with older mothers exhibiting higher odds of institutional delivery. For instance, mothers aged 20–24 years were 2.506 times more likely than those aged 15–19 years to undergo institutional delivery (aOR, 2.506; 95% CI, 2.504 to 2.507). Similarly, the likelihood increased with age, as evidenced by the higher odds for mothers aged 25–29 years (aOR, 2.600; 95% CI, 2.599 to 2.602), 30–34 years (aOR, 3.185; 95% CI, 3.183 to 3.187), 40–44 years (aOR, 3.495; 95% CI, 3.493 to 3.498), and 45–49 years (aOR, 7.865; 95% CI, 7.855 to 7.875) when compared to the reference group of mothers aged 15–19 years.
Education level also significantly influenced the likelihood of institutional delivery. Mothers with primary (aOR, 1.493; 95% CI, 1.492 to 1.494), secondary (aOR, 3.203; 95% CI, 3.201 to 3.206), and higher education (aOR, 4.044; 95% CI, 4.040 to 4.047) exhibited progressively higher odds compared to those without a formal education. Similarly, marital status was a significant predictor, with never-married mothers 8.421 times more likely to opt for institutional delivery than those who were widowed/divorced (aOR, 8.421; 95% CI, 8.411 to 8.431), while married mothers also show higher odds (aOR, 2.344; 95% CI, 2.343 to 2.346).
Socioeconomic status was another influential factor, with mothers from wealthier households exhibiting higher odds of institutional delivery. As economic status improved, the likelihood of institutional delivery increased, with mothers in the middle (aOR, 5.267; 95% CI, 5.265 to 5.269), richer (aOR, 6.961; 95% CI, 6.957 to 6.965), and richest economic categories (aOR, 8.029; 95% CI, 8.023 to 8.035) showing progressively higher odds than those in the poorest category. Moreover, parity status also played a significant role, with multiparous (aOR, 6.956; 95% CI, 6.953 to 6.960) and grand multiparous (aOR, 2.359; 95% CI, 2.359 to 2.360) mothers exhibiting higher odds of institutional delivery than primiparous mothers. These findings collectively highlight the multifaceted determinants influencing the choice of institutional delivery among mothers in the Philippines.
This study revealed that complete ANC was linked to institutional delivery among women in the Philippines, which suggests that pregnant women who receive comprehensive ANC are more inclined to choose to give birth in healthcare facilities. ANC involves regular visits to health facilities during pregnancy, emphasizing the importance of early care and delivery in a safe environment [15]. Women who consistently receive ANC are more likely to opt for institutional delivery, which is considered safe [16].
Effective ANC encompasses education and counseling for pregnant women, thereby raising awareness about the significance of prenatal care and safe delivery [17]. Quality ANC includes thorough medical examinations, early detection of medical conditions, and appropriate treatment to address any issues that may arise during labor [18]. Factors influencing the quality of ANC include the presence of trained healthcare personnel, availability of necessary medical equipment, ease of access to health facilities, and the information and education provided to expectant mothers during pregnancy [19].
Research conducted in the Lao People’s Democratic Republic highlighted the impact of a free childbirth-care policy on increasing the coverage of ANC with skilled personnel, thereby promoting institutional delivery [20]. A study in the Philippines from 1983 until 2017 showed a significant increase in the percentage of women aged 15–49 years receiving ANC from skilled providers, leading to a rise in institutional deliveries. Previous studies in the Philippines have not explored the correlation between ANC visits and the decision to opt for institutional delivery. The Philippine maternal and childbirth health services policy includes various initiatives and programs to enhance maternal and infant health and ensure access to quality healthcare services [21]. The country’s “Safe Motherhood” policy is designed to improve maternal health care and reduce maternal mortality rates [22].
This study showed that the number of ANC visits completed is still not optimal, with some mothers still making fewer than 8 visits. This can be attributed to the standard practice of 4 ANC visits in the Philippines, which falls short of the new WHO recommendation of ≥8 visits. The WHO revised its policy in 2016 to advocate for 8 ANC visits for pregnant women globally, particularly in low-income and middle-income countries, to address high maternal mortality rates [23]. Increasing the number of ANC visits from 4 to 8 aims to provide more comprehensive healthcare during pregnancy and childbirth. Research has shown that a higher frequency of ANC visits is associated with a lower risk of stillbirths, and that 8 ANC visits can reduce perinatal mortality to 8 per 1000 births [23]. Previous studies have also demonstrated that having >8 ANC visits significantly increases the likelihood of delivering in a health facility and receiving subsequent care as compared to only 4 ANC visits [24].
In addition to ANC visits, several other factors influence institutional delivery. Contrary to the findings from Afghanistan and the Lao People’s Democratic Republic, women in rural areas of the Philippines were more likely to deliver in health facilities than their urban counterparts [20,25]. This higher rate in rural areas is supported by initiatives such as the ‘Safe Motherhood’ program, aimed at enhancing access to safe delivery services for marginalized women in remote provinces. Government policies, including free maternal services and cash grants, have notably incentivized pregnant women to seek ANC and deliver at healthcare facilities. This strategy has increased ANC attendance and narrowed the gap in maternal healthcare access between urban and rural areas. Moreover, local regulations prohibiting home childbirth in rural areas act as a deterrent, backed by penalties for both mothers and birth attendants, further promoting institutional deliveries.
Our study identified 3 maternal factors associated with institutional delivery: age, marital status, and employment. Previous studies also indicated that these variables influence institutional delivery and comprehensive ANC [26,27]. Older women were more likely to opt for institutional delivery. This is consistent with findings from Bangladesh, where advanced maternal age significantly correlated with healthcare facility deliveries [28,29]. Marital status also played a role in a mother’s decision to give birth in a health facility. Married women may have better support and financial resources to attend antenatal appointments [30,31]. In societies with patriarchal traditions, men have significant decision-making power that heavily influences healthcare choices for women. Some studies have indicated that women are more inclined to choose institutional delivery when these decisions are made by their husbands or other family members rather than by themselves [25]. On the contrary, this study found that unmarried mothers showed a higher preference for institutional delivery than married or divorced/widowed mothers (Table 1). According to 2022 Philippine Statistics Authority data, over half (844 909 or 58.1%) of all registered live births were with unmarried mothers [32]. This high prevalence of single mother births suggests a greater likelihood that unmarried mothers will opt for institutional delivery, as they are not reliant on husbands or relatives for decision-making.
Maternal education levels and employment status significantly influenced institutional delivery. Education plays a crucial role in shaping power dynamics within relationships, particularly in paternalistic societies. Highly educated women often possess the autonomy to make informed health decisions and are empowered to make independent choices [3335]. Studies have shown a positive correlation between mothers’ education levels, antenatal visits, and facility-based deliveries [36]. Educated women typically comprehend the risks of childbirth and the advantages of skilled healthcare, suggesting that addressing the specific need to educate women could mitigate disparities in institutional delivery rates [26]. Furthermore, individuals with higher education levels are more likely to have the financial resources to access institutional care, often supported by health insurance through employment benefits [27,37].
This study found that women of higher wealth status were more inclined to choose institutional delivery than the poorest women. Wealth has consistently been associated with institutional delivery rates across various low-income and middle-income countries. This observation is corroborated by recent research in Nepal, where women from wealthier backgrounds significantly favoured institutional delivery services [26]. Higher socioeconomic status affords better access to healthcare facilities, enabling these women to cover transportation and medical expenses. These findings are consistent with previous research, which found that improved economic conditions correlated with increased utilization of maternal healthcare services. Disparities in delivery service utilization based on wealth status have been noted in previous studies across multiple countries [14,38,39].
In addition, the study concluded that primiparous women were significantly more inclined to choose institutional delivery than multiparous women. First-time mothers often lack experience and may anticipate childbirth complications, which motivates them to choose institutional delivery. Conversely, women with multiple childbirth experiences may forgo health facility deliveries, especially if previous births were uncomplicated [2].
Despite its important findings, this study had several limitations, which must be considered. This study did not consider the quality of the ANC visits, which can influence decisions about whether to deliver at a health institution. In addition, although the “no home-birthing policy” and other government interventions are referred to, there was no thorough analysis of how their implementation has affected institutional delivery rates. The higher level of institutional delivery in rural areas that was found in this study warrants more in-depth research, perhaps in terms of cultural beliefs or the quality of health services.
In conclusion, our study highlighted the critical role of ANC in increasing institutional delivery rates in the Philippines. The strong association between ANC utilization and institutional delivery underscores the necessity of enhancing access to ANC services. Policymakers should prioritize strategies that promote ANC utilization, such as ensuring adherence to the WHO-recommended minimum of 8 ANC visits, bolstering program effectiveness, conducting community outreach initiatives, addressing access barriers, and integrating comprehensive maternal health services. These initiatives can increase institutional birth rates and improve health outcomes for both mothers and infants.

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Author Contributions

Conceptualization: Senewe FP, Massie RGA, Latifah L. Data curation: Laksono AD. Formal analysis: Agustiya RI, Nuraini S. Funding acquisition: None. Methodology: Laksono AD. Writing – original draft: Senewe FP, Laksono AD, Massie RGA, Latifah L, Nuraini S, Agustiya RI, Propiona JK, Nugraheni WP. Writing – review & editing: Senewe FP, Latifah L, Nuraini S.

None.
Table 1
Descriptive statistics of institutional delivery in the Philippines, 2022 (n=4452)
Characteristics Institutional delivery (%) p-value
No (n=643) Yes (n=3809)
Complete antenatal care <0.001
 No 13.1 86.9
 Yes 2.8 97.2
Type of residence <0.001
 Urban 6.9 93.1
 Rural 12.9 87.1
Age (y) <0.001
 15–19 13.1 86.9
 20–24 7.2 92.8
 25–29 8.9 91.1
 30–34 9.7 90.3
 35–39 11.8 88.2
 40–44 14.0 86.0
 45–49 11.4 88.6
Education level <0.001
 No education 47.8 52.2
 Primary 30.2 69.8
 Secondary 9.4 90.6
 Higher 3.0 97.0
Marital status <0.001
 Never married 1.8 98.2
 Married/living with partner 10.1 89.9
 Divorced/widowed 14.9 85.1
Employment status <0.001
 Unemployed 12.1 87.9
 Employed 7.0 93.0
Socioeconomic <0.001
 Poorest 26.6 73.4
 Poorer 8.1 91.9
 Middle 3.7 96.3
 Richer 2.2 97.8
 Richest 1.3 98.7
Parity <0.001
 Primiparous 3.7 96.3
 Multiparous 9.2 90.8
 Grand multiparous 28.8 71.2
Table 2
Binary logistic regression results for determinants of institutional delivery in the Philippines, 2022 (n=4452)1
Variables Institutional delivery
Complete antenatal care
 No 1.000 (reference)
 Yes 2.486 (2.485, 2.487)***
Type of residence
 Urban 1.000 (reference)
 Rural 1.108 (1.108, 1.108)***
Age (y)
 15–19 1.000 (reference)
 20–24 2.506 (2.504, 2.507)***
 25–29 2.600 (2.599, 2.602)***
 30–34 3.185 (3.183, 3.187)***
 35–39 3.397 (3.395, 3.399)***
 40–44 3.495 (3.493, 3.498)***
 45–49 7.865 (7.855, 7.875)***
Education level
 No education 1.000 (reference)
 Primary 1.493 (1.492, 1.494)***
 Secondary 3.203 (3.201, 3.206)***
 Higher 4.044 (4.040, 4.047)***
Marital status
 Never married 8.421 (8.411, 8.431)***
 Married 2.344 (2.343, 2.346)***
 Widowed/divorced 1.000 (reference)
Employment status
 Unemployed 1.000 (reference)
 Employed 1.288 (1.288, 1.289)***
Socioeconomic status
 Poorest 1.000 (reference)
 Poorer 2.923 (2.922, 2.924)***
 Middle 5.267 (5.265, 5.269)***
 Richer 6.961 (6.957, 6.965)***
 Richest 8.029 (8.023, 8.035)***
Parity
 Primiparous 1.000 (reference)
 Multiparous 6.956 (6.953, 6.960)***
 Grand multiparous 2.359 (2.359, 2.360)***

Values are presented as adjusted odds ratio (95% confidence interval).

1 The results shown have been weighted.

*** p<0.001.

Figure & Data

References

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      Institutional Delivery in the Philippines: Does a Minimum of 8 Antenatal Care Visits Matter?
      Institutional Delivery in the Philippines: Does a Minimum of 8 Antenatal Care Visits Matter?
      Characteristics Institutional delivery (%) p-value
      No (n=643) Yes (n=3809)
      Complete antenatal care <0.001
       No 13.1 86.9
       Yes 2.8 97.2
      Type of residence <0.001
       Urban 6.9 93.1
       Rural 12.9 87.1
      Age (y) <0.001
       15–19 13.1 86.9
       20–24 7.2 92.8
       25–29 8.9 91.1
       30–34 9.7 90.3
       35–39 11.8 88.2
       40–44 14.0 86.0
       45–49 11.4 88.6
      Education level <0.001
       No education 47.8 52.2
       Primary 30.2 69.8
       Secondary 9.4 90.6
       Higher 3.0 97.0
      Marital status <0.001
       Never married 1.8 98.2
       Married/living with partner 10.1 89.9
       Divorced/widowed 14.9 85.1
      Employment status <0.001
       Unemployed 12.1 87.9
       Employed 7.0 93.0
      Socioeconomic <0.001
       Poorest 26.6 73.4
       Poorer 8.1 91.9
       Middle 3.7 96.3
       Richer 2.2 97.8
       Richest 1.3 98.7
      Parity <0.001
       Primiparous 3.7 96.3
       Multiparous 9.2 90.8
       Grand multiparous 28.8 71.2
      Variables Institutional delivery
      Complete antenatal care
       No 1.000 (reference)
       Yes 2.486 (2.485, 2.487)***
      Type of residence
       Urban 1.000 (reference)
       Rural 1.108 (1.108, 1.108)***
      Age (y)
       15–19 1.000 (reference)
       20–24 2.506 (2.504, 2.507)***
       25–29 2.600 (2.599, 2.602)***
       30–34 3.185 (3.183, 3.187)***
       35–39 3.397 (3.395, 3.399)***
       40–44 3.495 (3.493, 3.498)***
       45–49 7.865 (7.855, 7.875)***
      Education level
       No education 1.000 (reference)
       Primary 1.493 (1.492, 1.494)***
       Secondary 3.203 (3.201, 3.206)***
       Higher 4.044 (4.040, 4.047)***
      Marital status
       Never married 8.421 (8.411, 8.431)***
       Married 2.344 (2.343, 2.346)***
       Widowed/divorced 1.000 (reference)
      Employment status
       Unemployed 1.000 (reference)
       Employed 1.288 (1.288, 1.289)***
      Socioeconomic status
       Poorest 1.000 (reference)
       Poorer 2.923 (2.922, 2.924)***
       Middle 5.267 (5.265, 5.269)***
       Richer 6.961 (6.957, 6.965)***
       Richest 8.029 (8.023, 8.035)***
      Parity
       Primiparous 1.000 (reference)
       Multiparous 6.956 (6.953, 6.960)***
       Grand multiparous 2.359 (2.359, 2.360)***
      Table 1 Descriptive statistics of institutional delivery in the Philippines, 2022 (n=4452)

      Table 2 Binary logistic regression results for determinants of institutional delivery in the Philippines, 2022 (n=4452)1

      Values are presented as adjusted odds ratio (95% confidence interval).

      The results shown have been weighted.

      p<0.001.


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