Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking.

BACKGROUND: The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. OBJECTIVE: To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. METHODS: We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. RESULTS: There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. CONCLUSION: The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

Predicting optimal use of continuous glucose monitors in adolescents with type 1 diabetes: It's about benefit and burden.

PURPOSE: Youth with type 1 diabetes (T1D) often use Continuous Glucose Monitoring (CGM) devices; however, many do not wear them consistently enough to obtain optimal glycemic benefit. This study aimed to identify demographic and psychosocial predictors of optimal CGM use in adolescents with T1D to inform nurse-led interventions to improve adherence. DESIGN AND METHODS: Cross-sectional survey data from youth (12-19 years) using CGM were analyzed to determine whether perceived benefits/burdens of CGM, self-efficacy, and coping predicted being a "CGM Optimizer" (wearing CGM 6-7 days/week) or "CGM Sub-user." RESULTS: Of 282 adolescents (54% female), 161 were CGM Optimizers and 121 were CGM Sub-Users. Optimizers were younger (15.91 ± 2.17 years vs. 16.79 ± 2.17, p = 0.001), more likely non-Hispanic White (91.9% vs 83.5%, p = 0.029), and more likely to have private insurance (82.0% vs. 69.4%, p = 0.009). Every 1-point increase on Benefits of CGM scale was associated with 2.8 times greater odds of being an Optimizer (OR = 2.82, 95% CI 1.548-5.132, p = 0.001), and every 1-point increase on the Burdens of CGM scale was associated with a 52% decrease in odds (OR = 0.48, 95% CI = 0.283-0.800, p = 0.005), with final logistic regression model (including only these two predictors) explaining 22.3% of variance. CONCLUSION: CGM Optimizing adolescents were more likely to perceive higher benefit and lower burden of CGM. PRACTICAL IMPLICATIONS: Nurse-led interventions to promote benefits of CGM and mitigate burden may help youth increase adherence with CGM to achieve glycemic benefit.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study.

BACKGROUND: Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes. RESULTS: There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study.

BACKGROUND: The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to compare outcomes. RESULTS: There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Association between provider type and cesarean birth in healthy nulliparous laboring women: A retrospective cohort study.

BACKGROUND: Term nulliparous women have the greatest variation across hospitals and providers in cesarean rates and therefore present an opportunity to improve quality through optimal care. We evaluated associations between provider type and mode of birth, including examination of intrapartum management in healthy, laboring nulliparous women. METHODS: Retrospective cohort study using prospectively collected perinatal data from a United States academic medical center (2005-2012). The sample included healthy nulliparous women with spontaneous labor onset and term, singleton, vertex fetus managed by either obstetricians or certified nurse-midwives. Univariate and multivariate logistic regression was used to compare labor interventions and mode of birth by provider type. RESULTS: A total of 1339 women received care by an obstetrician (n = 749) or nurse-midwife (n = 590). The cesarean rate was 13.4% (179/1339). Adjusting for maternal and pregnancy characteristics, care by obstetricians was associated with an increased risk of unplanned cesarean birth (adjusted odds ratio [aOR] 1.48 [95% confidence interval {CI} 1.04-2.12]) compared with care by midwives. Obstetricians more frequently used oxytocin augmentation (aOR 1.41 [95% CI 1.10-1.80]), neuraxial anesthesia (aOR 1.69 [95% CI 1.29-2.23]), and operative vaginal delivery with forceps or vacuum (aOR 2.79 [95% CI 1.75-4.44]). Adverse maternal or neonatal outcomes were not different by provider type across all modes of birth, but were more frequent in women with cesarean than vaginal births. DISCUSSION: In low-risk nulliparous laboring women, care by obstetricians compared with nurse-midwives was associated with increased risk of labor interventions and operative birth. Changes in labor management or increased use of nurse-midwives could decrease the rate of a first cesarean in low-risk laboring women.

Applying a physiologic partograph to Consortium on Safe Labor data to identify opportunities for safely decreasing cesarean births among nulliparous women.

BACKGROUND: The timing of hospital admission for women with spontaneous labor onset and the criteria used to assess active labor progress and diagnose labor dystocia may significantly influence women's risk for primary cesarean birth. Our aims were to assess associations of labor status at admission (i.e., preactive or active) and active labor progress (i.e., dystocic or physiologic) with oxytocin augmentation, cesarean birth, and adverse neonatal outcome rates. METHODS: A sample of low-risk, nulliparous women admitted to hospitals for spontaneous labor onset was extracted from the Consortium on Safe Labor (n = 27 077). Binomial logistic regression was used to assess associations between labor classifications and outcomes. RESULTS: At admission, 68.0% of women were in preactive labor and 32.0% were in active labor. Cesarean rates for these groups were 18.0% and 7.2%, respectively (adjusted odds ratio [AOR] 2.69; 95% CI 2.45-2.96). Oxytocin augmentation and adverse neonatal outcomes were more likely for women admitted in preactive labor. Among women admitted in active labor, 9.3% experienced labor dystocia and 90.7% progressed physiologically. Cesarean rates for these groups were 20.4% and 5.9%, respectively (AOR 3.02; 95% CI 2.45-3.73). Nearly half of the cesareans performed for dystocia among women admitted in active labor occurred when cervical dilation was physiologic. Oxytocin augmentation and adverse neonatal outcomes were more likely when active labor was dystocic. CONCLUSIONS: Adoption of evidence-based, standardized approaches for diagnosing active labor onset, assessing labor progress, and diagnosing dystocia may safely decrease oxytocin augmentation and cesarean birth rates in the United States.

Temporal Immediacy: A Two-System Theory of Mind for Understanding and Changing Health Behaviors.

BACKGROUND: Health promotion and chronic disease management both require behavior change, but people find it hard to change behavior despite having good intentions. The problem arises because patients' narratives about experiences and intentions are filtered through memory and language. These narratives inaccurately reflect intuitive decision-making or actual behaviors. OBJECTIVES: We propose a principle-temporal immediacy-as a moderator variable that explains which of two mental systems (narrative or intuitive) will be activated in any given situation. We reviewed multiple scientific areas to test temporal immediacy as an explanation for findings. METHODS: In an iterative process, we used evidence from philosophy, cognitive neuroscience, behavioral economics, symptom science, and ecological momentary assessment to develop our theoretical perspective. These perspectives each suggest two cognitive systems that differ in their level of temporal immediacy: an intuitive system that produces behavior in response to everyday states and a narrative system that interprets and explains these experiences after the fact. FINDINGS: Writers from Plato onward describe two competing influences on behavior-often with moral overtones. People tend to identify with the language-based narrative system and blame unhelpful results on the less accessible intuitive system, but neither is completely rational, and the intuitive system has strengths based on speed and serial processing. The systems differ based on temporal immediacy-the description of an experience as either "now" or "usually"-with the intuitive system generating behaviors automatically in real time and the narrative system producing beliefs about the past or future. DISCUSSION: The principle of temporal immediacy is a tool to integrate nursing science with other disciplinary traditions and to improve research and practice. Interventions should build on each system's strengths, rather than treating the intuitive system as a barrier for the narrative system to overcome. Nursing researchers need to study the roles and effects of both systems.

Comparing Different Partograph Designs for Use in Standard Labor Care: A Pilot Randomized Trial.

Backgound Partographs are used in many labour settings to provide a pictorial overview of a woman's cervical dilation pattern in the first stage of labor and to alert clinicians to slow progress possibly requiring intervention. Recent reviews called for large trials to establish the efficacy of partographs to improve birth outcomes whilst highlighting issues of clinician compliance with use. Previous studies have also reported issues with participant recruitment related to concerns regarding the possibility of a longer labour. Objectives We sought to compare a standard partograph with an action line, to a newly designed partograph with a stepped line, to determine the feasibility of recruitment to a larger clinical trial. Methods A pragmatic, single-blind randomised trial wherein low-risk, nulliparous women in spontaneous labour at term were randomized to an action-line or stepped-line partograph. First stage labour management was guided by the allocated partograph. Primary outcomes included the proportion of eligible women recruited, reasons for failed recruitment and compliance with partograph use. Secondary outcomes included rates of intervention, mode of birth, maternal and neonatal outcomes. Results Of the 384 potentially eligible participants, 38% (149/384) were approached. Of these 77% (116/149) consented, with 85% (99/116) randomized, only nine women approached (6%) declined to participate. A further 9% (14/149) who were consented antenatally were not eligible at onset of labor and 7% (10/149) of women approached in the birth suite but did not meet the inclusion criteria. Compliance with partograph completion was 65% (action) versus 84% (dystocia line). Conclusions for Practice Participant recruitment to a larger randomized controlled trial comparing new labour management guidelines to standard care is feasible. Effective strategies to improve partograph completion compliance would be required to maintain trial fidelity.

The Effect of High Fidelity Simulators on Knowledge Retention and Skill Self Efficacy in Pediatric Advanced Life Support Courses in a Rural State.

PURPOSE: Rural health care providers (HCPs) care for millions of Americans despite challenges. Pediatric Advanced Life Support (PALS) provides rural HCPs training in assessment and interventions for critically ill/injured pediatric patients (American Heart Association, 2015). The purpose of this study was to determine the effects of integration of high fidelity simulators into PALS courses in a rural setting. DESIGN AND METHODS: Participants were randomized by course to control or experimental PALS conditions where the control group received PALS with low fidelity static manikins (LFM) and the experimental group received PALS with high-fidelity simulators (HFS). Multiple level modeling (MLM) was used to examine participants time-to-task on pre-identified skills on PALS core case scenarios during testing on the last day of the course. MLM also was used to examine the differences in PALS knowledge and skills self-efficacy (SEI) between control and experimental groups at course end and six months later. RESULTS: The experimental and control groups had similar scores on the PALS post course knowledge exam, however the skill performance of the experimental group on time-to-task in core case scenarios was significantly better when compared to the control group (p=0.05). A decrease in knowledge exam scores and SEI scores occurred in both groups over time, however the control group had significantly greater declines in PALS written exam (p=0.042) and SEI (p=0.003). CONCLUSIONS AND PRACTICE IMPLICATIONS: Integration of HFS into PALS may increase HCPs' ability to recall valuable knowledge when seconds matter most. Further research in long-term recall of knowledge and retention of skills following PALS training is needed.

Likelihood of cesarean delivery after applying leading active labor diagnostic guidelines.

BACKGROUND: Friedman, the United Kingdom's National Institute for Health and Care Excellence (NICE), and the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) support different active labor diagnostic guidelines. Our aims were to compare likelihoods for cesarean delivery among women admitted before vs in active labor by diagnostic guideline (within-guideline comparisons) and between women admitted in active labor per one or more of the guidelines (between-guideline comparisons). DESIGN: Active labor diagnostic guidelines were retrospectively applied to cervical examination data from nulliparous women with spontaneous labor onset (n = 2573). Generalized linear models were used to determine outcome likelihoods within- and between-guideline groups. RESULTS: At admission, 15.7%, 48.3%, and 10.1% of nulliparous women were in active labor per Friedman, NICE, and ACOG/SMFM diagnostic guidelines, respectively. Cesarean delivery was more likely among women admitted before vs in active labor per the Friedman (AOR 1.75 [95% CI 1.08-2.82] or NICE guideline (AOR 2.55 [95% CI 1.84-3.53]). Between guidelines, cesarean delivery was less likely among women admitted in active labor per the NICE guideline, as compared with the ACOG/SMFM guideline (AOR 0.55 [95% CI 0.35-0.88]). CONCLUSION: Many nulliparous women are admitted to the hospital before active labor onset. These women are significantly more likely to have a cesarean delivery. Diagnosing active labor before admission or before intervention to speed labor may be one component of a multi-faceted approach to decreasing the primary cesarean rate in the United States. The NICE diagnostic guideline is more inclusive than Friedman or ACOG/SMFM guidelines and its use may be the most clinically useful for safely lowering cesarean rates.

Differences in inflammatory markers between nulliparous women admitted to hospitals in preactive vs active labor.

OBJECTIVE: To determine whether labor-associated inflammatory markers differ between low-risk, nulliparous women in preactive vs active labor at hospital admission and over time. STUDY DESIGN: Prospective comparative study of low-risk, nulliparous women with spontaneous labor onset at term (n = 118) sampled from 2 large Midwestern hospitals. Circulating concentrations of inflammatory markers were measured at admission and again 2 and 4 hours later: namely, neutrophil, and monocyte counts; and serum inflammatory cytokines (interleukin -1ß, interleukin-6, tumor necrosis factor-α, interleukin-10) and chemokines (interleukin-8). Biomarker concentrations and their patterns of change over time were compared between preactive (n = 63) and active (n = 55) labor admission groups using Mann-Whitney U tests. RESULTS: Concentrations of interleukin-6 and interleukin-10 in the active labor admission group were significantly higher than concentrations in the preactive labor admission group at all 3 time points. Neutrophil levels were significantly higher in the active group at 2 and 4 hours after admission. The rate of increase in neutrophils and interleukin-10 between admission and 2 hours later was faster in the active group (P < .001 and P = .003, respectively). CONCLUSION: Circulating concentrations of several inflammatory biomarkers are higher and their rate of change over time since admission is faster among low-risk, nulliparous women admitted to hospitals in active labor, as compared with those admitted in preactive labor. More research is needed to determine if progressive changes in inflammatory biomarkers might be a useful adjunct to improving the assessment of labor progression and determining the optimal timing of labor admission.

A concept analysis of watchful waiting among providers caring for women in labour.

AIM: This paper is a report of an analysis of the concept of watchful waiting. BACKGROUND: Little is known about differences between the intrapartum care processes of midwives and physicians. In this time of growing rates of surgical birth outcomes, intrapartum care processes are a key area for research and improvement. Watchful waiting is a common care plan used by both midwives and physicians that involves the timing of interventions in labour. DESIGN: Rodgers' Evolutionary Model was used to conduct a concept analysis of the term watchful waiting. DATA SOURCES: Scientific literature authored by, and about, midwives and physicians, as located via an intrapartum-focused database search inclusive of years 1922-May 2012. Thirty English-language articles from nine different countries were located, representing the midwifery and physician scientific literature focusing on watchful waiting in labour and provider decision-making processes. REVIEW METHOD: Attributes, consequences, antecedents and affecting themes were identified through a thematic analysis of the identified articles. RESULTS: Data analysis reveals that many midwives and physicians define watchful waiting differently, based on their philosophies of care. CONCLUSION: The care of women in labour is complicated as a result of different understandings by some providers of common processes of intrapartum care.

Serum lactate dehydrogenase profile as a retrospective indicator of uterine preparedness for labor: a prospective, observational study.

BACKGROUND: Lactate dehydrogenase (LDH) isoenzymes are required for adenosine triphosphate production, with each of five different isoenzymes having varying proficiencies in anaerobic versus aerobic environments. With advancing pregnancy, the isoenzyme profile in uterine muscle shifts toward a more anaerobic profile, speculatively to facilitate uterine efficiency during periods of low oxygen that accompany labor contractions. Profile shifting may even occur throughout labor. Maternal serum LDH levels between 24-48 hours following delivery predominantly originate from uterine muscle, reflecting the enzymatic state of the myometrium during labor. Our purpose was to describe serum LDH isoenzymes 24-30 hours post-delivery to determine if cervical dilation rates following labor admission were associated with a particular LDH profile. We also compared differences in post-delivery LDH isoenzyme profiles between women admitted in pre-active versus established active labor. METHODS: Low-risk, nulliparous women with spontaneous labor onset were sampled (n = 91). Maternal serum LDH was measured at labor admission and 24-30 hours post-vaginal delivery. Rates of cervical dilation during the first four hours after admission were also measured. Spearman's rho coefficients were used for association testing and t tests evaluated for group and paired-sample differences. RESULTS: More efficient dilation following admission was associated with decreased LDH1 (p = 0.029) and increased LDH3 and LDH4 (p = 0.017 and p = 0.017, respectively) in the post-delivery period. Women admitted in established active labor had higher relative serum levels of LDH3 (t = 2.373; p = 0.023) and LDH4 (t = 2.268; p = 0.029) and lower levels of LDH1 (t = 2.073; p = 0.045) and LDH5 (t = 2.041; p = 0.048) when compared to women admitted in pre-active labor.Despite having similar dilatations at admission (3.4 ± 0.5 and 3.7 ± 0.6 cm, respectively), women admitted in pre-active labor had longer in-hospital labor durations (12.1 ± 4.3 vs. 5.3 ± 1.4 hours; p < 0.001) and were more likely to receive oxytocin augmentation (95.5% vs. 34.8%; p < 0.001). CONCLUSIONS: More efficient cervical dilation following labor admission is associated with a more anaerobic maternal serum LDH profile in the post-delivery period. Since LDH profile shifting may occur throughout labor, watchful patience rather than intervention in earlier labor may allow LDH shifting within the uterus to more fully manifest. This may improve uterine efficiency during labor and decrease rates of oxytocin augmentation, thereby improving birth safety.

Accuracy and Interrater Agreement of Registered Nurses' Assignment of Apgar Scores to Standardized Clinical Vignettes.

The purpose of our study was to test whether registered nurses assign the correct Apgar score when provided all pertinent data, whether they assign an Apgar score even if all pertinent data are not provided, and to evaluate the Apgar score's interrater agreement. We conducted a REDCap survey and provided nurses with color photograph/vignette combinations of neonates, some of which lacked pertinent data points needed to correctly assign Apgar scores. Over 90% of study participants assigned Apgar scores even if data points for heart rate or respiratory effort were omitted. Participants' correct assignment of the component score for respiratory effort was affected by the description of the respiratory effort and whether neonatal heart rate was known. Interrater agreement was generally low to moderate. Our findings are consistent with earlier findings and support the conclusion that the Apgar score requires significant revision or needs to be retired and replaced.

Shape shifters: biobehavioral determinants and phenomena in symptom research.

Symptom assessment and management are critical to patient-centered care. Traditionally, the determinants of a symptom are viewed as separate from the phenomena associated with that symptom. By separating determinants and phenomena, however, the complexity and dynamism of the patient experience are ignored. Likewise, categorizing symptom determinants and phenomena as solely biological or behavioral minimizes their dimensionality and may hinder interdisciplinary dialogue. Here we propose that determinants and phenomena are not fixed but shift between each other depending on perspective. To illustrate this way of thinking the metaphor of the "shape shifter" from folklore is used. A shape shifter moves between states and may be seen differently by the same person at different times or by multiple individuals at one time. To guide discussion, we present 5 exemplars of increasing complexity, wherein a determinant becomes a phenomenon or vice versa, depending upon context. Suggestions for statistical testing of the model are included with each. We conclude by exploring how shifting between determinants and phenomena may affect symptom cluster assessment and management.

A Final Thought on the Future of Nursing.

Final thoughts on the opportunities and challenges ahead for nurses and nursing in the context of the The Future of Nursing 2020-2030.

Gratitude for JOGNN's Peer Reviewers.

Microaggression can influence perinatal health outcomes; however, the science is limited by inconsistencies in the definition and measurement of the term.

JOGNN's Editorial Statement on Justice, Equity, Diversity, and Inclusion, 2021.

A summary of JOGNN's commitment to promoting justice, equity, diversity, and inclusion in health and health care through editorial policies and processes and published articles.

Childbirth Self-Efficacy Inventory and Childbirth Attitudes Questionnaire: psychometric properties of Thai language versions.

AIM: This paper is a report of the psychometric properties of the Thai language versions of the Childbirth Self-Efficacy Inventory and the Childbirth Attitudes Questionnaire, and the equivalence of the Thai and English versions of these instruments. BACKGROUND: The Childbirth Self-Efficacy Inventory and the Childbirth Attitudes Questionnaire were developed to measure women's abilities to cope with labour and fear of childbirth. Consistent with Bandura's Self-Efficacy Theory, women who have greater confidence in their ability to cope with labour have reported having less fear in childbirth. However, research is needed to validate the measures and this relationship in countries other than the United States of America, where the tools were developed. METHODS: Back-translation was used. Content validity was examined by experts. The psychometric properties were estimated with internal consistency reliability, construct validity, contrasted groups and criterion-related validity with 148 pregnant women at a hospital in Thailand in 2008. RESULTS: Both measures were shown to have high internal consistency. Contrasting group and criterion-related validity were consistent with self-efficacy theory and findings in the United States. Differences between the stages of labour across expectancies in the Childbirth Self-Efficacy inventory were found only for second stage. CONCLUSION: Support for good validity and reliability of the instruments when used with Thai women was demonstrated. It may be appropriate for Thai women to use The Childbirth Self-Efficacy Inventory only in relation to the second stage of labour.

Black Women's Lives Matter.

Black women die from pregnancy-related causes in the United States three times more frequently than White women.