Original Article

The Effectiveness of Prenatal Intervention

on Pain and Anxiety during the Process of
Childbirth‑Northern Iran: Clinical Trial Study
Firouzbakht M1,2, Nikpour M2,3, Khefri S4, Jamali B1, Kazeminavaee F1, Didehdar M5
Department of Midwifery, Islamic Azad university, Babol Branch, Babol, Departments of 2Social Determinant of Health,
1

Midwifery and 4Science, Babol University Medical Science, 5Department of Psychology, Elicit and Researchers Club, Tehran, Iran
3

Address for correspondence: Abstract

Dr. Maryam Nikpour,
Department of Midwifery, Babol Background: Due to the painful nature of childbirth and its maternal and neonatal complications,
University Medical Science, Babol, Iran. the woman needs support in this phase of their life. Increased knowledge and skills during
E‑mail: maryamnikpour19@yahoo. pregnancy prepares pregnant mothers for labor and leads to promoted health. Aim: This study
com was designed to evaluate the effectiveness of “prenatal education” on the process of childbirth.
Subjects and Methods: This clinical trial was conducted on 195 pregnant women, that is,
control group (N = 132) and case group (N = 63) attending health centers in Amol‑Iran from
20 weeks of gestation age during 2012. Case group members attended in “prenatal education”
class and the control group only received routine care. Data were collected through demographic
questionnaire, standard hospital anxiety questionnaire, and a checklist related to childbirth
information, and intensity of pain based on visual analogue scale and McGill scales. The data
were analyzed by Statistical Package for the Social Sciences software using t‑test and Chi‑square
test. Results: The result of this study showed that the parent with a high level of education
was more interested to participant in prenatal classes. The anxiety level in case group (who
received education) was 14.47 (4.69) and in control group it was 16 (4.86), (P < 0.001) the pain
intensity in case group was 85.68 (1.85) and in control group was 90.99 (14.72) (P = 0.03),
intervention on labor such episiotomy was 39 %66.1 (39/63) in case group and 80 %72.8
(80/132) in control group (P = 0.01) and cesarean section was 13 %17.1 (13/63) in case group
and 58 %32.2 (58/132) in control group (P = 0.01). Conclusions: According to findings of
this study, the prenatal education and psychological support are beneficial for mothers during
pregnancy and labor. Therefore, it is recommended for educating all the pregnant women.

Keywords: Delivery, Obstetric, Pregnancy training classes, Prenatal care, Prenatal education

Introduction times, women have used rites or strategies and sought support
from more experienced women during these deep life changes.
Childbirth is a life‑turning event, in the most basic sense of the This need for support is also associated with awareness of the
word. It means giving birth to a new life but also becoming fact that childbirth is associated with pain[2] and risk of infant
something new: A parent. The birth of a child alters all aspects and maternal morbidity.[3] Even these days, despite of very low
of the new parents’ lives.[1] Both their inner and outer worlds threats to the infant’s and mother’s health for women who have
change and these changes last forever. A new personality access to modern obstetric care, and pain relief, the women
adapted to the needs of the baby evolves, and for a woman the and their partners still are worry about the birth.[4]
physiological transformations are profound. In all cultures and
Over 90% of prenatal stress and anxiety is related to the process
Access this article online
of childbirth.[5] Mother’s anxiety in this period mostly is due to
Quick Response Code:
the lack of knowledge and prenatal fear of the unknown risks
Website: www.amhsr.org
and childbirth. As a result of fear and anxiety, secretion of
stress hormones increases and can lead to preterm birth, lack
DOI:
of progress, low birth weight of the child, and fetal hypoxia.[6]
***** Women’s access to all health services, along with increased
awareness through education and counseling during pregnancy

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 Firouzbakht, et al.: Effect of prenatal intervention on pain

and childbirth are critically effective factors in the prevention were selected at the governmental healthcare center of the
from mortality and complications in this stage. Promotion of city of Amol, Iran. The inclusion criteria were as follows:
prenatal knowledge and skill prepares mothers for delivery and Completion of the 5th grade of elementary school, current
enhance their health. Today, emphasized by United Nations gestational age of 16–20 weeks, 17–35‑year‑old, and no
Educational, Scientific and Cultural Organization, learning is contraindication for natural delivery, without any complication
devoted part of human life.[7] during pregnancy. The women who interested in attending
prenatal classes were selected as the case group (102 people),
In many parts of the world, prenatal and delivery trainings that and the rest were selected as a control group (190 people).
educate pregnant women and their spouses about childbirth
and parenthood is routinely provided for women as part of Intervention
prenatal care.[8] The case group attended eight training sessions run by four
doulas (women having experienced childbirth before and
In Iran, prenatal care is limited to regular examinations, tests, trained in this regard) at two private consultation and healthcare
and ultrasound. This program is insufficient for mothers and centers of the city of Amol. Each class lasted 90 min into
their lack of knowledge and preparation cause anxiety and three parts. Part one was about physical and anatomical
increased medical interventions, especially cesareans. [6,9] changes during pregnancy, psychological health, warning
Cesarean section (CS) in Iran is performed on 40% of cases, symptoms during pregnancy, the pros and cons of vaginal and
while World Health Organization (WHO) recommends 15%, caesarian delivery, stages of delivery, breastfeeding, and family
it is 23% in the U.S., and 10.7% in Sweden.[6] Implementation planning theoretical training, that was presented by means
of safe labor policies, mother‑friendly hospitals, prenatal of audio‑visual instruments like videos of natural delivery.
education classes, and establishing standard delivery wards Part two included consultations of 15 min long in forms of
together with changes of attitude and behavior of midwives and questions and answers. Part three covered mental and muscular
obstetricians could help reduce cesarean and other emergency exercises, training proper positions during labor and delivery,
interventions.[10] proper breathing during pregnancy, labor and delivery, and
30 min of practicing for pregnant women. The control group
Many studies have shown positive and useful effects of prenatal were conducted routine prenatal care.
education classes. In a study by McGrath and Kennell (2008)
in Sweden, applying prenatal education the rate of CS and Tools
the need for epidural in the trained group had significantly The questionnaires included demographic information,
reduced.[11] In a study in Spain (2010), trained mothers’ anxiety pregnancy information, and labor information. Hospital
level was lower, but no difference was observed in duration of Anxiety and Depression Scale (HADS) was used to assess
the first and second stages of delivery, type of delivery, perineal anxiety, visual analog scale (VAS) and McGill questionnaire
injury, and 5‑min Apgar of the baby.[12] In a study in Iran by were used to assess pain. The Persian version of HADS is
Mehdizadeh et al. (2003), back and hip pain and fatigue were a standardized tool[14] whose reliability and validity was
less in trained mothers. In addition, the rate of cesarean and confirmed by Montazeri. He has been found to be 0.78 for
duration of delivery stages were significantly lower in trained HADS for anxiety subscale and 0.86 for HADS depression
women.[6] In another study done by Bergstrom (2009), use subscale.[15] It has seven four‑point Likert scale questions; with
of epidural anesthesia in the trained group compared to the lower scores showing less anxiety.
standard group had not reduced; also in experience of delivery
and level of parents stress, no improvement observed.[13] Visual Analog Scale is one of the numerical visual scales with
scores 0–100. 0 means no pain and one 100 shows the highest
This study was conducted to assess the effect of prenatal amount of pain felt by the patient.[16]
training classes on the process of delivery at Imam Ali Hospital
in Amol/Iran during 2012–2013. The McGill pain questionnaire (MPQ) with three sensory,
affective, and evaluative aspects is a strong tool to assess
Subjects and Methods pain,[17] and numerous studies have approved its reliability and
validity.[18] The MPQ reliability and validity was confirmed by
The proposal of this study approved by the Islamic Azad Adelmanesh et al. (2011), the internal consistency was found
University of Babol and code and Ethical approval was by Cronbach’s alpha to be 0.951, 0.832, and 0.840 for sensory,
51561910717008/2013. 8.23. affective, and total scores, respectively. Item to subscale score
correlations supported the convergent validity of each item
Sampling to its hypothesized subscale. Correlations were observed to
This study was a semi‑experimental study from June 2012 range from r2 = 0.202 to r2 = 0.739.[19] In the present study,
to April 2013 in health centers of Amol‑Iran. Simple random the affective aspect of pain was assessed, including tiring,
sampling was used, and the sample size was determined sickening, fearful, and punishing that is attributed to labor
through other studies.[6] Two hundred and ninety‑two women pain as a punishment because the affective aspect indicates

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 Firouzbakht, et al.: Effect of prenatal intervention on pain

a wide range of feelings ranging from merely feeling ill to

Table 1: Demographic characteristics of study groups
extremely feeling pain. In this questionnaire, lower points
Demographic Classes Control
indicate less pain. Four observers collected data from samples. P
characteristics education group group
The reliability of the observer was 0.72. Age (mean±SD) 25.42 (4.9) 25.62 (5.28) 0.99
Weight (kg) 68.2 (11.8) 67.8 (13.4) 0.88
Procedure Length (m) 1.62 (0.14) 1.59 (0.17) 0.56
When labor pain began, in case group a doula accompanied n (%)
the parturient to the labor room in Imam Ali Hospital in Mother education
Amol/Iran, and during labor performed all the procedures she Primary 15 (24.2) 66 (50.0) 0.03
had learned: Comforting, reassuring, encouraging, talking, and High school 28 (45.2) 40 (30.3)
massaging her back, shoulders, and limbs, helping with the University 19 (30.6) 26 (19.7)
best position for different stages of labor, using acupressure to Father education
reduce pain, using birth balls, and applying counter‑pressure Primary 19 (31.7) 71 (53.8) 0.12
on sacrum, and parturient walking. The midwife completed High school 20 (33.3) 35 (26.5)
HADS questionnaire on arrival, VAS at cervical dilatation 3–4, University 21 (35.5) 26 (19.7)
Mother occupation
8–10 cm and the second stage of labor, and McGill scale during
Housewife 52 (83.9) 116 (87.9) 0.44
the active phase of labor. Information about progress of labor,
At work 10 (16.1) 16 (12.1)
need for oxytocin and analgesic, type of delivery, and condition
Father occupation
of the newborn (weight, Apgar score, breastfeeding) were
Employer 17 (27.4) 18 (13.6) 0.18
collected using a questionnaire. The control group received
Worker 11 (17.7) 30 (22.7)
only routine prenatal care by the delivery room personnel. Business 34 (54.8) 84 (63.6)
Residency
Statistics City 36 (63.2) 59 (48.4) 0.06
Data were analyzed by analysis of covariance, t‑test and Chi‑square Village 56 (90.3) 63 (51.6)
test, using Statistical Package for the Social Sciences version 16 Income level
analytical software (233, South Wacker Drive, 11th Floor, Chicago, Low 6 (9.7) 15 (11.4) 0.72
USA). The significance level was set at 0.05. Average 56 (90.3) 117 (88.6)
SD: Standard deviation. *Mothers education and residency are significant

Results
Table 2: Adjusted results of comparing the education and
Initially, 292 women were selected for the study, of control group in pain and hospital anxiety
whom 97 (10 due to noncooperation, 4 due to incomplete
Variables Covariates Sum Df Mean F
questionnaires, 12 because of high‑risk pregnancies, 71 squares squares
due to emergency cesareans) were excluded from the study Hospital Education 19.883 1 19.883 1.730
(39 in case group, and 58 in control group). Statistical analysis anxiety Age 4.226 1 4.226 0.368
was performed on 195 women (132 in the control group and Parity 1884.725 1 1884.725 164.033
63 in case). The result of this study showed that the parent with Groups 834.753a 1 834.753 72.651*
a high level of education were more interested to participant Error 1406.429 191 7.364
in prenatal classes (P = 0.07, P = 0.03). The anxiety level in Pain Education 20.419 1 20.419 0.358
case group (who received education) was 14.47 (4.69) and in Age 35.530 1 35.530 0.622
control group, it was 16 (4.86), (P < 0.001), the pain intensity Parity 1.060 1 1.060 0.019
in case group was 85.68 (1.85) and in control group was Group 480.854b 1 480.854 8.420*
90.99 (14.72) (P = 0.03). The demographic characteristics Error 1259.250 191 6.593
include age, mother and spouse occupation, education level, *significant. aR2=0.839 (adjusted R2=0.824), bR2=0.201 (adjusted R2=0.127)

parity, income level, and place of residence, demonstrated in

Table 1. labor, use of oxytocin, and need for analgesic. However, in
educated mothers CS rate (P = 0.01) and episiotomy rate
There is a significant effect of intervention after controlling for (P = 0.02) were significantly reduce. In terms of the infant’s
the effect of education, parity, and age in pain F (1, 191) = 8, condition, no significant difference was found between the
P = 0.02 and pain anxiety F (1, 191) = 72, P = 0.01. This implies two groups in terms of baby’s weight, head circumference,
the group who received education experienced lower pain and 5‑min Apgar and breastfeeding. In terms of pain intensity
anxiety during labor in compare to the group who did receive using VAS, the results showed the difference between the two
only usual care [Table 2]. groups were insignificant in a latent phase (3–4 cm in cervical
dilatation), and in the second stage. However, in a transitional
Study results indicated that there was no significant difference phase (8–10 cm in cervical dilatation), pain intensity was
between groups in duration of the first and second stages of significantly less in the case group. Comparison of McGill

350 Annals of Medical and Health Sciences Research | Sep-Oct 2015 | Vol 5 | Issue 5 |
 Firouzbakht, et al.: Effect of prenatal intervention on pain

scale score in the two groups during active delivery phase trials, involving 2284 women. No consistent results were found.
showed significantly lower score in trained mothers [Table 3]. No data were reported concerning anxiety, breastfeeding success,
or general social support. Knowledge acquisition, sense of control,
Discussion factors related to infant‑care competencies, and some labor and
birth outcomes were measured. This high‑quality study showed
The results of this study showed that the prenatal education similar rates of vaginal birth after CS in “verbal” and “document”
reduced level of hospital anxiety and intensity of pain in trained groups (relative risk 1.08, 95% confidence interval 0.97–1.21).[22]
women, as well as the need for episiotomy and emergency
cesarean. The results from World Bank and WHO studies Another review in 2010 by Bryanton and Beck reported that
on 4000 American women showed that use of breathing the benefits of educational programs to participants and their
techniques and massage caused reduction in fear and pain of newborns remain unclear. Education on sleep enhancement
delivery, resulting in reduced rate of cesarean and mother and appears to increase infant sleep and education about infant
baby complications.[20] behavior potentially enhances mothers’ knowledge; however,
more and larger, well‑designed studies are needed to confirm
Ip et al. believed that based on Bandura’s self‑efficacy theory this.[23]
the educational intervention is effective in promoting pregnant
women’s self‑efficacy for childbirth and reducing their Adequate and correct training increased mothers’ awareness
perceived pain and anxiety in the first two stages of labor.[21] about pregnancy and delivery and enabled them to use of
problem‑solving strategies. [3,24] Furthermore, adaptation of the
In 2007, a systematic review by Gagnon and Sandall was trained group and use of skills to apply these techniques causes
conducted evaluating the effect of both individual and group reduction of anxiety, pain, and even postnatal depression.[25]
antenatal education for childbirth or parenthood. They concluded
that high‑quality evidence was lacking and that the effects of The results of this study showed that the duration of different
antenatal education are largely unknown. However, since 2007, stages of delivery did not have a significant difference in
more randomized trials have been conducted, and results from two groups. While in a study by Gupta and Nikodem,[26] and
these trials might alter this conclusion. They were included nine Mehdizade et al.[6] duration of delivery stages was shorter in
trained women. In Bergstrom study (2009), natural childbirth
preparation including training in breathing and relaxation did
Table 3: Obstetrics characteristics of study groups not decrease the use of epidural analgesia during labor, either
Characters Case Control P did it improve the birth experience or affect parental stress in
group (%) group (%) early parenthood in nulliparous women and men, compared
Parity with a standard form of antenatal education.[13]
Nulipar 39 (63.9) 66 (50) 0.09
Multipar 22 (36.1) 66 (50) In the hospital where this study was conducted, oxytocin is
Mode of delivery
routinely used to induce labor. Furthermore, methods such as
Vaginal 63 (82.9) 122 (67.7) 0.02*
changing positions and breathing technique trainings were used
Spontaneous delivery 11 (16) 17 (13.9) 0.80
for untrained mothers by midwifery students and some delivery
Episiotomy 39 (66.1) 80 (72.8) <0.001*
ward personnel. These could perhaps be the reason for the lack
Laceration 13 (19.1) 25 (20.5) 0.70
of difference between groups in duration of delivery. Since
Cesarean section 13 (17.1) 58 (32.2) 0.01*
Mean (SD)
this hospital is a child‑friendly hospital, breastfeeding begins
Gestational age (week) 38.7 (1.8) 39 (2.3) 0.64
for all infants without problem within the first ½ h of birth. In
Weight of baby (kg) 3.58 (0.49) 3.36 (0.39) 0.36 this study, no difference was observed in Apgar, weight, and
Apgar (5 min) 9.3 (0.89) 9.49 (0.62) 0.54 breastfeeding start. In Smith study (2010), no differences were
Head circumference (cm) 34.1 (2.8) 34.3 (1.3) 0.32 seen in Apgar and weight of the infant, either.[27]
Length of labor
1st stage (h) 6.43±3.65 5.92±4.94 0.52 There was a significant difference between education level of
2nd stage (min) 41.04±25.75 41.78±28.6 0.46 case and control groups education level. This is explainable
3rd stage (min) 4.40±2.57 4.12±2.25 0.89 with method of administration of two groups because mothers
Pain intensity who were interested to participation in classless were more
First phase 38.13 (28.007) 40.61 (29.5) 0.58 educated. The weeks of this study were that the cases were not
Latent phase (3-4 cm) 85.68 (18.5) 90.99 (14.72) 0.03* selected randomly because we could not deprive a woman of
Transitional phase 86.08 (18.37) 90.44 (16.64) 0.19 attending training classes if she was interested. The subjects
(8-10 cm) second of the two groups were not matched for education; mothers
phase labor
having completed higher levels of education more likely took
McGill in the second 8.34 (2.35) 9.16 (2.14) 0.01*
phase labor part in these classes. Then, the effect of the agent on the main
*significant. SD: Standard deviation variables was adjusted in the analysis.

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 Firouzbakht, et al.: Effect of prenatal intervention on pain

Conclusion Bacigalupe A, et al. The benefits of antenatal education for

the childbirth process in Spain. Nurs Res 2010;59:194‑202.
Prenatal education and psychological support of mothers 13. Bergström M, Kieler H, Waldenström U. Effects of natural
during labor reduce anxiety, pain intensity, and interventions childbirth preparation versus standard antenatal education
like episiotomy and CS. Prenatal trainings as part of routine on epidural rates, experience of childbirth and parental stress
in mothers and fathers: A randomised controlled multicentre
pregnancy care could be used as an effective means of trial. BJOG 2009;116:1167‑76.
improving mothers’ health. This study included some
14. Mayou R, Sprigings D, Birkhead J, Price J. A randomized
limitations such as lack of randomization and unmatched controlled trial of a brief educational and psychological
groups. The authors suggest to future researchers to select intervention for patients presenting to a cardiac clinic with
sample from several culture with different variables to evaluate palpitation. Psychol Med 2002; 32:699‑706.
the effectiveness of education on delivery. 15. Montazeri A, Vahdaninia M, Ebrahimi M, Jarvandi S. The
Hospital Anxiety and Depression Scale (HADS): Translation
and validation study of the Iranian version. Health Qual Life
Acknowledgment Outcomes 2003;1:14.
This article was extracted from a research project funded by the Islamic 16. Vixner L, Schytt E, Stener‑Victorin E, Waldenström U,
Azad University of the city of Babol. The authors wholeheartedly Pettersson H, Mårtensson LB. Acupuncture with manual and
thank the research deputy of the university, the personnel of the electrical stimulation for labour pain: A longitudinal randomised
delivery room of Imam Ali Hospital in the city of Amol, Fereshte controlled trial. BMC Complement Altern Med 2014;14:187.
Husseini, Shayeste Assadi and all the pregnant mothers without whose 17. Melzack R, Taenzer P, Feldman P, Kinch RA. Labour is still
collaboration this research would be impossible. painful after prepared childbirth training. Can Med Assoc J
1981;125:357‑63.
The study was supported by Research ward of Islamic Azad University 18. Banth S, Ardebil MD. Effectiveness of cognitive behavioural
Babol. (The code and Ethical approval was 51561910717008/2013. 8.23). therapy on pain of patients with low back pain. J Cogn Behav
Psychother Res 2014;3:46‑52.
19. Farhad Adelmanesh, Ali Jalali, Hamid Attarian, Behzad Farahani,
References Seyed Mehdi Ketabchi, Ali Arvantaj, et al. Results from the
1. Stem D. The Motherhood Constellation. A Unified View of translation and adaptation of the Iranian Short‑Form McGill Pain
Paret‑Infant Psychotherapy. London: H. Karnac Books Ltd.; 1998. uestionnaire (I‑SF‑MPQ): Preliminary evidence of its reliability,
construct validity and sensitivity in an Iranian pain population.
2. Melzack R. The myth of painless childbirth (the John J. Bonica Sports Med Arthrosc Rehabil Ther Technol 2011;3:27.
lecture). Pain 1984;19:321‑37.
20. Bonapace J, Chaillet N, Gaumond I, Paul‑Savoie E,
3. Saisto T, Halmesmäki E. Fear of childbirth: A neglected Marchand S. Evaluation of the Bonapace Method: A specific
dilemma. Acta Obstet Gynecol Scand 2003;82:201‑8. educational intervention to reduce pain during childbirth.
4. Eriksson C, Salander P, Hamberg K. Womenen’s experiences J Pain Res 2013;6:653‑61.
of intense fear related to childbirth investigated in a Swedish 21. Ip WY, Tang CS, Goggins WB. An educational intervention to
qualitative study. Midwifery 2006;22:240‑8. improve women’s ability to cope with childbirth. J Clin Nurs
5. Hosseininasab D, Taghavi S. The effectiveness of prenatal 2009;18:2125‑35.
education in decreasing the childbirth pain and anxiety. Med 22. Gagnon AJ, Sandall J. Individual or group antenatal education
J Tabriz Univ Med Sci Health Serv 2010;31:24‑30. for childbirth or parenthood, or both. Cochrane Database Syst
6. Mehdizadeh A, Roosta F, Chaichian S, Alaghehbandan R. Rev 2007;CD002869.
Evaluation of the impact of birth preparation courses on the health 23. Bryanton J, Beck CT. Postnatal parental education for
of the mother and the newborn. Am J Perinatol 2005;22:7‑9. optimizing infant general health and parent‑infant
7. Toghyani R, Ramezani MA, Izadi M, Shahidi Sh, Aghdak P, relationships. Cochrane Database Syst Rev 2010;CD004068.
Motie Z, et al. The effect of prenatal care group education on 24. Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C,
pregnant mothers’ knowledge, attitude and practice. Iran J Dodin S, et al. Mind‑body interventions during pregnancy for
Med Educ 2008;7:317‑23. preventing or treating women’s anxiety. Cochrane Database
8. Fabian HM, Rådestad IJ, Waldenström U. Childbirth and Syst Rev 2011;CD007559.
parenthood education classes in Sweden. Women’s opinion and 25. Brixval CS, Axelsen SF, Andersen SK, Due P, Koushede V.
possible outcomes. Acta Obstet Gynecol Scand 2005; 84:436‑43. The effect of antenatal education in small classes on obstetric
9. Sanavi FS, Rakhshani F, Ansari‑Moghaddam A, Edalatian M. and psycho‑social outcomes: A systematic review and
Reasons for elective cesarean section amongst pregnant meta‑analysis protocol. Syst Rev 2014;3:12.
women; a qualitative study. J Reprod Infertil 2012; 13:237‑40. 26. Gupta JK, Nikodem VC. Woman’s position during second
10. Yazdizadeh B, Nedjat S, Mohammad K, Rashidian A, Changizi N, stage of labour. Cochrane Database Syst Rev 2000;CD002006.
Majdzadeh R. Cesarean section rate in Iran, multidimensional 27. Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary
approaches for behavioral change of providers: A qualitative and alternative therapies for pain management in labour.
study. BMC Health Serv Res 2011;11:159. Cochrane Database Syst Rev 2006;CD003521.
11. McGrath SK, Kennell JH. A randomized controlled trial of
continuous labor support for middle‑class couples: Effect on
How to cite this article: ???.
cesarean delivery rates. Birth 2008;35:92‑7.
12. A r t i e t a ‑ P i n e d o I , P a z ‑ P a s c u a l C , G r a n d e s G ,
Remiro‑Fernandezdegamboa G, Odriozola‑Hermosilla I, Source of Support: Nil. Conflict of Interest: None declared.

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