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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 195-200

Partograph adherence and its barriers in a tertiary care hospital: A mixed-method study


Department of Community Medicine, Medical College, Kolkata, West Bengal, India

Date of Submission30-May-2022
Date of Acceptance13-Jun-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Adwitiya Das
First Floor, 42C, Ramkamal Street, Khidirpur, Kolkata - 700 023, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_50_22

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  Abstract 


Background: Partograph is a low cost, effective and mandatory tool for intrapartum monitoring. However, the partograph has been grossly underutilised. Aims and Objectives: The present study aims to find out the extent of the use of a partograph and the barriers to effectively using the same in a tertiary care facility. Materials and Methods: This cross-sectional study comprises quantitative and qualitative methods. The quantitative component consisted of a retrospective review of case sheets of patients undergoing uncomplicated vaginal delivery between 1 January 2020 and 15 February 2020. The percentage of cases where a partograph was initiated and completed was assessed. For the qualitative part, staff nurses on duty in the labour room during the study period and responsible for recording the partograph were invited to participate in a focused group discussion (FGD). Sister-in-charges, supposed to supervise the staff nurses were invited to participate an In-depth interview (IDI). Results: Out of 131 case sheets, a partograph was initiated in 64 (48.85%) cases and completed in 4 out of 64 partographs (6.25%). The 'Cervical dilatation' parameter was plotted in all 64 cases, while the 'amniotic fluid condition' was the least plotted parameter (12 [18.75%]). Data regarding the 'time of rupture of membranes' (15.63%) and 'condition at birth' (4.69%) were also neglected parameters. The FGD and IDI revealed 'shortage of staff and heavy workload', 'presentation in advanced labour', 'poor training and supervision', 'incomplete documentation of clinical information by doctors' and 'policy level lacunae' as the potential barriers to partograph adherence and completeness. Conclusion: Partograph adherence and completeness appeared inadequate in this tertiary care centre.

Keywords: Mixed methods, partograph adherence, partograph completeness, partograph


How to cite this article:
Manna N, Bhattacharya P, Mukherjee R, Das A. Partograph adherence and its barriers in a tertiary care hospital: A mixed-method study. Hamdan Med J 2022;15:195-200

How to cite this URL:
Manna N, Bhattacharya P, Mukherjee R, Das A. Partograph adherence and its barriers in a tertiary care hospital: A mixed-method study. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:195-200. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/195/364687




  Introduction Top


Complications during labour account for a large proportion of adverse maternal and foetal outcomes. Continuous monitoring during the intrapartum period helps in the early detection of labour complications, thereby preventing morbidity and mortality. Partograph is a simple, effective and low-cost monitoring tool to record the intrapartum events. It is a pre-printed paper with a graphical representation of observations made on the progress of labour, foetal condition, maternal vital signs and interventions.[1] The World Health Organization promoted partograph as the 'gold standard' method and mandated its plotting in every delivery.[2] The government of India also has set a target under the 'LaQshya-Quality Improvement Initiative' stating that at least 90% of deliveries in labour rooms should be monitored using real-time partograph.[3] Previous studies have shown that maternal and foetal complications were less common when the progress of labour was monitored using a partograph.[4],[5] In spite of its proven benefit in monitoring labour, partograph has been grossly underutilised.[6],[7] There is a limited number of studies from the Indian sub-continent which assess the proportion of deliveries monitored by partograph. The present study undertaken in a tertiary care hospital in Eastern India aims to find out the extent of use of partograph and the barriers to effectively using the same.


  Methods Top


This facility based cross-sectional study that combined both quantitative and qualitative methods in data collection was conducted in a tertiary care hospital in Eastern India from 1 January 2020 to 29 February 2020. For the quantitative component, a retrospective review of selected maternity case sheets among all mothers who were admitted to the facility at any gestational age or with cervical dilatation of any degree if undergone vaginal delivery (Either spontaneous or assisted vaginal delivery) between 1 January 2020 and 15 February 2020, was carried out to find out the adherence to partograph. Mothers delivered by elective or emergency caesarean section or those presenting with obstetric complications like eclampsia, pre-eclampsia or intrauterine foetal death were excluded from the study. The sample size for the number of maternity case sheets to review for Partograph adherence was determined using the formula n = 4pq/l2; where n = required sample size, P = proportion (prevalence) of the partographs used or completed, estimated from the previous study, q = 100-p, l = Relative error (20% of P). We assumed partograph adherence of 48.7% obtained from a study done in Odisha by Palo et al.[8] The minimum sample size estimated was 105.

A pre-designed, pre-tested semi-structured schedule was developed for the quantitative part. The first part of the schedule comprised background data of the pregnant women including age, address, religion, 1st day of last menstrual period (LMP), parity, gravida and date and time of admission. The second part was framed to assess the completeness of the partograph based on the standard parameters included in the partograph: foetal condition (including foetal heart rate and condition of the amniotic fluid), maternal condition (pulse, blood pressure, temperature), the progress of labour (cervical dilatation, uterine contraction) and intervention: Medications administered.

Foetal heart rate, condition of amniotic fluid, maternal pulse and uterine contractions are monitored every 30 min, whereas cervical dilatation, maternal blood pressure and temperature are monitored every 4 h. 'Completely filled partograph' was defined as a partograph with all parameters recorded at correct time intervals as per protocol. Any deviation from the above was defined as an 'incomplete partograph'. A partograph was considered to be initiated or plotted if at least one assessment of any one of the parameters mentioned earlier was plotted against time. Adherence was defined as (number of maternity case sheets with partograph plotting/total number of case sheets reviewed) ×100. Completeness was defined as: (Number of maternity case sheets with complete partographs/total number of case sheets with partograph plotting) ×100. Completeness of documentation of patient identification data including name, husband's name, age, parity, registration number, date and time of admission and date and time of rupture of membrane (ROM) and recording of the delivery outcome, which are also essential parts of partograph, was assessed in the second part of the schedule.

Quantitative data were coded, cleaned, entered and validated using MS Excel 2010 version. Data were then exported and analysed using IBM Statistical Package for Social Sciences version 20.0 (USA). The categorical variables were summarised by proportion, whereas the continuous variables were summarised by the mean and standard deviation.

For the qualitative part, the staff nurses who were on duty in the labour room during the study period and were mostly responsible for recording the partograph were traced from the duty roster and invited to participate in a focused group discussion (FGD). Nine out of twelve staff nurses posted during the study period gave informed written consent for participation. In-depth interviews (IDIs) involving sister-in-charges who were responsible for supervising the labour room activities of the staff nurses were planned planned. At the outset, it was intimated to the participants that the study was done purely for academic purposes. Two out of three sisters-in-charges gave consent to take part in the study and were interviewed. Staff nurses and sister-in-charges who did not give consent or were on leave at the time of data collection were excluded from the study.

Data extraction for both FGD and IDI was done at the institutional level on the very day of their scheduled presence, adjacent to work stations at a convenient time between change of shifts, ensuring anonymity, confidentiality and protection of the information shared. Strict anonymity was maintained and there was no incentive for participating. As IDIs were performed on hierarchical superiors of the participants in FGD, additional care was taken to ensure that the participants of FGD and IDI do not get interviewed in presence of each other. An open semi-structured schedule in the local language (Bengali) was developed to guide the FGD and IDIs. The FGD and IDIs were continued till no new ideas were being imparted (data saturation).

The FGD and IDIs were audio-recorded, transcribed in verbatim and translated into English. Then they were again translated to vernacular and back translated to English to ensure semantic equivalence. The data were then analysed using the conventional content analysis method. To validate the content of the interview, the recorded transcript was verified with the respondents whenever deemed necessary. The transcripts were read and responses were coded and listed by eyeballing. Repeated quotes were identified, coded and clubbed. The content of each coded club was placed next to quotes from interview transcripts and interpreted for identification of thematic areas. The evolving themes included intrapersonal, inter-personal, institutional, social and health policy. Broad determinants were listed from these interpretations and analysis was done using standard techniques of qualitative analysis. The study design was a hybrid of transformative (between qualitative and quantitative string) and parallel convergent (between FGD and IDI).[9]

The study was approved by the Institutional Ethics Committee.


  Results Top


The mean age of the study population was 23.55 (±4.68) years. Twenty-five (19.08%) mothers presented with pre-term labour while four (3.05%) mothers presented post-term. Nine (6.87%) mothers could not inform the 1st day of their LMP. The mean gestational age of those 122 mothers who could confirm the 1st day of their LMP was 38.25(±0.26) weeks. The median duration of stay at the hospital before delivery (time interval between admission and delivery) was 6.62 h. [Table 1] shows the background characteristics of the mothers. Among 131 deliveries, partograph plotting (adherence) was found in only 80 (61.07%) cases while only four (5.00%) partographs were completely out of those 80 partographs (completeness).
Table 1: Background characteristics of the study population (n=131)

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Based upon the review of 80 available partographs, the 'cervical dilatation' parameter was found to be plotted in 64 (80.00%) cases while the amniotic fluid condition was in the (12 [15.00%]). Parameter-wise plotting of the partograph has been given in [Table 2].
Table 2: Parameter-wise completeness of partographs (n=80)

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Intervention (either Injection Oxytocin or Intravenous fluid) were done in 64 mothers out of those 80 mothers (retrieved from clinical notes). But the intervention was documented in partograph in the case of 23 mothers (35.94%).

[Table 3] shows the parameter-wise plotting of identification data and delivery outcome, where the 'time of ROM' and 'condition at the birth' of the newborn were the neglected parameters.
Table 3: Documentation of identification data and delivery outcome (n=64)

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Qualitative component

All the participants of FGDs and IDIs were aware of the importance of the use of partographs and also knew that partograph should be filled up for all deliveries. All of the participants received in-service training on partograph. Several Factors came out of the analysis of FGDs held:

Shortage of staff and heavy workload

One staff nurse pointed out, 'In addition to providing care to the intra-partum mothers, we have to do so many works which we are not supposed to do; like sterilization of the instruments, drum packing, etc. We do not get adequate time for documentation'. Another nursing staff opined 'Initial examination of all pregnant females attending the hospital is done in the labour room, irrespective of whether she is in labour or not. Thus, the workload sometimes increases manifold'.

'There is so much to do and so many patients that even if we are determined to monitor a patient's partograph, we have to leave that and attend some other emergency patient, and when we are finally done with that, it is either too late to go back to that partograph or impossible to keep track of the labour events that occurred in the meantime'.

'It is impossible to juggle the various tasks in the labour room and then fill up the partograph diligently'.

Mothers coming to the hospital at a later stage of labor

One nurse opined, 'In case of late presentation to the hospital, that is during the second stage of labour, attending the patient seemed more necessary than paperwork, hence partograph was not filled in those cases'.

'Partograph has to be started early in labour. When we receive the patient, it is too late to monitor that. We fill out the patient identification just for our satisfaction. It feels pointless, though'.

Inadequate training and lack of proper supervision

'The training we receive regarding partograph during our student life is mostly theoretical and lacks practical touch. We fall short in the proper implementation of our training in day-to-day clinical practice,' commented one nurse. Another nurse added, 'The approach of the immediate seniors is fault finding rather than supportive. Most of the time there is no supervision on the part of the senior sisters'.

Poor documentation by doctors

According to one staff nurse, 'We are not properly informed by the treating resident doctors regarding the information required in filling the partograph. Clinical notes are often incomplete. As we fill up the partograph from the clinical notes, it also remains incomplete'.

Policy level

'Filling (of partograph) has no credit, we get slowed down in paper work and are often scolded for tardiness if we try to adhere to the partographs. This may affect us'.

'Partograph is essential, but not mandatory. But patient care is mandatory. We naturally prioritize that'.

'During shift change, it becomes impossible to keep track of partographs. Make it mandatory, the scenario will change'.

In-depth interviews involving the sisters in charge revealed

Not appreciating the importance of partograph

'The nurses do not want to fill up the partograph, saying it is a waste of time. They always say that they have more important things to do,' said a sister-in-charge.

'During my visit to the labour room, I found an intra-partum mother who was being observed in the labour room for more than 3 h. Today, the labour room was not running so much busy. The findings of the examination of the patients were documented in the case sheet. But, in spite of that, no staff nurse initiated the partograph. I don't want to categorize it as negligence, but none of the staff nurses could explain the cause behind the non-initiation of the partograph', narrated another respondent.

Inadequate knowledge about partograph

'Many staffs did not properly learn how to fill a partograph during their training, and unfortunately we do not get adequate time or opportunity to teach them.

Societal concept of care

'Caregivers or birth companions who accompany the pregnant women often get agitated if any time is spent in paperwork, and not by the patient's side. This happens more in case of complicated cases or those who have travelled far to arrive at this institution'.

'Most people do not appreciate the importance of record keeping, especially for labour monitoring or medico legal purposes', was another sister in charge's comment.

Policy level lacunae

'The sisters work in tandem at all the work stations, so the expertise developed in partograph is often forgotten as they are rotated sometimes in other departments in case of sudden work load'.

From the quoted statements and interpretation of their thematic area, an attempt was made to explore the possible determinants influencing the pattern and completeness of the partograph.

The broad areas identified from the study are shown in [Table 4].
Table 4: Broad areas identified in the focused group discussion and in-depth interview

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  Discussion Top


The present study showed that partograph was initiated in 80 (61.07%) deliveries, and it was complete in only 4 out of 80 cases (5.00%), thereby reflecting the inadequacy of intrapartum and post-partum monitoring. 'Cervical dilation' was the most frequently plotted parameter, whereas 'amniotic fluid condition' was the least plotted parameter. A study from Odisha, India by Palo et al. reported partograph adherence in 48.7% cases which is similar to the present study, but partograph completeness in only 1.03%.[8] They observed that 'maternal pulse rate' was the most frequently plotted parameter and 'maternal temperature' was the least. Another study from Madhya Pradesh, India by Chaturvedi et al. showed only 6% partograph adherence, and the staffs showed a low competence in plotting the partograph.[7] However, a study from Bangladesh found partograph adherence of 98%, which is much higher than the present study.[10] Studies from Ghana (87%) and Uganda (more than 95%) also showed better partograph adherence.[4],[6] A study from Ethiopia showed partograph adherence of 69.9%, which is also higher than the present study.[11] Wrongly plotted partographs without any plotting of cervical dilation was observed in significant number of cases in studies from Odisha and Bangladesh, similar to the present study.[8],[10] However, 'cervical dilation' was consistently plotted in the study from Ghana.[4]

Foetal heart rate was completely plotted in 25.00% of cases, less than studies from Uganda (39.4%) and another study from Ethiopia by Gebrehiwot et al. (93.3%)[6],[12] Amniotic fluid condition was completely recorded in 6.25%, less than the study from Uganda (32%).[6] Recording of maternal pulse, blood pressure and temperature was also done in a small percentage of cases, as in other studies.[6],[13]

The time of ROM was also poorly documented in the present study. The study from Uganda fared better in this regard.[6]

As regards documentation of delivery outcome and condition at birth, both parameters were recorded completely only in 4.69% of cases. There was no mention of Apgar score at birth. A study by Yisma et al. found that the Apgar score was mentioned in 95.9% of cases.[14]

All the above findings suggest poor documentation of most of the parameters, which could hinder the early detection of complications.

The FGD revealed that a shortage of manpower coupled with an excessive workload in the labour room were the major contributors to poor documentation. Lack of awareness, lack of skill and competency, knowledge gaps, lack of commitment, negligence and misunderstanding were the other contributors to routine non-utilisation of partograph. Similar findings were described in previous studies.[6],[8] The discordance between knowledge and awareness, regarding the importance of partograph and the low partograph initiation, among the Staff nurses was attributed to workload, a finding similar to studies done elsewhere.[6],[15],[16] Late presentation to the hospital, which was a tertiary care institution, might also be a contributor in non-initiation of the partograph, as pointed out by the previous studies as well.[6],[8] Lack of supervision and proper guidance on the part of immediate seniors and on duty doctors can result in non-initiation and incompleteness of the partograph, which is evident in the present study. Similar findings were reported by some other studies as well.[17],[18] The FGD also pointed out that a lack of proper knowledge in plotting the partograph could be a reason for incompleteness. IDIs indicated an inability to appreciate the importance of partograph as a probable reason for non-initiation. This is in line with some prior studies.[6],[8],[17] Unlike some other studies, the lack of a partograph was not an issue in the present one.[6],[19] Lack of institutional policy making partograph filling a mandatory activity in the labour room was another issue in our study, which is in line with studies done by Konlan et al. and Regasa et al.[19],[20]

Like any study, the present is not without limitations, the principal being tertiary level teaching institution where cases come from peripheral referral institutes, leading to possible selection bias. Considered the place of study being an esteemed apex institute for obstetrics, the use of a partograph was not made mandatory among residents and staff nurses. In the qualitative component, FGDs and IDIs involved staff nurses and in-charges but not obstetricians or policy decision makers. This might have failed to shed light on the entire picture.


  Conclusion Top


The present study being a retrospective review of deliveries conducted in a tertiary care center in a limited time period, may not reflect the actual scenario. The results of this study may lack generalisability. However, it suggested that partograph initiation and completeness may be poor in this tertiary hospital, and it identified several barriers to the proper implementation of the partographic monitoring of labour. Future research should focus on identifying these barriers on a larger scale and addressing them properly in order to ensure better use of the partograph.

Ethical clearance

Obtained from Institutional Ethics Committee of Medical College, Kolkata. Ref No. MC/KOL/IEC/NON-SPON/1223/11/2021 dated 12/11/2021.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consents for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lavender T, Hart A, Smyth RM. Effect of partogram use on outcomes for women in spontaneous labour at term. Cochrane Database Syst Rev 2013;(7):CD005461.  Back to cited text no. 1
    
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Kwast BE, Lennox C, Farley T, Olayinka I. World Health Organization partograph in management of labour. Lancet 1994;343:1399-404.  Back to cited text no. 2
    
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Government of India. Resource Package for Quality Improvement Cycles in LaQshya. New Delhi, India; November, 2018. Available from: http://www.nhm.gov.in. [Last accessed on 2021 Feb 25].  Back to cited text no. 3
    
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Anokye R, Acheampong E, Anokye J, Budu-Ainooson A, Amekudzie E, Owusu I, et al. Use and completion of partograph during labour is associated with a reduced incidence of birth asphyxia: A retrospective study at a peri-urban setting in Ghana. J Health Popul Nutr 2019;38:12.  Back to cited text no. 4
    
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Sanyal U, Goswami S, Mukhopadhyay P. The role of partograph in the outcome of spontaneous labor. NJOG 2014;9:52-7.  Back to cited text no. 5
    
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Mukisa J, Grant I, Magala J, Ssemata AS, Lumala PZ, Byamugisha J. Level of partograph completion and healthcare workers' perspectives on its use in Mulago National Referral and teaching hospital, Kampala, Uganda. BMC Health Serv Res 2019;19:107.  Back to cited text no. 6
    
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Chaturvedi S, Upadhyay S, De Costa A, Raven J. Implementation of the partograph in India's JSY cash transfer program for facility births: A mixed methods study in Madhya Pradesh province. BMJ Open 2015;5:e006211.  Back to cited text no. 7
    
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Palo SK, Patel K, Singh S, Priyadarshini S, Pati S. Intrapartum monitoring using partograph at secondary level public health facilities – A cross-sectional study in Odisha, India. J Family Med Prim Care 2019;8:2685-90.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Tomasi J, Warren C, Kolodzey L, Pinkney S, Guerguerian AM, Kirsch R, et al. Convergent parallel mixed-methods study to understand information exchange in paediatric critical care and inform the development of safety-enhancing interventions: A protocol study. BMJ Open 2018;8:e023691.  Back to cited text no. 9
    
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Khan AN, Billah SM, Mannan I, Mannan II, Begum T, Khan MA, et al. A cross-sectional study of partograph utilization as a decision making tool for referral of abnormal labour in primary health care facilities of Bangladesh. PLoS One 2018;13:e0203617.  Back to cited text no. 10
    
11.
Markos D, Bogale D. Documentation status of the modified World Health Organization partograph in public health institutions of Bale zone, Ethiopia. Reprod Health 2015;12:81.  Back to cited text no. 11
    
12.
Gebrehiwot SW, Abrha MW, Weldearegay HG. Health care professionals' adherence to partograph use in Ethiopia: Analysis of 2016 national emergency obstetric and newborn care survey. BMC Pregnancy Childbirth 2020;20:647.  Back to cited text no. 12
    
13.
Zelellw D, Tegegne T. The use and perceived barriers of the partograph at public health institutions in East Gojjam Zone, Northwest Ethiopia. Ann Glob Health 2018;84:198-203.  Back to cited text no. 13
    
14.
Yisma E, Dessalegn B, Astatkie A, Fesseha N. Completion of the modified World Health Organization (WHO) partograph during labour in public health institutions of Addis Ababa, Ethiopia. Reprod Health 2013;10:23.  Back to cited text no. 14
    
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Opiah MM, Ofi AB, Essien EJ, Monjok E. Knowledge and utilization of the partograph among midwives in the Niger Delta Region of Nigeria. Afr J Reprod Health 2012;16:125-32.  Back to cited text no. 15
    
16.
Bazirete O, Mbombo N, Adejumo O. Utilisation of the partogram among nurses and midwives in selected health facilities in the Eastern Province of Rwanda. Curationis 2017;40:e1-9.  Back to cited text no. 16
    
17.
Bedada KE, Huluka TK, Bulto GA, Ephrem Yohannes Roga. Low utilization of partograph and its associated factors among obstetric care providers in governmental health facilities at west Shoa Zone, Central Ethiopia. Int J Reprod Med 2020;2020:3738673.  Back to cited text no. 17
    
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Wakgari N, Tessema GA, Amano A. Knowledge of partograph and its associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: A cross sectional study. BMC Res Notes 2015;8:407.  Back to cited text no. 18
    
19.
Konlan KD, Kombat JM, Wuffele MG, Aarah-Bapuah M. Knowledge and attitudes of midwives on the use of the partogram: A study among midwives in the Tamale Metropolis. Matern Health Neonatol Perinatol 2016;2:2.  Back to cited text no. 19
    
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Regasa H, Tilahun T, Adem H. Utilization of partograph and associated factors among obstetric care givers in hospitals of Western Oromia, Ethiopia, 2017. Panacea J Med Sci 2018;8:21-4.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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