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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.36 no.spe Porto Alegre  2015

http://dx.doi.org/10.1590/1983-1447.2015.esp.56769 

Original Articles

“The Unified Health System that works”: actions of humanization of prenatal care

Camila Nunes Barretoa 

Laís Antunes Wilhelmb 

Silvana Cruz da Silvac 

Camila Neumaier Alvesd 

Luiza Cremoneseb 

Lúcia Beatriz Resselb 

a Secretaria Estadual de Saúde do Rio Grande do Sul. 8ª Coordenadoria Regional de Saúde. Cachoeira do Sul, Rio Grande do Sul, Brasil.

b Universidade Federal de Santa Maria. Programa de Pós-graduação em Enfermagem. Santa Maria, Rio Grande do Sul, Brasil.

c Universidade Federal do Rio Grande do Sul. Programa de Pós-graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil.

d Universidade Federal de Pelotas. Programa de Pós-graduação em Enfermagem. Pelotas, Rio Grande do Sul, Brasil.

ABSTRACT

Objective

to know how the approach of public policy humanization prerequisites and health programs proposed by the Ministry of Health occur in the practice of prenatal of care usual risk.

Method

field study, exploratory descriptive qualitative approach. The survey was conducted from February to June 2014, with participant observation and semi-structured interviews in four family health units where five nurses and three doctors attended. Operative Proposal was chosen for data analysis.

Results

the categories revealed in this study that promoted the humanization of prenatal care were: The approach and linking of pregnant woman and their family to family health units and Permanent education as a facilitator for humanization in prenatal care.

Conclusions

it is understood that to approach humanized attention, an enlarged look in face of women’s singularities is required.

Key words: Pre-natal care; Humanization of assistance; Primary Health Care; Millennium Development Goals

INTRODUCTION

Prenatal care is a singular building space, influenced by family and social set of the mother and also by the work of health professionals. These womens references and relationships must be considered, as they directly reflect on adherence to prenatal care, the understanding of the attention and the care provided (1).

Other aspects are also indispensable in the search for qualified and humanized prenatal care as a larger view to the needs of women, providing care according to ethical principles, respect for others, ensuring dignity and autonomy. It also emphasizes the importance of the search for strategies to improve access to health services and reduce users’ waiting time (2).

Such detail in the attention provided to pregnant women is closely linked to the qualification and humanization of care. In this sense, it emphasizes the National Humanization Policy (PNH), which guided this study and seeks to strengthen other Brazilian strategies from the perspective of care humanization. The PNH, discussed since 2003, recognizes advances and reinforces the need to overcome persisting challenges and problems in the health services. Considering primary care as a space of major significance to the recognition of humanization as a policy and its significance to the consolidation of the Unified Health System (SUS), due to the approach with the users, the solidarity exchanges and therapeutic ties in this context that are made possible (3).

In this context, the PNH highlights the importance of strengthening the visibility of the “SUS that works”, this being a political task of the different subjects responsible for health production, i.e. health professionals, managers and users. In addition, it reinforces the vital role of researchers to cooperate in the recognition of the advances that contribute to care qualification (4).

In addition, there is the existence of a gap in attention to pregnancy and childbirth related prenatal consultations in primary care (5). Since they were characterized by a focus on procedures and routines, leaving sharing knowledge and experiences of women in the background, the role of care itself was weakened.

Moreover, when there is talk of humanization, studies generally cover delivery more than the other stages of pregnancy, however, the other stages should not be ignored, since every stage of the gestation process has a unique representation in the life of a woman. Thus, the care of women and their families should be longitudinal, respecting each stage of pregnancy and its significance in their life (5).

By choosing to have a broader look regarding the humanization of prenatal care in primary care, the significant positive impact of quality prenatal care in the rates of maternal and perinatal morbidity and mortality was considered, which declined in Brazil in the past years. But specifically with respect to the fifth Millennium Development Goal (MDG) regarding “improving maternal health”, strongly associated with the quality of prenatal care, weaknesses were still evidenced, which hinder its reach within the time established. This objective covers two overall goals: to reduce maternal mortality by three-quarters from the level observed in 1990, and universalizing access to sexual and reproductive health (6).

The importance of discussing the humanization theme in this unique period of a woman’s life is noteworthy in this context, as qualified prenatal care contributes to the well being of the woman and baby, corroborating with the fifth goal of the MDGs, which seeks to improve maternal health.

On this track of thought, based on the proposals of the Ministry of Health (MOH) focused on women’s health and guided by the HNP the research question of this study is: what are the factors that promote an approach towards humanization prerequisites of public health policies and programs proposed by MS in the practice of usual risk prenatal care?

Thus, the purpose of this paper is to know how the approach towards public policy humanization prerequisites and health programs proposed by the Ministry of Health in the practice of usual risk prenatal care occurs.

METHODOLOGY

This was a field study, exploratory and descriptive, with a qualitative approach. This paper originated from a master’s thesis entitled “Humanization of prenatal care in the practice of health professionals”, the Graduate Program in Nursing at the Federal University of Santa Maria (7).

The primary care (AB) in municipal health where the study was developed consists of 31 units, of which 18 are traditional Primary Health Units (UBS) and 13 are Family Health Units (USF), where three units have a double team, withr 16 teams in total. The scenario that composed this study included four Family Health Units from the primary health network from a municipality in Southern Brazil.

The selection of fields of study was carried out by drawing lots, and implemented by data saturation. As for the organization of these services, three counted with a family health team (single team) and a double team. The double team corresponds to two simple family health teams, sharing the same health facility in order to cover the entire population that makes up the territory.

The prenatal care in the four USF scenarios in this study were organized as follows: in three services the prenatal consultations were centralized in a single day of the week with flexibility of care according to spontaneous demand. In addition, one of the services would make its schedule available, making it possible to schedule any day of the week.

The criteria for participant inclusion accounted for nurses and doctors that developed actions related to prenatal care. The exclusion criteria were nurses and doctors who were removed from service at the time of the survey, or who were newcomers who arrived during the data collection period.

The selection of participants (8) occurred through data saturation and when the researcher realized the objectives proposed by the study were achieved, which justifies the development of research in four health services. Considering these issues, participants responded to five nurses and three doctors.

The data collection phase took place between February and June of 2014. The participant observation techniques and semi-structured interviews were used. The first amounted to 140 hours of observation and the time spent on each service ranged from one to two months.

The researcher explored participant observation in a detailed way that can be translated into three phases. In the first phase, the observation was designed to facilitate alignment with the participants, and bridge the gap between researcher and subject. The second phase required that when observing, the researcher be free of pre-established concepts and seek to understand the researched community as a whole, along with the different factors that understood and influenced the actions and perceptions of the participants in order to know the reality of each service. The third and last phase was characterized by its complexity, and demands the systematization and organization of data, which respected the methodological issues as closely as possible in order to ensure valid and reliable results (9).

In this context, the importance of a recording instrument is highlighted, in this case the field note journal. This allowed the notes of the observations to be taken in real time and also later, with further deepening the observer (9).

Furthermore, the semi-structured interview contributed to the production of data. It was decided the interview would take place at the end of the observations, in a complementary manner. The interviews were scheduled according to the availability of participants. The content of the interviews included: the perception of health professionals about the humanization of prenatal care, knowledge of public health policies and programs aimed at humanizing the strengths and weaknesses in practice to implement humanized care, and recognition strategies that approach humanized care in prenatal care and the daily life of health professionals, complementing observations previously taken.

Data analysis was based on the proposed operative(8), characterized by two operational levels. First, the researchers sought to explore and understand the context of the researched group, called an exploratory operational level. At this stage, the researcher sought to get to know the routine of the shares offered in the USF’s prenatal care and approached health professionals to monitor the approach used with the pregnant woman and their family at the moment of prenatal care. Then, these notes were aligned with empirical facts made possible by the study, described by the author as the point of departure and arrival of any research, being it of a second operational level, called interpretive. The interpretive stage corresponds to two stages simultaneously: data ordering and classification of data, the latter of which includes the horizontal and thorough reading of the texts, the cross reading, the final analysis and drafting of a report with the presentation of the results. When putting the data in order, the researcher transcribed the interviews held with professionals and deepened the discussions carried out in the field diary, making it possible to recognize the actions made in favor of humanization in prenatal care. In the classification of data, humanization approach factors were listed in a detailed manner, which are discussed jointly with the PNH, the guiding policy of this study, and also other health policies and programs aimed at women’s health.

In order to maintain the anonymity of the participants and health services, the identification data occurs through the alphanumeric system. The observations made at each USF were identified by the letter “O” and the services were numbered randomly. And the statements expressed in interviews with health professionals were presented with the letter “E” for nurses and “M” for doctors with numbering also respecting the random criterion.

This study was conducted according to the precepts of Resolution no. 466/12 of the National Health Council, Ministry of Health, which establishes guidelines and regulations governing research involving the participation of human subjects (10). The ethical issues foreseen englobed the participants signing the Free and Informed Consent form and the main researcher signing the term of confidentiality. The research was approved by the Research Ethics Committee of UFSM, according to opinion N. 513,040.

RESULTS AND DISCUSSIONS

The results of this study corroborate with the PNH goals by pointing out initiatives in the organization and provision of health practices, which bring the humanization of praxis closer to prenatal care, strengthening the “SUS that works.” The categories that contributed to the approaching the prerequisites of the national policy were: The approach and linking of pregnant woman and thier family with family health units and Permanent education as a facilitator for humanization in prenatal care.

The approach and linking of pregnant woman and their families to family health units

The PNH highlights the importance of recognizing the context and social demands of users, valuing the subjective dimension and building solidarity bonds. in the following passages, the approach of pregnant woman and their families to the health teams can be noticed:

I believe I can maintain a link with the pregnant woman who approaches the humanization proposal. The question of observing her needs, the demands that they believe are important and demands that I highlight as a professional. Having a look that is more focused on the family, asking how the family is doing, the children [...]. (E3).

During the medical consultation, the mother questioned the professional regarding delivery options. The doctor explained the pregnant woman’s doubts and encouraged them to talk to their families, especially the mother figure to know how this experience was, the type of delivery experienced and the feelings experienced. (02).

The recognition of pregnancy as a singular, family event, surrounded by social influences and feelings is one of the initial foundations for achieving comprehensive care. Still, the respect for beliefs and peculiarities of pregnant women strengthen the link between health care providers and users, allowing the real demands in prenatal care to be met.

The warm and respectful care provided to pregnant women, reflected positively on adherence to prenatal care. Empathy with the health team, the bond with the professionals, the appreciation of the pregnant woman’s culture, recognition of the social context, especially the family and the provision of services according to the demands of pregnant women assist the active participation of woman in the care provided (11).

Another aspect unveiled in the study concerns the joint actions in the care of pregnant women with community health workers. Due to greater proximity between the pregnant women and their family, because they belong to the community, the positive influence of this professional in the performance of this prenatal care coverage was noticed, as can be seen below:

The nurse reported that the increased coverage of prenatal actions also reflects training held for and with community health workers (CHW) at the end of 2013. This strategy aimed to orchestrate these professionals to perform adequate active searches and recognize priorities when it comes to the treatment of women. Autonomy and knowledge of the guidelines provided to pregnant women by ACS were observed in this Family Health Unit (USF). (02).

The ACS can be considered the first contact approximation with health services because it is inserted in the community, . The professional development of community health agents, as observed in this study, significantly contributed to the increased coverage of prenatal actions. Furthermore, it strengthened co-responsibility of the various professionals working in the USF, and teamwork, as recommended by the PNH.

In a study conducted in Maranhão, there is evidence of an expansion of access to prenatal consultations in recent years. It is suggested that this change is associated with the reorganization that the USF proposes with reference teams, which promote actions that articulate the participation of nurses and community health workers (12).

Encouragement of the companion’s participation in prenatal and pregnancy care was evidenced by health professionals as promoters of a humanized care. The importance of considering the family in this care context can be seen:

In nursing consultation, the nurse asked about the involvement of the baby’s father in care during pregnancy. Pregnant women reported good acceptance, partnership and concern in nursing. The nurse encouraged the participation of the father in prenatal care, if it is the desire of the mother. (03).

I believe that the care I provide to pregnant women is good, because the mother has enough space to talk, ask questions of her own, and I always encourage the partner to come to us so we can debate the care together. (M2).

The encouragement given for the partner to participate in prenatal care was understood by professionals as a fundamental approach to humanized care. The space made available to the couple in prenatal care made it possible for the family to take on active participation and co-responsibility for the care. In this context, the subjective dimension and the social relations of pregnant woman are valued, following the recommendations of the HNP.

The direct or indirect insertion of the partner in prenatal care positively contributes to the continuity of care. Since it is a cultural element with a strong significance, it influences the understanding of prenatal and early and ongoing adherence to service. It is the responsibility of health professionals to reference the father figure, consider their opinions and desires, since the partner’s participation is valued by pregnant women (1).

The bond between the mother and the nurse was observed in this study as a promoter of more humanized care. Maintaining supportive links between users and health professionals denoted feelings of security on the part of pregnant women. As was realized in the following excerpts:

There was intense closeness and affinity of pregnant women with the nurse. The professional recognizes the community, having good interaction and a peaceful way of talking with the user. The pregnant woman felt the urge to share her routine, questioning when necessary and expressing confidence in the work of the nurse. (04).

Many prefer to have their prenatal appointments with me (nurse) and not with the doctor, I believe that it may sometimes be due to the qualified listener and the bond created You know, pregnant women arrive here at the USF at any time of day, and you are available and willing to talk to them, and it ends up creating bond. I also believe it is very particular to nurses and their training, to have a more welcoming side when compared to other professionals. (E2).

The recognition of the subjective and social dimension of users by nurses strengthened the ties between them. By establishing and keeping this bond, a space for spontaneous, active participation of woman was made possible, making this professional a reference to the pregnant woman when returning for health care.

Also, practitioners justified this approach because of the time spent at the USF and for the more direct contact with pregnant women, regardless of pre-determined appointed. Still, the highlighted characteristics in the education of the nurse that corroborate with the foundations of humanization, such as the welcoming of the user and the creation of links.

The nurse’s role as an active element in the health team increasingly widens in primary care. At first, the presence of nurses can generate feelings of mistrust and insecurity in women, which is the result of a cultural construction focused only on doctor-centered care. But, it turns out that these concepts undergo changes, as pregnant women are attended by nurses end up developing a relationship of trust and safety due to the special, welcoming attention based on scientific knowledge (13).

As for the undergraduate nursing diploma, you can see a strong didactic and pedagogical current that has contributed in overcoming the biologicist model. However, changes are needed in the educational process of all professions, breaking with the dichotomy between teaching and practice, bringing social health policies and programs of the reality of services together. It is understood that the training should include proactive learning, recognition of the other and active listening when providing care for pregnant women (14).

The ease of access to laboratory and preventive tests collaborated towards the action solvability in prenatal care and also in the approach and pregnant connection with health care, with emphasis on observed services. As is displayed in the following excerpts:

Laboratory tests were collected on a specific day of the week in their own USF, and on average over the period of one week the results returned to the units for evaluation by health professionals. Also, in the services where there was internet, access occurred online once results were made available by the laboratories. Even in cases of utmost urgency, it was requested that the pregnant women collect directly in laboratories accredited by the municipality and as soon as the results were available, take them to the USF. (O1, 02, 03, 04).

there was good organization USF and they performed Pap smears.. All pregnant women that received prenatal care underwent the test. In unity, there was a book to monitor the exams that were collected, the results and the women’s phone to contact them when needed. The nurse reported that all test results were assessed when they reached the lab, when any abnormalities were found, they contacted the mother so she could begin treatment immediately, as needed. (03).

Easy access to laboratory and preventive exams directly influenced the quality of care. The return was considered in a timely manner, facilitated the care and monitoring of pregnant women and the computerized communication optimized the service. The clinical exams at USF and the return of results from the service itself prevent the mother from seeking different health facilities. In addition, maintaining the link with the unit strengthened the family health team as a reference for pregnant women throughout the prenatal care.

In the study, it was noted that coverage of cervical cancer screening in prenatal care was significant, all exams recommended by the MS are offered and periodic examinations are updated if not carried out by the women in the period. In addition, the professionals evaluated the results and organized a network of contacts for early accession to the defendants care, ensuring the immediate start of treatment when any alterations are confirmed.

In a study conducted in southern Brazil, the largest number of laboratory tests was pointed out as being in the group of women who joined prenatal care in the first trimester. It was revealed that 52% of pregnant women began care in the first quarter, 84.2% underwent the exams recommended by MS. The relevance of strategies for early identification of pregnant women is reinforced, because the period of initiation interferes with coverage of actions (15).

Permanent education as the facilitator of prenatal humanization

In this category, different strategies are presented, fueled by the continuing education that facilitated the promotion of humane attention to the woman. In this context, the work of the Integrated Multidisciplinary Residency urged professionals to rethink their practice. Of the observed services, three are study fields of multi-professional residencies, positively emphasized by health professionals to contribute to the renewal of health practices.

One good thing is that the multi-residence. Brings new things, it renews the service [...]. (E1).

In the ESF, which are study fields for multi-professional residencies (nurse, speech therapist, psychologist, nutritionist, physiotherapist, veterinarian, physical educator, social worker), greater ease in carrying out actions aimed at prenatal care it was observed. Mainly the implementation of educational activities and active participation of users that are driven by the residence. (01,03,04).

The Integrated Multidisciplinary Residency programs inserted in primary healthcare, and to the formation of a professional who is more prepared to meet the demands of care and SUS management, impact the health of hired/state employed workers service. Participation in the residency was considered renewing and encouraged practitioners to rethink their health practices.

In addition, it enabled the work of professionals from different fields, supporting the family health team in their multidimensional attention to pregnant women. Something else observed regards health education practices being leveraged by the residency with actions that promote the role of pregnant women and strengthen their autonomy.

Undoubtedly, the multi-professional residency is a strong SUS strategy, aimed at critical training emphasized in PNH by encouraging lifelong learning. Multi-professional residency presents, through direct contact learning with the reality of health services, educational and political potential to transform the health care model and to pregnant women care practices (16).

Adherence to the Ministry of Health’s manual has been recognized by health professionals as essential in carrying out a treatment based on the principles of humanization, as was noticed below:

Busco perform the physical examination, the clinic itself, the order of exams, what is proposed in the Ministry of Health protocols. (E4).

I have access to the manuals of the Ministry of Health. [...] They are always there, any questions I have, they are here by my side so I take them, read, study. I’m always reviewing every situation that appears. (E5).

Behaviours in the care of pregnant women during prenatal care are grounded on the recommendations of the Ministry of Health (MH). In this study, it was found that professionals, especially nurses, attempted to base their practice on scientific evidence available in MS publications. Access to these contents contributed to the resolution and effectiveness of care, without disregarding the demands and peculiarities of the pregnant woman and are similar to the PNH prerequisites.

In research conducted in the same county of this study, it was revealed that most of the approaches recommended by MS in prenatal care were performed more frequently in family health services, compared to the traditional basic units (17). Another study pointed out the performance of procedures already established in the independent prenatal care model, such as verification measures and test ordering (18).

Within the scope of USFs, this study showed more attendance in regards to educational and preventive actions, the use of ferrous sulfate, the performance of vaccines, conducting preventive examinations of cervical and breast cancer and encouragement of healthy practices during pregnancy. These actions are highlighted in health textbooks and notebooks as essential in prenatal care.

The reflection of the professional improvement in the quality of care provided to pregnant women corroborates one of the axes prioritized by the PNH, which emphasizes the importance of continuing education in the reformulation of health practices. The contribution of the educational process and the qualification of the service was noted in the following excerpts:

[...] Carrying out this specialization in family health through the university was essential to improving the quality of the work process and prenatal care. This graduate program was really a lifelong learning, because I had more access and contact with scientific literature related to prenatal care. So this changed my daily life routine, improved prenatal care, notes about the developments and widened my eyes to other demands. (E2).

Because I was part of the first class of the residency, we worked a lot on these aspects related to humanization, welcoming and health networks. Especially in relation to the care and health networks, seeking to strengthen the services. (E2).

The continuity in the educational process carried out by professionals strengthened the renewal of practices and approaches in health. Lifelong learning encouraged workers to reflect on their work process and base themselves on scientific evidence to develop actions in prenatal care. In addition, the prominence in post-graduate courses in family health and multidisciplinary residences in the inclusion of issues such as the humanization, welcoming and health care networks, which encourage the shift from watching model.

It is understood that SUS and its policies, such as the PNH, run through a continuous social construction process. In this sense, lifelong learning has proved with one of the main strategies to guarantee humanized care. The teaching and practice can not be dissociated. It is necessary to rescue reflective practice and actively engage professionals at this stage so that they can, through their actions and studies, promote changes in the guided work process in the humanization of care (19 ).

Promotion strategies and health education enriched in the sphere of basic care excelled in ensuring the role and autonomy of pregnant women, as recommended by the PNH

The group of pregnant women conducted at USF, monthly, started from the beginning of a family by the nurse health specialization. The professional reported that the approach of the scientific literature and thinking outside the course of the intervention plan instigated the importance of actions aimed at promoting health, making this initiative a permanent action in the service. The nurse stressed the importance of the group of pregnant women for their early identification, creating bonds with the service and the opportunity to give voice to pregnant women. (02).

The groups are part of the ESF policy, holding groups, educational activities, this is important, without educating the family health unit is a “Postinho” [...] Do they always say that more medical care, more tests, and education is needed? We are the preventive service, so it is no use for us to get here and just get consulted, listen to the heartbeat and the see the pregnant woman leave. I believe this has to have a continuing education. (E5).

Educational actions were understood by professionals as essential to approach humanization. Participation in specialized courses reflected in greater access to scientific literature, contributing to the demystification of the clinical evaluation as a priority in prenatal care. It was understood that spaces like the group of pregnant women, made the expression of women’s experiences, active participation, and bonds between user and professionals possible, besides bringing awareness about the importance of prenatal and early onset of such care.

The reorganization proposed by the family health teams in SUS’ care and management model was referenced in the reports, which emphasizes the need to transcend the vision of the USF as a “Postinho”. Primary care must strengthen its role as a gateway, ensure access and continuity in prenatal care, especially to be mediators of women’s empowerment, enabling them to be protagonists of their own history.

Despite the recognition of the importance of educational activities are perceived weaknesses in this context, because according to a recent study carried out in this municipality, in family health teams and traditional basic units, it stands out that less than 20% of pregnant women followed at some Upon prenatal participated in group of pregnant women or guidelines in the waiting room (17).

This confirms that one of the main strategies to avoid the medicalization in the puerperal pregnancy period, refers to actions aimed at promotion and health education, based on practices involving minimal interventions. In this line of thought, a space for sharing experiences and that promotes the active participation of women, additionally empowering woman, making that woman a multiplier of knowledge. It is believed that by prioritizing these actions, the gap between pregnant women and health services decreases and reflects positively on the quality of prenatal and consequently in maternal and child morbidity and mortality indicators (20).

CONCLUSIONS

The approach to humanizing in prenatal care involves a personal and professional commitment from health workers, since the challenge to overcome every day difficulties and seek comprehensive humanized care for pregnant women. The first step in humanizing care during the prenatal period includes the recognition of the other, that is, to recognize the mother as a subject of rights, marked by a history of work and family life, this culture being what will guide her in adherence to care.

The co-responsibility of different professionals that make up the family health team denotes the essentiality of working together. In this context, community health workers stood out, which duly qualified, contributed positively in the coverage of actions in the puerperal pregnancy period.

It is understood that the change in the model of care and SUS management is long-term, based on discussions and reflections, curriculum reforms and for a continuing process of education. This study reaffirmed the importance of primary care in this process, already glimpsing good results in health care of women.

The relevance of a qualified prenatal care still stands out to guarantee improved maternal health, one of the MDG targets. The actions presented contribute to the humanization approach to, demonstrate the importance of promotion and health education practice for the empowerment of women and the effectiveness of prenatal care.

It is understood that this study has limitations related to a qualitative research, as the number of participants and generalization of the results. However, its contribution to the deepening of the theme is understood.

It is hoped that the actions highlighted contribute in the health professional practices and encourage a reflective process in face of humanized care in prenatal care, seeking to meet the real demands of women. Furthermore, discussions that may expand the practices that enable the realization of the “SUS that works” is expected.

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Received: June 29, 2015; Accepted: November 03, 2015

Author’s address: Camila Nunes Barreto. Rua Aníbal Loureiro, 370, Santo Antônio. 96506-770 Cachoeira do Sul – RS. E-mail: camilabarreto_6@msn.com

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