The Ongoing U.S. Struggle with Maternal Mortality

Abstract

Despite significant efforts over the past two decades, the maternal mortality rate (MMR) in the United States remains at least double that of most other high-income countries (HICs). In addition, substantial racial disparities exist with MMRs among Black and American Indian/Alaska Native women two to three times higher than White, Hispanic, and Asian/Pacific Islander counterparts. Of the three surveillance systems currently in place, Maternal Mortality Review Committees (MMRCs) are widely considered to provide the highest quality data. MMRCs in combination with Perinatal Quality Collaboratives and other successful initiatives provide the best hope of reversing these concerning trends. The state of maternal health in the United States is at a critical juncture. To reach the ultimate goal of rendering the United States as one of the “safest countries in the world to give birth” will require greater coordination and consolidation of national efforts across the entire prenatal, perinatal, and postpartum continuum. The authors make suggestions to create a robust federal infrastructure to finally provide equitable high-quality maternal care and bring U.S. maternal mortality into alignment with other HICs.

Key Points

• U.S. MMRs are double that of other HICs.

• Black MMRs are two to three times higher than White MMRs.

• “Maternity care deserts” show a marked increase in maternal mortality.

• Listed strategies have shown success in reversing these trends.

 

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Keywords

maternal mortality - maternal morbidity - health equity - international comparators

On December 7, 2021, history was made when The White House hosted the first-ever Maternal Health Day of Action.[1] On that occasion, Vice President Harris made note of the poor international standing of the United States wherein more women die “before, during and after childbirth…than any other developed nation in our world.”[1] Vice President Harris went on to note the attendant racial, ethnic, and rural disparities in the national prevalence of maternal mortality,[1] defined as maternal death during pregnancy or within 1 year after birth. This latter forum was followed on June 24, 2022, by the release of the White House Blueprint Addressing the Maternal Health Crisis which outlines a sustained multiyear, multiagency effort to combat maternal mortality and morbidity and racial, ethnic, and rural disparities thereof.[2]

Despite significant efforts at reducing the incidence of maternal mortality in the United States over the past two decades, the OECD Health Statistics 2022 report reveals that the maternal mortality rate (MMR) in the United States is at least double that of most other high-income countries (HICs).[3] Furthermore, clear and dramatic racial disparities continue to plague the prevalence of maternal mortality in the United States. Indeed, MMRs among Black and American Indian/Alaska Native women are two to three times higher than those encountered in White, Hispanic, and Asian/Pacific Islander counterparts.[4] These realities are especially perplexing given that the United States leads the way in health care spending by a significant margin when compared with other HICs.[5] This Commentary seeks to examine the troubling state of maternal mortality in the United States, explore the promise of state-based Maternal Mortality Review Committees (MMRCs) and Perinatal Quality Collaboratives (PQCs), and identify potential federal remedies to this intractable national challenge.

The U.S. Maternal Mortality Rate

The MMR is defined as the death of a woman while pregnant or within 42 days of being pregnant, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management per 100,000 deliveries.

In 2022, the last year for which international comparisons were available, the U.S. MMR stood at 22.3 deaths per 100,000 live births, that is, almost 2- to 20-fold higher than that reported for 13 other HICs ([Fig. 1]).[3]

Fig. 1 Maternal mortality rates for the United States and other high-income countries as well as racial–ethnic breakdowns in the United States (adapted from The Commonwealth Fund).[3] Data for all countries, except the United States, from OECD Health Statistics 2023. Showing data from 2015 for FRA; 2017 for UK; 2018 for NZ; 2020 for CAN and SWIZ; 2021 for AUS, GER, JPN, KOR, NETH, and SWE; 2022 for CHL (provisional) and NOR. Data for the United States from Hoyert.[9] US, United States.

Furthermore, between 2000 and 2020, an interval during which the World Health Organization (WHO) reported a significant decrease followed by a flattening of worldwide MMRs, the U.S. MMR increased by as much as 27%.[6] [7]

After a 40% increase in 2021 U.S. MMR to 32.9 deaths per 100,000 live births, the rate improved to 22.3 deaths per 100,000 live births in 2022.[8] [9] These changes were felt to be related to the coronavirus disease 2019 (COVID-19) Delta variant surge in the fall and winter months of 2021 with subsequent improvement in 2022.[10] Additional maternal mortality increments are expected in the wake of the Supreme Court decision in Dobbs v. Jackson Women's Health Organization.[11] Indeed, safe access to abortion has previously been shown to reduce maternal mortality by as much as 13%.[12]

Pregnancy-related death, in contrast, refers to the death of a woman while pregnant or within 1 year of the end of a pregnancy regardless of the outcome, duration, or site of the pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Data reported by the Centers for Disease Control and Prevention (CDC) stratify pregnancy-related deaths temporally: pregnancy, the day of delivery, within 42 days of delivery, or between 43 days and 1 year of delivery ([Fig. 2]). It is estimated that 60 to 80% of all pregnancy-related deaths in the United States are preventable to at least some degree, regardless of when they occur.[13] [14] Most recent data show improvement in maternal death proximate to delivery with only 25% of maternal mortality occurring during the day of delivery and the next 6 days which contrasts with 53% mortality between day 7 and 1 year postpartum.[14] The improvement in maternal deaths in this period is likely the result of quality improvement efforts focused on delivery hospitalization and reinforces the importance of similar efforts throughout the pregnancy and postpartum continuum.

Fig. 2 Breakdown of pregnancy-related deaths by time with the listing of the principal cause(s) of death.[14]

In considering the backdrop of maternal mortality, a substantial rate of severe maternal morbidity (SMM) is inevitably present. As defined by the CDC, SMM (expressed per 10,000 delivery hospitalizations) includes “unexpected outcomes of labor and delivery that give rise to significant short- or long-term consequences to a woman's health.”[15] It is estimated that 50 to 100 women experience SMM for each maternal death in the United States.[16] After excluding blood transfusions as a cause of morbidity, the U.S. SMM rate is deemed to have increased by 15% between 2012 (69.5) and 2019 (79.7).[17] The U.S. SMM rate is in effect as high as 259 per 10,000 delivery hospitalizations were one to include prenatal and postpartum admissions for ≤42 days.[18]

 

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U.S. Maternal Mortality Metrics: The Data Tracking Systems

Two CDC-based and one state-based surveillance systems are presently deployed to monitor the U.S. MMR: the National Vital Statistics System (NVSS), the Pregnancy Mortality Surveillance System (PMSS), and the MMRCs. The NVSS, a component of the Division of Vital Statistics of the National Center for Health Statistics (NCHS) derives the U.S. MMR from death certificates issued by local clinicians, recorded by jurisdictional registrars, and provided rapidly to NCHS by state agencies. The WHO utilizes the NVSS data to generate international comparisons of national mortality rates.

Although all three surveillance systems have presented challenges, the NVSS has proven to be the most controversial. Central to the debate has been the introduction and gradual implementation of the Pregnancy Checkbox. Initially added to death certificates in 2003 in an effort to improve ascertainment, the methodology has proven to misclassify some maternal deaths. These findings have led to recent publications categorizing the increase in MMRs over the past two decades as an “artifact.”[19] [20] These difficulties in accurate ascertainment are not unique to the United States and regardless of these uncertainties several facts are beyond dispute: the checkbox was added as earlier studies showed 30% of maternal deaths were missed,[21] the United States has significantly higher MMRs than most other HICs and maternal mortality among Black and American Indian/Alaska Native women are two to three times higher than the White counterparts.

In contrast to the NVSS, the PMSS utilizes medically trained epidemiologists to “review and analyze death records, linked birth records and fetal death records, if applicable” with an eye toward calculating the pregnancy-related mortality rate.[22]

Unlike the CDC-based NVSS or PMSS, the MMRCs constitute state-based entities. Widely regarded as providing the highest quality data on maternal mortality, MMRCs currently exist within 49 states at different stages of development.[23] The funding required to expand the MMRC construct to all 50 states, tribes, and territories, was recently afforded by the Consolidated Appropriations Act, 2023.[24] Uniquely positioned to access a broad array of primary data sources, the MMRCs are informed by medical records, autopsy reports, police reports, social media, and, in some states, family interviews. The MMRC reviews so generated are aggregated via the CDC Maternal Mortality Review Information Application (MMRIA), a web-based standardized data abstraction tool.[25] To date, data reporting inconsistencies have been identified between the 49 MMRCs but there are ongoing efforts to refine MMRIA and develop other methodologies to better standardize data reporting and sharing. The efforts of MMRCs are further supported by the American College of Obstetricians and Gynecologists (ACOG) and the CDC via the “Review to Action” resource.[26]

Although unaccounted for in the U.S. MMR, perinatal deaths due to homicide and suicide are carefully reviewed by many MMRCs as they constitute the leading causes of pregnancy-associated deaths.[27] This category references a maternal death within 1 year of pregnancy, regardless of cause. These deaths include pregnancy-related and pregnancy-associated but not related deaths. Violent deaths during pregnancy or within 1 year of childbirth are reported via the National Violent Death Reporting System which is deemed paramount to identify women at-risk for whom appropriate screening and intervention could potentially preclude a fatal outcome.[27] [28] Data from these MMRCs have demonstrated that perinatal and postpartum homicide is a more common cause of maternal mortality than the three leading obstetrical causes of maternal death.[29]

 

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The U.S. Maternal Mortality Rate: Racial, Ethnic, and Geographic Disparities

Racial and ethnic disparities in maternal morbidity and mortality (MMM) have long been recognized. These inequities have been further highlighted academically by high-quality data suggesting three-fold higher rates among Black and Native American/Alaska Native populations and societally by the recent pregnancy-related death of Olympic medalist, Torie Bowie, and by cases of SMM among several other high-profile Black female athletes.[30] The CDC identifies multiple contributors to these disparities which include structural racism, implicit bias, variation in the quality of health care, and underlying chronic conditions.[31] Social determinants of health (SDOHs) also contribute to a lower likelihood of being insured or of receiving timely prenatal care.[32] [33] [34]

Geographic disparities are also associated with inequities in MMM in the United States. Women living in rural areas, unlike their urban counterparts, display higher rates of SMM and mortality, likely due to reduced access to prenatal care.[35] [36] “Maternity care deserts”—the present-day reality of over 1,000 counties in the United States—are defined as areas in which there are no obstetrical hospital facilities nor obstetrician–gynecologists or certified nurse midwife providers. These service-poor counties display a markedly increased risk of maternal mortality. For example, the risk of maternal mortality in the state of Louisiana was found to be ≥3.3-fold higher among women residing in a “maternity care desert” as compared with women living in areas with access to obstetric care.[37]

 

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Strategies for Reducing the U.S. Maternal Mortality Rate

National strategies intent on reducing the U.S. MMR are carefully enumerated in the White House Blueprint for Addressing the Maternal Health Crisis from June 24, 2022.[2] Comparable national strategies were previously delineated in December 2020 in the “Action Plan to Improve Maternal Health in America,” which was issued by the U.S. Department of Health and Human Services (HHS). Both documents lay out comprehensive plans intent on transforming the United States into one of the “safest countries in the world to give birth.”[4]

The “White House Blueprint” offers five goals replete with goal-specific action items. The goals in question propose to (1) increase access to and coverage of comprehensive high-quality maternal health services, (2) ensure that those giving birth are heard and are decision-makers in accountable systems of care, (3) advance data collection, standardization, harmonization, transparency, and research, (4) expand and diversify the perinatal workforce, and (5) strengthen economic and social supports for people before, during and after pregnancy.[2]

Achieving the hoped-for maternal health targets will require that any and all of the planned initiatives focus not only on medical systems but also on social justice, that is, on reversing the role of identified SDOHs and implicit bias in health care systems. Such efforts would do well to include a dedicated consensus safety bundle from the Partnership for Maternal Safety which targets those factors that are modifiable by clinicians and institutions (e.g., professional training regarding biases affecting maternal care for racial and ethnic minority groups).[38]

Many of the aforementioned proposals, and most of the key elements of the 12-point Black Maternal Health Momnibus Act were incorporated into the Build Back Better Act but neither of these have been enacted.[39] [40] Viewed in perspective, the Build Back Better Act was to make the largest investments in American history toward the saving of maternal lives, ending racial and ethnic maternal health disparities, and advancing birth equity across the United States. To date, however, only one “Momnibus” provision, that is, improving pregnancy and postpartum support for veterans in the Protecting Moms Who Served Act of 2021, has been enacted into federal law.[41] Concurrently, California and Delaware, for their part, enacted state versions of the “Momnibus” template.[42] [43] Until such time that all of the “Momnibus” provisions have been implemented, the national policy focus should be on bolstering existing programs that have proven effective in reducing maternal mortality overall as well as disparities in MMRs. Resources along these lines include state or multistate PQCs (networks of teams working to improve the quality of care for mothers and babies), the Alliance for Innovation in Maternal Health (AIM; a national data-driven maternal safety and quality improvement initiative based on interdisciplinary consensus-based practices to improving maternal safety and outcomes), Medicaid postpartum coverage extension efforts, increasing access to midwifery services, and leveraging technology-based innovation.

 

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Perinatal Quality Collaboratives

Statewide or regional PQCs represent a critical adjunct to MMRCs because they develop and operationalize solutions intent on addressing conditions and system vulnerabilities identified by MMRC case reviews. At the time of this writing, all 50 states and the District of Columbia are home to PQCs.[44] The funds required to establish PQCs in the last few states and territories were recently afforded by the Consolidated Appropriations Act, 2023.[24] The California Maternal Quality Care Collaborative (CMQCC) is widely deemed to constitute the prototype for the PQC concept in that it oversaw a 55% decrease in statewide maternal mortality at a time when the United States experienced a 65% increase in the national MMR.[45] [46] One key to the success of CMQCC is the development and implementation of toolkits intent on addressing the sources of MMM (e.g., hemorrhage, hypertensive disorders of pregnancy, and cardiovascular disease). Another driver of success of the CMQCC is the Maternal Data Center which links birth certificates with hospital discharge data with an eye toward providing accurate and timely performance analysis. The analytic infrastructure also supports high-quality clinical research that aims to improve maternal care. The success of the CMQCC is also attributable, in part, to its engagement with partner organizations, public health agencies, the state Medicaid program (Medi-Cal), health plans, community groups, and public interest organizations. Historically, PQCs have focused on hospital care and now need to extend their activities to prenatal, postpartum, and interconceptual periods.

 

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The Alliance for Innovation in Maternal Health

The AIM, a multiorganizational ACOG-based national program that is supported by the Health Resources and Services Administration (HRSA), has made significant contributions to the improvement of maternal care in the United States. The efforts of AIM to develop evidence-based bundles recognize that resources differ between institutions. It is, therefore, the policy of AIM to encourage the standardization of care with algorithms that are compatible with resources and capabilities. Thus far, AIM has been adopted by 48 states and the District of Columbia. Plans call for expansion of AIM to all 50 states, U.S. Territories, and the Indian Health Service. Notably, the AIM bundles for hemorrhage and hypertension now form the basis of related perinatal core measures recently implemented by The Joint Commission. It is the PQCs that provide the quality infrastructure that supports the dissemination and implementation of AIM bundles.[47]

 

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Extending Postpartum Coverage by Medicaid

At present, Medicaid provides coverage to 43% of U.S. women who receive obstetrical care.[48] Though the 2020 HHS Action Plan suggests that the high proportion of insured perinatal patients provides Medicaid programs with an opportunity to drive change, this potential is undermined by the fact that each state largely controls its own Medicaid program and that pregnancy-related Medicaid insurance expires within 60 days in many of the states.[48] [49] The loss of health insurance within 6 months disproportionately affects minority women. Approximately two-thirds of the births of Black, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander women are covered by Medicaid ([Fig. 3]).[50] Lapses in insurance coverage place women with preexisting or other pregnancy-related conditions at risk of poor outcomes, including maternal mortality.[48] [51] ACOG has recommended the expansion of Medicaid coverage to 12 months and the replacement of the traditional single-visit approach to postpartum care with a model that includes a patient-specific process that transitions women with chronic medical conditions and postpartum depression to a primary care provider and/or appropriate specialists.[32] [52] The state of California has recently taken that step with a Medicaid-led redesign of postpartum care.

Fig. 3 Share of births by payer and maternal race/ethnicity, 2018 (reproduced with permission from KFF).[50] Centers for Disease Control and Prevention, National Center for Health Statistics, Natality Records, 2018. WONDER Online Database. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis, other groups are non-Hispanic. Medicaid includes Medicaid or comparable state programs; others include Indian Health Service, CHAMPUS/TRICARE, and other government programs. AIAN, American Indians and Alaska Natives; NHOPI, Native Hawaiians and Other Pacific Islanders.

The extension of Medicaid coverage for at least 1 year after delivery will help reduce what has been described as the “postpartum cliff,” that is, the discontinuation of federally subsidized health insurance 60 days after delivery.[53] On April 1, 2022, the State Plan Amendment provision of the American Rescue Plan Act of 2021 offered states the option to extend Medicaid coverage to 1 year postpartum.[54] To date, 46 states, including the District of Columbia, have implemented the postpartum extension of Medicaid coverage to 12 months.[55] [56] [57] Under the Consolidated Appropriations Act of 2023, the 12-month postpartum extension has been rendered permanent as of January 2024.[24] Given that 53% of maternal deaths occur between 7 and 365 days postpartum ([Fig. 2]), extending the postpartum coverage by Medicaid to a year is crucial. Encouraging all of the remaining states to follow suit is a principal goal of the White House Blueprint.[2] [14] These changes should provide the framework for further research to improve postpartum visit attendance and guide improved health outcomes.[57]

 

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Risk-Appropriate Care

The CDC Levels of Care Assessment Tool (LOCATe^SM) was developed with the intent of providing pregnant women and infants with risk-appropriate care at the state and regional levels. The essence of these efforts is to ensure that pregnant women and infants at high risk of complications receive care at a birth facility best suited to meet their needs.[58] The web-based LOCATe tool has been developed using the most recent guidelines and policy statements of ACOG, the Society for Maternal–Fetal Medicine, and the American Academy of Pediatrics.[59] [60] A verification pilot was conducted by national stakeholders to facilitate the effective use of this tool.[61]

 

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Expanding Access to Midwives in Appropriate Maternal Levels of Care

A 2020 report by the Commonwealth Fund identified a shortage of maternity providers in the United States.[62] Whereas most other high-income nations report 25 to 78 providers per 1,000 births, the U.S. rate stands at 15 providers per 1,000 births. The composition of the workforce is also skewed in the sense that obstetrician–gynecologists constitute 73% of maternity care providers at a point in time when midwives constitute 52 to 91% of birthing providers in comparable nations. Low-risk births attended by midwives have been associated with lower rates of cesarean delivery (and potentially lower maternal morbidity) and higher rates of vaginal birth after cesarean and breastfeeding than those attended by obstetrician–gynecologists.[63] Increased patient satisfaction and decreased cost of care constitute additional benefits of the integration of midwifery care.[63]

Efforts to develop a more robust and diverse midwifery presence in the United States are urgently needed. The ACOG Levels of Care Guidelines make it possible for low-risk women to be cared for by midwives while high-risk counterparts are to be triaged to the appropriate level of care per a standardized approach.[59] The assignment of midwives as birth providers for low-risk women could render rural facilities “OB Ready” and thereby reduce inequities in Maternity Care Deserts as suggested by a 2022 General Accounting Office report.[64] Obstacles to operationalizing such a plan include a lack of comprehensive insurance coverage for midwifery services, restrictive state and federal regulations that limit midwifery practice, and an absence of public subsidies for midwifery education.[63]

 

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Leveraging Technology to Increase Access to Perinatal Care

The momentum toward telehealth required by the COVID-19 pandemic should be maintained. Over the last few years, several studies have reported on the benefits of integrating advanced technology into prenatal care, although significant barriers must be overcome to implement this integration on a population level.[65] [66] [67] Remote patient monitoring with the ability to measure and transmit biometric data, assess mental health, and enable patient-to-care coordinator bidirectional messaging, were shown to improve access to care for underserved patients in both rural and urban settings.[65] [67] [68] With the enactment of the Data Mapping to Save Moms' Lives Act [Public Law No: 117–247], telehealth availability should improve in that the legislation directs the Federal Communications Commission to include data on maternal mortality and SMM in its broadband health mapping tool.[69]

 

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Research

In the fiscal year 2020, the National Institutes of Health (NIH) invested over $200 million in support of MMM research. The National Institute of Minority Health and Health Disparities (NIMHD), as part of the NIH, maintains its own research framework. The NIMHD focuses on both the biological and social determinants of health in advancing its mission to promote health equity.[70] This latter research emphasis most definitely needs to be sustained. Apart and distinct from the aforementioned research efforts, HHS has awarded $65 million to 35 HRSA-funded health centers to “implement innovative approaches to improve maternal health outcomes and reduce disparities for patients at highest risk.”[71] In addition, National Institute of Child Health and Human Development (NICHD) has announced further funding for 10 Maternal Health Centers of Excellence to serve as research centers that will develop and evaluate innovative approaches to reduce pregnancy-related complications and deaths and promote maternal health equity.[72]

 

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Next Steps

The goal of Healthy People 2030 is to reduce the U.S. MMR from 17.4 per 100,000 live births (as recorded in 2018) to 15.7 per 100,000 live births in 2030.[73] Given the continued and significant increases in maternal mortality, it would appear that this goal should be revised by the Federal Interagency Workgroup. The White House Blueprint for Addressing the Maternal Health Crisis adds structure to federal efforts intent on improving maternal health and reducing maternal mortality by providing 50 specific recommended actions, many of which are alluded to in this review.[2]

In this context, note is also made of the establishment by the Centers for Medicare and Medicaid Services (CMS) of the “Birthing-Friendly” hospital designation with an eye toward driving improvements in maternal health outcomes.[74] This designation is being used to assist consumers in choosing hospitals for care utilizing the Care Compare online tool.[75] Initially implemented in 2021, the standard required each hospital to attest to its commitment to the quality and safety of the maternal care that they provide under the Maternal Morbidity Structural Measure of the Hospital Inpatient Quality Reporting Program of CMS.[75] As of November 2023, participating hospitals are annually required to confirm their involvement in a statewide or national perinatal quality improvement collaborative including implementation of safety bundles including, but not limited to, hemorrhage, severe hypertension/preeclampsia, and sepsis.[76] [77] As promised, CMS recently announced the implementation of additional health-equity measures including hospital-required screening for SDOHs to address Health-Related Social Needs.[78]

The development of a network of nationally integrated state and regional PQCs that share data and processes as well as experience through the formation of the National Network of Perinatal Quality Collaboratives (NNPQC) in 2016 constitutes a major step forward in the improvement of maternal health.[79] In developing this partnership, the CDC and the states should uphold California, a state that records nearly 12% of all U.S. births annually, as a model of success.

In addition to the previously mentioned awards to HRSA-funded health centers to improve maternal health outcomes and reduce disparities, HHS has taken the lead in standardizing data-collection and data-linking practices. These initiatives, coordinated by HHS' Assistant Secretary for Planning and Evaluation, are intended to operationalize the work of the Office of the Secretary Patient-Centered Outcomes Research Trust Fund, which has prioritized maternal health research.[80] These efforts could be further coordinated with NNPQC to provide a robust infrastructure for data aggregation and sharing as well as management of the implementation of clinical improvement and disparity-reducing strategies. This collaboration in combination with academic centers and clinical leaders may constitute the best vehicle to coordinate state and federal efforts intent on addressing this public health emergency.

 

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Conclusion

The state of maternal health in the United States is at a critical juncture. Despite concerted national efforts over the past two decades, the U.S. MMR continues to worsen under the weight of unconscionable racial disparities. Many of the elements responsible were identified with significant quality improvement efforts expended to date. To reverse these trends with an eye toward reaching the ultimate goal of rendering the United States as one of the “safest countries in the world to give birth” will require greater coordination and consolidation of national efforts across the entire prenatal, perinatal, and postpartum continuum. Of even greater consequence is the need to eliminate racial disparities by addressing the extant SDOHs. The authors recommend that these corrective initiatives include the ongoing work through HRSA and HHS with the addition of the NNPQCs to create a robust federal infrastructure to finally provide equitable high-quality maternal care and bring U.S. maternal mortality into alignment with other HICs.

 

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Conflict of Interest

None declared.

Acknowledgments

The authors wish to thank Mr. Daniel P. O'Mahony of the John D. Rockefeller, Jr. Library of Brown University for his dedicated and invaluable assistance in procuring documents with pending and enacted legislation related to the subject matter.

Authors' Contributions

J.A.O'B.: conceptualization, writing—original draft. A.K.L.: conceptualization, writing—review and substantive revision. E.K.M.: conceptualization, writing, and substantive revision. E.Y.A.: conceptualization, writing—review and substantive revision.

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Publication History

Received: 21 August 2024

Accepted: 26 August 2024

Article published online:
10 October 2024