In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women’s health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists.
Forty years ago, leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade ( Supplementary Data available at www.AJOG.org ). They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women’s health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists.
Since then, we have advanced the fields of reproduction and family planning. Thanks to these developments, women can now prevent pregnancy with safer and more effective forms of contraception (most recently long-acting reversible methods), with simple and sensitive hormonal and sonographic methods to determine pregnancy status and duration, and with new methods of infertility treatment and prenatal testing that rely on the option of terminating intended pregnancies that are diagnosed as abnormal. To terminate pregnancies, clinicians now use misoprostol and mifepristone for “medical abortion” (which in 2009 accounted for 16.5% of terminations in the United States and can be office-based) and use sonographic guidance of intrauterine procedures along with new methods for inducing cervical dilation and uterine contraction; patients benefit from innovations in counseling and new approaches to pain control. Studies of abortion practice and outcomes are also much more sophisticated than they were 40 years ago.
We have had 40 years of medical progress but have witnessed political regression that the 100 professors did not anticipate. In 2011 alone, 24 states passed 92 legislative restrictions on abortion. Waiting periods after consent are now law in 26 states. Alabama, Arizona, Florida, Kansas, Louisiana, North Carolina, Oklahoma, and Texas require patients to view ultrasound images and, in Arizona, Louisiana, Mississippi, and Texas, to listen to fetal heart beats. Laws in 27 states force physicians to provide deceptive counseling including false statements about risks of breast cancer, infertility, and mental health. They include laws to limit second-trimester abortion under the guise of protecting the fetus from pain (Alabama, Idaho, Indiana, Kansas, Louisiana, Nebraska, and Oklahoma). Laws directed specifically at medical education in Arizona, Kansas, and Texas prohibit abortion training in public institutions and another 7 states ban abortion in public hospitals, precluding training in them.
What vision of the future of legalized abortion did the 100 professors have? How accurately did they estimate the need for safe, legal abortion and anticipate their colleagues’ willingness and commitment to meeting it? They wrote, “In view of the impending change in abortion practices generated by new state legislation and federal court decisions, we believe it helpful to [respond] to this increasingly liberal course of events…by contributing to the solution of an imminent problem.” Forty years later, the change is not liberal. Its effects will threaten, not improve, women’s health and already obstruct physicians’ evidence-based and patient-centered practices. We review our predecessors’ 1972 statement and judge how it comports with what actually occurred and with legislation that has been adopted over the 40 years since their writing and the passage of Roe v Wade.
The 100 professors were remarkably prescient in anticipating the need for 1 million legal abortions and today’s abortion rate of 1 in 4 pregnancies. They predicted that teaching hospitals with specialized outpatient facilities could meet the demand and believed that abortions were the responsibility of hospitals. But today, 90% of abortions, which include the 10% that are in the second trimester, are done away from hospitals. Many hospitals enforce fetal and maternal health restrictions that are not based in the law but are contrived and enforced by the same kind of “ethics committees” that were common before the professors’ 1972 statement. Some institutions offer terminations only to save a woman’s life; others will perform the procedure under no circumstances at all. At the same time, many states have passed legislation to shut down the freestanding clinics that are now responsible for most abortions by enacting cumbersome and expensive building regulations that are disguised as patient safety requirements. There are now 25 states that, under the guise of patient safety, restrict abortions to hospitals that have their own restrictions or to specialized facilities.
In our view, hospitals have disregarded the responsibility that our academic predecessors expected them to assume. Although most first-trimester and many second-trimester abortions can be done safely and efficiently in a clinic setting, some second-trimester abortions, particularly those that are complicated by medical conditions, should be done in a hospital with rapid access to the operating room, interventional radiology, blood bank, and other emergency interventions. Hospitals and expert clinicians are essential for the education of students and training residents who care for complicated cases and for treating complications.
The 100 professors went on to say that physicians should learn uterine aspiration, which is an outpatient procedure that today accounts for 82.3% of abortions, and local anesthesia and analgesia, which includes conscious sedation, so that complications and expense of general anesthesia would be reduced. Today, some hospitals confine pregnancy termination, even routine first and uncomplicated second-trimester spontaneous and induced abortions, to operating rooms and have credentialing rules that prohibit the use of conscious sedation for these patients. Ignoring the 100 professors’ counsel not only dramatically increases patients’ recovery time and expense, but also adds significant and unnecessary staffing and clinical costs that discourage hospitals from providing abortions at all.
Regarding hospital policies and the role of “abortion committees,” the 100 professors wrote “therapeutic abortion boards will have no place…in states with laws which stipulate that abortion decisions are to be made by the physician and his [her] patient.” The 100 professors commented on the physician’s duty to counsel regarding abortion: “There are patients…who should be actively encouraged to consider abortion—for example, women who are unaware of a teratogenic threat to their pregnancies.” At that time, the professors would have been thinking of rubella and did not know that advances in prenatal diagnosis would give obstetricians the opportunity and responsibility to make their patients aware of a wide range of genetic anomalies and to offer abortion if requested. The 100 professors certainly would not have envisioned the legislation recently proposed in Oklahoma to entitle physicians to withhold information in cases of known fetal deformity because a knowledgeable patient might choose termination.
Writing about doctors with conscientious objections, the 100 professors said that these physicians must be excused from performing abortion but must refer patients to colleagues who can care for them. Recent “conscience clause” legislation does not require referral for abortion, and some states (Colorado, Ohio, Wisconsin, Michigan, and Texas) specifically prohibit referral for abortion by physicians who work in institutions that receive state funding for women’s health services. The American College of Obstetricians and Gynecologists, which discussed the limits of objection, recommends that “Any conscientious refusal that conflicts with a patient’s well-being should be accommodated only if the primary duty to the patient can be fulfilled.” Despite this guidance, many physicians are now prohibited by law from referring patients to vital services. In Texas, for example, referral for abortion can result in denial of contraceptive funding.
The 100 professors predicted that space and resources for hospitals to provide abortion would result from “…the lessened number of septic abortions.” The Centers for Disease Control and Prevention and others subsequently documented a steep decline in hospital admissions and morbidity and mortality rates from illegal abortion promptly after Roe v Wade made abortion legal in all the states.
The savings in lives and money from legalization were soon forgotten, and many hospitals now claim they cannot afford to provide abortions even if they wanted to because, among other arguments, reimbursement rates are too low (but abortion is certainly not the only service in this category), free-standing clinics provide faster and cheaper services with which hospitals cannot hope to compete (but some hospitals are able to provide cost-effective abortions), and hospital employees, notably nurses, refuse to provide abortion care (unlikely true of all or most nurses).
Some hospitals with abortion services still face legislative challenges. Even though many residency programs have integrated abortion training successfully, individual states and, recently the US Congress, have legislated restrictions on abortion training in disregard of Accreditation Council on Graduate Medical Education training mandates. These restrictions ultimately threaten women’s health by denying residents training in uterine evacuation, which further reduces access to safe abortion.
The 100 professors considered the consent process for abortion, stating that “…it has been ruled by [some] courts that an adult woman is free to make this decision by herself.” However, several state legislatures have interfered in the consent process by requiring that irrelevant, even untrue, information be given by the physician (eg, abortion causes breast cancer and fetal pain) and enacting burdensome waiting periods that increase risks and costs. They further predicted “that the courts will someday decide that “any girl who is physically mature enough to conceive should, ipso facto, be granted the freedom to determine the fate of her pregnancies.” Yet politicians in 37 states have restricted freedom of access of minors to abortion by implementing parental consent or notification laws, often with clumsy, prolonged “judicial bypass” requirements that lead to dangerous delays.
The professors addressed the need for postabortion contraception to decrease the need for abortion, endorsing it as “an integral part of any abortion program,” but today the most effective contraceptives are still not easily accessible immediately after abortion when women most want them. Although the American College of Obstetricians and Gynecologists, Planned Parenthood, and other organizations promote postabortion use of long-acting reversible contraception, the family planning funding regulations of many states do not pay for immediate postabortion methods, and several states (eg, Indiana and Texas) and the US House of Representatives have attempted to eliminate family planning from their budgets entirely.
Finally, the 100 professors recommended that “abortion should be made equally available to the rich and the poor.” Ironically, shortly after the 1973 Roe v Wade decision that our predecessors anticipated, the Hyde Amendment prohibited the use of federal dollars for abortion so that women in the military or who have received Medicaid have had severely limited access to abortion for nearly 40 years, unless they can pay themselves or happen to live in one of the 13 states that use their own funds for abortion. Richer women, on the other hand, usually have private health insurance for abortions but there, too, the US Congress threatens women’s health by insisting that the Affordable Care Act restrict even private payers from directly including abortion.
In consideration of current legislative threats to the autonomy of our patient relationships, to evidence-based medical practice, to the training of our students and residents, and ultimately to the health of our patients, we 100, including 2 of the original signers, join the 100 of 1972 in affirming our academic responsibilities to (1) teach future practitioners about all methods of contraception and about uterine evacuation throughout pregnancy, which ranges from miscarriage management to emergent evacuations and the treatment of complications in accordance with our professional mandate from Accreditation Council for Graduate Medical Education; (2) provide evidence-based information to all patients who seek family planning or pregnancy termination; (3) provide evidenced-based information to legislators who propose laws requiring inaccurate information or unindicated procedures for women seeking to terminate a pregnancy; (4) insist that the hospitals where we care for women and teach students and residents admit patients who require hospital-based pregnancy terminations, and (5) ensure the availability of all methods of contraception, particularly long-acting reversible contraception methods, to reduce the need for abortion.
Appendix
100 Professors
Dr David F. Archer
Professor of Obstetrics and Gynecology
Eastern Virginia Medical School
Norfolk, VA
Dr Amy (Meg) Autry
President-elect, Association of Professors of Gynecology and Obstetrics
Professor of Obstetrics, Gynecology and Reproductive Sciences
University of California, San Francisco
San Francisco, CA
Dr Robert L. Barbieri
Kate Macy Ladd Professor and Chair
Department of Obstetrics and Gynecology
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
Dr Jonathan S. Berek
Laurie Kraus Lacob Professor and Chair
Department of Obstetrics and Gynecology
Stanford University
Stanford, CA
Dr Sarah L. Berga
Professor and Chair
Associate Dean Women’s Health Research
Department of Obstetrics and Gynecology
Wake Forest University
Winston-Salem, NC
Dr Ira M. Bernstein
John Van Sicklen Maeck Professor and Chair
Department of Obstetrics and Gynecology
Senior Associate Dean for Research
University of Vermont
Burlington, VT
Dr Michael Brodman
Professor and Chair
Department of Obstetrics, Gynecology and Reproductive Science
The Mount Sinai Medical Center
New York, NY
Dr Haywood Brown
Professor and Chair
Department of Obstetrics and Gynecology
Duke University
Durham, NC
Dr Pierre Buekens
W.H. Watkins Professor
Tulane University School of Public Health and Tropical Medicine
New Orleans, LA
Dr Serdar E. Bulun
John J. Sciarra Professor and Chair
Department of Obstetrics and Gynecology
Northwestern University
Chicago, IL
Dr Ronald T. Burkman
Professor of Obstetrics and Gynecology
Tufts University
Springfield, MA
Dr Winston A. Campbell
Professor and Interim Chair
Department of Obstetrics and Gynecology
University of Connecticut Health Center
Farmington, CT
Dr Linda F. Carson
Professor and Head
Department of Obstetrics, Gynecology and Women’s Health
University of Minnesota
Minneapolis, MN
Dr Aaron B. Caughey
Professor and Chair
Department of Obstetrics and Gynecology
Oregon Health and Science University
Portland, OR
Dr Gautam Chaudhuri
Distinguished Professor and Executive Chair
Department of Obstetrics and Gynecology
University of California, Los Angeles
Los Angeles, CA
Dr David Chelmow
Leo J. Dunn Distinguished Professor and Chair
Department of Obstetrics and Gynecology
Virginia Commonwealth University Medical Center
Richmond, VA
Dr Frank Chervenak
Professor and Chair
Department of Obstetrics and Gynecology
Cornell University
New York, NY
Dr Daniel L. Clarke-Pearson
Robert A. Ross Distinguished Professor and Chair
Department of Obstetrics and Gynecology
University of North Carolina
Chapel Hill, NC
Dr Mitchell Creinin
Professor and Chair
Department of Obstetrics and Gynecology
University of California, Davis
Sacramento, CA
Dr Mary D’Alton
Willard C. Rappleye Professor and Chair
Department of Obstetrics and Gynecology
Columbia University
New York, NY
Dr Vani Dandolu
Associate Professor and Chair
Department of Obstetrics and Gynecology
University of Nevada School of Medicine
Reno, NV
Dr Philip D. Darney
Distinguished Professor
Department of Obstetrics, Gynecology and Reproductive Sciences
University of California, San Francisco
San Francisco, CA
Dr Richard Derman
Endowed Chair of Obstetrics and Gynecology
Christiana Care Health Services
Newark, DE
Dr Deborah A. Driscoll
Luigi Mastroianni, Jr Professor and Chair
Department of Obstetrics and Gynecology
University of Pennsylvania
Philadelphia, PA
Dr David A. Eschenbach
Professor and Chair
Department of Obstetrics and Gynecology
University of Washington
Seattle, WA
Dr James E. Ferguson
The W. Norman Thornton, Jr Professor and Chair
Department of Obstetrics and Gynecology
University of Virginia School of Medicine
Charlottesville, VA
Dr Harold E. Fox
Dr Dorothy Edwards Professor and Chair
Department of Obstetrics and Gynecology
Johns Hopkins University
Baltimore, MD
Dr Arnold J. Friedman
Chair, Department of Obstetrics and Gynecology
Beth Israel Medical Center
New York, NY
Dr Melissa Gilliam
Professor of Obstetrics, Gynecology and Pediatrics, Associate Dean for Diversity
Division of the Biological Sciences
The University of Chicago
Chicago, IL
Dr Todd Griffin
Associate Professor and Chair
Department of Obstetrics and Gynecology
Stonybrook Medicine
Stony Brook, NY
Dr David A. Grimes
Clinical Professor Department of Obstetrics and Gynecology
University of North Carolina
Chapel Hill, NC
Dr Daniel R. Grow
Professor and Deputy Chair
Department of Obstetrics and Gynecology
Tufts University
Boston, MA
Dr Linda Giudice
Distinguished Professor and Chair
Department of Obstetrics, Gynecology and Reproductive Sciences
University of California, San Francisco
San Francisco, CA
Dr Arthur Haney
Professor and Chair
Department of Obstetrics and Gynecology
University of Chicago
Chicago, IL
Dr Wendy F. Hansen
Professor and Chair
Department of Obstetrics and Gynecology
University of Kentucky
Lexington, KY
Dr Christopher Harman
Professor and Chair
Department of Obstetrics, Gynecology and Reproductive Sciences
University of Maryland
Baltimore, MD
Dr Linda J. Heffner
Professor of Obstetrics and Gynecology
Boston University School of Medicine
Boston, MA
Dr Paul Hendessi
Interim Chair and Clinical Associate Professor
Department of Obstetrics and Gynecology
Boston Medical Center
Boston, MA
Dr William Allen Hogge
Milton C. McCall Professor and Chair
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of Pittsburgh
Pittsburgh, PA
Dr Ira R. Horowitz
John D. Thompson Professor and Chair
Department of Gynecology and Obstetrics
Emory University
Atlanta, GA
Dr Jeffrey Jensen
Leon Speroff Professor of Obstetrics and Gynecology
Oregon Health and Science University
Portland, OR
Dr Timothy R.B. Johnson
Professor and Chair
Department of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI
Dr Donna Johnson
Professor and Chair
Department of Obstetrics and Gynecology
Medical University of South Carolina
Charleston, SC
Dr Julia Johnson
Professor and Chair
Department of Obstetrics and Gynecology
University of Massachusetts Medical School
Worcester, MA
Dr Harry S. Jonas
Professor Emeritus and Dean Emeritus
University of Missouri-Kansas City
Kansas City, MO
Dr Howard W. Jones III
Professor and Chair
Department of Obstetrics and Gynecology
Vanderbilt University
Nashville, TN
Dr David Keefe
Stanley H. Kaplan Professor and Chair
Department of Obstetrics and Gynecology
New York University Medical Center
New York, NY
Dr Sarah J. Kilpatrick
Professor and Chair
Department of Obstetrics and Gynecology
Cedars-Sinai Medical Center
West Hollywood, CA
Dr Mark B. Landon
Professor and Chair
Department of Obstetrics and Gynecology
Ohio State University
Columbus, OH
Dr John W. Larsen
Professor and Chair
Department of Obstetrics and Gynecology
The George Washington University
Washington, DC
Dr Douglas W. Laube
Professor and Past Chair
Department of Obstetrics and Gynecology
University of Wisconsin–Madison
Madison, WI
Dr Lee A. Learman
Clarence E. Ehrlich Professor and Chair
Department of Obstetrics and Gynecology
Indiana University School of Medicine
Indianapolis, IN
Dr Kimberly K. Leslie
Professor and Head
Jennifer R. Niebyl Endowed Chair
Department of Obstetrics and Gynecology
University of Iowa
Iowa City, IA
Dr Edward Linn
Associate Professor and Chair
Department of Obstetrics and Gynecology
Cook County Health and Hospitals System
Northwestern University
Chicago, IL
Dr James H. Liu
Arthur H. Bill Professor and Chair
Department of Reproductive Biology
Case Western Reserve University
Cleveland, OH
Dr Curtis Lowery
Professor and Chair
Department of Obstetrics and Gynecology
University of Arkansas for Medical Sciences
Little Rock, AR
Dr George A. Macones
Professor and Chair
Department of Obstetrics and Gynecology
Washington University in St Louis
St. Louis, MS
Dr Veronica Mallet
Professor and Founding Chair
Department of Obstetrics and Gynecology
Texas Tech University
Lubbock, TX
Dr Dev Maulik
Professor and Chair
Department of Obstetrics and Gynecology
University of Missouri–Kansas City
Kansas City, MO
Dr Irwin R. Merkatz
Professor and Chair
Department of Obstetrics and Gynecology and Women’s Health
Albert Einstein College of Medicine
Bronx, NY
Dr Daniel R. Mishell Jr
Endowed Professor of Obstetrics and Gynecology
University of Southern California
Los Angeles, CA
Dr Owen Montgomery
Chair
Department of Obstetrics and Gynecology
Drexell University
Philadelphia, PA
Dr Valerie Montgomery Rice
Dean and Executive Vice President
Morehouse School of Medicine
Atlanta, GA
Dr Thomas Moore
Professor and Chair
Department of Reproductive Medicine
University of California, San Diego
San Diego, CA
Dr Laila Muderspach
Associate Professor and Chair
Department of Obstetrics and Gynecology
University of Southern California
Los Angeles, CA
Dr Anita L. Nelson
Professor of Obstetrics and Gynecology
Harbor Hospital University of California, Los Angeles
Los Angeles, CA
Dr Jennifer R. Niebyl
Professor and Vice-Chair
Department of Obstetrics and Gynecology
University of Iowa Hospitals and Clinics
Iowa City, IA
Dr Errol R. Norwitz
Louis E. Phaneuf Professor and Chair
Department of Obstetrics and Gynecology
Tufts University
Boston, MA
Dr Valerie Parisi
Professor of Obstetrics and Gynecology
Dean, School of Medicine
Wayne State University
Detroit, MI
Dr Kirtly Parker Jones
Professor and Vice Chair of Educational Affairs
Department of Obstetrics and Gynecology
University of Utah
Salt Lake City, UT
Dr Maureen G. Phipps
Associate Professor and Interim Chair
Department of Obstetrics & Gynecology
Brown University
Providence, RI
Dr Manuel Porto
Professor and the E.J. Quilligan Endowed Chair
Department of Obstetrics and Gynecology
University of California, Irvine
Irvine, CA
Dr Gabriella Pridjian
C. Jeff Miller Professor and Chair
Department of Obstetrics and Gynecology
Tulane University
New Orleans, LA
Dr J. Gerald Quirk
Professor of Obstetrics, Gynecology and Reproductive Medicine
Stony Brook University
Stony Brook, NY
Dr Janet S. Rader
Jack A. and Elaine D. Klieger Professor and Chair
Department of Obstetrics and Gynecology
Medical College of Wisconsin
Milwaukee, WI
Dr William F. Rayburn
Randolph Seligman Professor and Chair
Department of Obstetrics and Gynecology
University of New Mexico
Albuquerque, NM
Dr Richard Reindollar
Professor and Chair
Department of Obstetrics and Gynecology
Dartmouth-Hitchcock Medical Center
Hanover, NH
Dr Hope A. Ricciotti
Acting Chair and Associate Professor
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
Dr Laurel Rice
Professor and Chair
Department of Obstetrics and Gynecology
University of Wisconsin
Madison, WI
Dr Gloria Richard-Davis
Professor and Chair
Department of Obstetrics and Gynecology
Meharry Medical College
Nashville, TN
Dr Juana I. Rivera-Vinas
Professor and Chair
Department of Obstetrics and Gynecology
University of Puerto
San Juan, PR
Dr Nanette Santoro
Professor and E Stewart Taylor Chair
Department of Obstetrics and Gynecology
University of Colorado
Aurora, CO
Dr Andrew J. Satin
Professor and Vice Chair
Department of Gynecology and Obstetrics
Johns Hopkins University
Baltimore, MD
Dr Lynnae Millar Sauvage
Professor and Chair
Department of Obstetrics, Gynecology and Women’s Health
University of Hawaii
Honolulu, HI
Dr William D. Schlaff
Professor and Chair
Department of Obstetrics and Gynecology
Thomas Jefferson University
Philadelphia, PA
Dr Jack Sciarra a
Professor and Chair Emeritus
Department of Obstetrics and Gynecology
Northwestern University Medical School
Chicago, IL
Dr Robert K. Silverman
Professor and Chair
Department of Obstetrics and Gynecology
SUNY-Upstate Medical University
Syracuse, NY
Dr Carl V. Smith
Professor and Chair
Department of Obstetrics and Gynecology
University of Nebraska
Omaha, NE
Dr Leon Speroff
Professor Emeritus of Obstetrics and Gynecology
Oregon Health and Science University
Portland, OR
Dr Morton Stenchever a
Professor and Chair Emeritus
University of Washington
Seattle, WA
Dr Jerome F. Strauss, III
Professor and Dean
Department of Obstetrics and Gynecology
Virginia Commonwealth University
Richmond, VA
Dr Phillip Stubblefield
Emeritus Professor of Obstetrics and Gynecology
Boston University
Boston, MA
Dr Hugh S. Taylor
Anita O’Keeffe Young Professor and Chair
Department of Obstetrics, Gynecology and Reproductive Sciences
Yale University
New Haven, CT
Dr J. Peter Van Dorsten
Professor and Past Chair
Department of Obstetrics and Gynecology
Medical University of South Carolina
Charleston, SC
Dr Eugene Washington
Vice Chancellor of UCLA Health Sciences
Dean of the David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, CA
Dr Gerson Weiss
Professor and Chair
Department of Obstetrics and Gynecology
The University of Medicine and Dentistry of New Jersey
Newark, NJ
Dr Carolyn Westhoff
Professor of Obstetrics, Gynecology, and Public Health
Columbia University
New York, NY
Dr Robert Stanford Williams
Harry Prystowsky Professor and Chair
Department of Obstetrics and Gynecology
University of Florida
Gainesville, FL
Dr James Woods
Henry A. Thiede Professor and Chair
Department of Obstetrics and Gynecology
University of Rochester
Rochester, NY
Dr Jerome Yankowitz
James M. Ingram Professor and Chair
Department of Obstetrics and Gynecology
University of South Florida
Tampa, FL
a Original signer of 1972 list.
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