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Sunuwar DR, Singh DR, Adhikari B, Shrestha S, Pradhan PMS. Factors affecting anaemia among women of reproductive age in Nepal: a multilevel and spatial analysis. BMJ Open 2021; 11:e041982. [PMID: 33782019 PMCID: PMC8009228 DOI: 10.1136/bmjopen-2020-041982] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The main objective of this study was to explore the factors affecting anaemia among women of reproductive age (WRA) in Nepal using spatial and multilevel epidemiological analysis. DESIGN This cross-sectional study analysed data from the 2016 Nepal Demographic and Health Survey. Spatial analysis was performed using ArcGIS software V.10.8 to identify the hot and cold spots of anaemia among WRA (15-49 years). Data were analysed using multilevel mixed-effect logistic regression analysis. SETTING Nepal. PARTICIPANTS A total of 6414 WRA were included in the analysis. MAIN OUTCOME MEASURE Anaemia defined by WHO as haemoglobin level less than 120 g/L in non-pregnant women and less than 110 g/L in pregnant women. RESULTS The spatial analysis showed that statistically significant hotspots of anaemia were in the southern Terai region (four districts in province 1, eight districts in province 2, one district in Bagmati province, two districts in province 5 and one district in Sudurpaschim province) of Nepal. At the individual level, women who underwent female sterilisation (adjusted OR, aOR: 3.61, 95% CI 1.10 to 11.84), with no education (aOR: 1.99, 95% CI: 1.17 to 3.39), and from middle socioeconomic class families (aOR: 1.65, 95% CI: 1.02 to 2.68) were more likely to be anaemic, whereas, older women (>35 years) (aOR: 0.51, 95% CI: 0.26 to 0.97) and those women who were using hormonal contraceptives (aOR: 0.63, 95% CI: 0.43 to 0.90) were less likely to be anaemic. At the community level, women from province 2 (aOR=2.97, 95% CI: 1.52 to 5.82) had higher odds of being anaemic. CONCLUSION WRA had higher odds of developing anaemia, and it varied by the geographical regions. Nutrition-specific and nutrition-sensitive interventions can be tailored based on the factors identified in this study to curb the high burden of anaemia.
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Affiliation(s)
- Dev Ram Sunuwar
- Department of Nutrition and Dietetics, Armed Police Force Hospital, Kathmandu, Nepal
- Department of Public Health, Asian College for Advance Studies, Purbanchal University, Lalitpur, Nepal
| | - Devendra Raj Singh
- Department of Public Health, Asian College for Advance Studies, Purbanchal University, Lalitpur, Nepal
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Santosh Shrestha
- Agriculture Research, Agricultural Technology Center, Lalitpur, Nepal
| | - Pranil Man Singh Pradhan
- Department of Community Medicine, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal
- Nepalese Society of Community Medicine (NESCOM), Kathmandu, Nepal
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Affiliation(s)
- Rebecca J Stoltzfus
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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Kozuki N, Lee AC, Katz J. Moderate to severe, but not mild, maternal anemia is associated with increased risk of small-for-gestational-age outcomes. J Nutr 2012; 142:358-62. [PMID: 22190028 DOI: 10.3945/jn.111.149237] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Anemia is highly prevalent globally, estimated at 40-50% in women of reproductive age. Prior studies have produced inconclusive evidence as to the association between maternal anemia and intrauterine growth restriction (IUGR). We conducted a systematic review of the literature containing associations between maternal anemia and small for gestational age (SGA) outcomes (as a proxy for IUGR). A meta-analysis was performed to pool associations, categorized by the hemoglobin cutoffs presented by the authors. We identified 12 studies reporting associations between maternal anemia and SGA. For the meta-analysis, there were 7 associations with a hemoglobin cutoff <110 g/L, 7 with a cutoff <100 g/L, and 5 with a cutoff <90 or <80 g/L. Although the <110- and <100-g/L categories showed no significant relationship with SGA, the <90- or <80-g/L category was associated with a 53% increase in risk of the newborn being SGA [pooled OR = 1.53 (95% CI: 1.24-1.87); P < 0.001]. Moderate to severe, but not mild, maternal anemia appears to have an association with SGA outcomes, but the findings must be viewed with caution due to the great heterogeneity of the studies. Further examination should be conducted using datasets with better standardized definitions and measurements of exposure and outcome.
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Affiliation(s)
- Naoko Kozuki
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Derosas R. The joint effect of maternal malnutrition and cold weather on neonatal mortality in nineteenth-century Venice: An assessment of the hypothermia hypothesis. Population Studies 2009; 63:233-51. [DOI: 10.1080/00324720903165449] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Pickett KE, Rathouz PJ, Dukic V, Kasza K, Niessner M, Wright RJ, Wakschlag LS. The complex enterprise of modelling prenatal exposure to cigarettes: what is 'enough'? Paediatr Perinat Epidemiol 2009; 23:160-70. [PMID: 19159402 PMCID: PMC10087299 DOI: 10.1111/j.1365-3016.2008.01010.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
While there is a burgeoning body of research linking smoking during pregnancy to problem behaviour in offspring, a major criticism of this work has been the crude measurement of exposure in these studies (e.g. retrospective, self-reported only) that could lead to biased estimates. To address this issue, we used a pregnancy cohort with repeated prospective measures of exposure as well as biological assays to generate estimates of exposure patterns using a range of modelling techniques. In this paper we report on the analytical approaches we have developed, including patterns of exposure over time and best-estimate approaches that combine self-report and cotinine measures, and compare their predictive value in relation to different dimensions of fetal growth as a first step towards examining the utility of greater precision of exposure measurement. Surprisingly, in this sample the more complex assessments of exposure, including biological measures, generally did not perform better than simple indicators of exposure based on repeated self-report measures, with one exception: a combined self-report cotinine 'best estimate' of third trimester exposure was uniquely associated with lower brain : body ratio. Further study is needed using more sophisticated cotinine assays and testing prediction of a range of outcomes to ascertain whether these findings represent true differences or are specific to the sample, methods and outcomes used. Such research will inform the development of guidelines for adequate exposure characterisation in developmental studies.
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Affiliation(s)
- Kate E Pickett
- Department of Health Sciences, University of York, Heslington, York, UK.
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Neufeld LM, Haas JD, Grajéda R, Martorell R. Changes in maternal weight from the first to second trimester of pregnancy are associated with fetal growth and infant length at birth. Am J Clin Nutr 2004; 79:646-52. [PMID: 15051610 DOI: 10.1093/ajcn/79.4.646] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite our knowledge of the negative consequences of stunting during early childhood and the important role that maternal nutritional status plays in the development of intrauterine growth retardation, we do not know the extent to which maternal nutritional status influences the growth in length of the fetus or whether a sensitive period for fetal linear growth exists during gestation. OBJECTIVE Our objective was to explore the relation between maternal weight gain during different stages of pregnancy and linear growth of the fetus. DESIGN Ultrasound examinations were conducted at 15-24 (x: 17.5) and 28-32 (x: 29.9) wk of gestation in 200 women from 4 rural Guatemalan villages. The associations between maternal weight gain from approximately 10 to 20 and 20 to 30 wk of pregnancy (from the first to the second and from the second to the third trimester, respectively) and fetal linear growth were tested with the use of ordinary least-squares regression. RESULTS Maternal weight gain from the first to the second trimester was associated with fetal femur and tibia lengths measured at both means of 17 and 30 wk (P < 0.05) and infant length at birth (P < 0.001). Weight gain from the second to the third trimester of pregnancy did not predict fetal linear growth or infant length at birth. CONCLUSIONS Maternal weight change from the first to the second trimester of pregnancy is strongly associated with fetal growth. Mid-gestation may be a sensitive period for fetal linear growth.
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Villar J, Merialdi M, Gülmezoglu AM, Abalos E, Carroli G, Kulier R, de Onis M. Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery: an overview of randomized controlled trials. J Nutr 2003; 133:1606S-1625S. [PMID: 12730475 DOI: 10.1093/jn/133.5.1606s] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and beta-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right.
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Affiliation(s)
- José Villar
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, CH-1211 Geneva 27, Switzerland.
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Milsom I, Ladfors L, Thiringer K, Niklasson A, Odeback A, Thornberg E. Influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. Acta Obstet Gynecol Scand 2002; 81:909-17. [PMID: 12366480 DOI: 10.1034/j.1600-0412.2002.811003.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. OBJECTIVE To investigate risk factors for Apgar score-defined birth asphyxia, birth asphyxia with hypoxic-ischemic encephalopathy and birth asphyxia-related death/disability. MATERIAL AND METHODS Retrospective case-control study in term neonates with birth asphyxia defined as Apgar score < 7 at 5 min. Cases originating from nonasphyctic causes (e.g. infection, maternal sedation) were excluded. Hypoxic-ischemic encephalopathy was diagnosed according to criteria by Sarnat. Maternal, obstetric and fetal risk factors were registered in 225 cases of birth asphyxia diagnosed in 42 203 live births occurring in the urban Swedish population studied. A matched control group was used for statistical evaluation. RESULTS Asphyxia was associated with single civil status, OR = 7.1 (95%CI 2.0, 27.6); intrauterine meconium release, OR = 4.1 (95%CI 1.8, 9.8); operative delivery, OR = 8.7 (95%CI 3.4, 24.6); breech delivery, OR = 20.3 (95%CI 3.0, 416.5); oxytocin augmentation, OR = 2.9 (95%CI 1.4, 6.3); cord complication, OR = 15.8 (95%CI 2.1, 341.5); external compression to assist delivery OR = 6.2 (95%CI 1.3, 45.7); and cardiotocography score, OR = 0.5 (95%CI 0.4, 0.6). Normal fetal heart rate variability, OR = 0.4 (95%CI 0.2, 0.6), repeated late decelerations irrespective of amplitude or repeated variable decelerations, OR = 29.4 (95%CI 5.7, 540.8) or occasional late or variable decelerations, OR = 2.2 (95%CI 1.3, 3.8), and no accelerations, OR = 5.2 (95%CI 2.0, 16.4), were associated with asphyxia. Operative or instrumental delivery was more common in all three asphyxia groups compared with controls. Leanness was a risk factor for asphyxia and for hypoxic-ischemic encephalopathy. Maternal age, smoking and illnesses, time of delivery (day/night, seasonal) and previous caesarean section were not associated with birth asphyxia. CONCLUSIONS An association between neonatal asphyxia and cardiotocography parameters, intrauterine meconium release, operative delivery, breech delivery, single civil status, oxytocin augmentation, cord complication, external compression to assist delivery and neonatal leanness was found. Abnormal fetal heart rate variability, repeated late decelerations irrespective of amplitude or repeated variable decelerations, occasional late or variable decelerations and no accelerations were associated with asphyxia.
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Affiliation(s)
- Ian Milsom
- Department of Obstetrics, Göteborg University, Sweden.
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Roth S, Chang TC, Robson S, Spencer JA, Wyatt JS, Stewart AL. The neurodevelopmental outcome of term infants with different intrauterine growth characteristics. Early Hum Dev 1999; 55:39-50. [PMID: 10367981 DOI: 10.1016/s0378-3782(99)00002-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The objective of this study was to test the hypothesis that neurodevelopmental outcome would differ between two groups of small-for-gestational age infants born at term showing different in utero growth characteristics during the third trimester. The design was a prospective cohort study done at a tertiary referral centre. The 76 subjects who fulfilled the inclusion criteria had an estimated fetal weight below the 10th centile for their gestation. Subsequent to enrolment, repeat ultrasound scans were performed weekly to determine growth velocity. Twenty-three infants whose change in fetal abdominal circumference between first and last scan was greater than -1.5 standard deviation scores (SDS) were assigned to the intrauterine growth retardation group (IUGR) while 53 infants whose fetal abdominal circumference changed less than 1.5 SDS were assigned to the small-for-gestational-age (SGA) group. Ten infants with normal intrauterine growth were enrolled as controls. Following delivery all infants had a neurological examination and a cranial ultrasound scan. At 1 year, 75 infants (87%) were traced and reassessed (49 SGA, 18 IUGR and eight controls) with a neurological examination and a developmental assessment. At birth, impairments were found in 27 (51%) of the SGA, 13 (57%) of the IUGR groups and one (10%) of the controls. At 1 year, 18 (37%) of the SGA subjects, six (33%) of the IUGR subjects and one (13%) of the control infant were impaired, including three (6%) of the SGA subjects and one (6%) of the IUGR subjects who were disabled. We conclude that in term fetuses with an estimated birthweight below the 10th centile for their gestation, the pattern of growth in the third trimester does not affect outcome at 1 year. In spite of optimum obstetric management, nearly one-third of the combined SGA and IUGR term fetuses had suffered some, albeit minor, neurological damage.
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Affiliation(s)
- S Roth
- Department of Paediatrics, University College London Medical School, UK.
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Caulfield LE, Stoltzfus RJ, Witter FR. Implications of the Institute of Medicine weight gain recommendations for preventing adverse pregnancy outcomes in black and white women. Am J Public Health 1998; 88:1168-74. [PMID: 9702142 PMCID: PMC1508301 DOI: 10.2105/ajph.88.8.1168] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This study examined the relation between gestational weight gain and risk of delivering a small-for-gestational-age or large-for-gestational-age infant by race, along with the implications of gaining weight according to the Institute of Medicine guidelines. METHODS Logistic regression methods were used to identify risk factors for small- and large-for-gestational-age births among 2617 Black and 1253 White women delivering at the Johns Hopkins Hospital between 1987 and 1989. RESULTS Rate of total weight gain was related to risk of small- and large-for-gestational-age births; the relationship differed according to maternal body mass index but not race. No differences in outcome by race were evident for women with low body mass indexes; among those with average or high indexes, however, Black women were at higher risk of small-for-gestational-age births and at lower risk of large-for-gestational-age births. CONCLUSIONS Having Black women gain at the upper end of the recommended range is unlikely to produce measurable reductions in small-for-gestational-age births. Some beneficial reductions in the risk of large-for-gestational-age births may occur if weight gain recommendations are lowered for average-weight and overweight White women.
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Affiliation(s)
- L E Caulfield
- Center for Human Nutrition, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD 21205, USA.
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Li R, Haas JD, Habicht JP. Timing of the influence of maternal nutritional status during pregnancy on fetal growth. Am J Hum Biol 1998; 10:529-539. [DOI: 10.1002/(sici)1520-6300(1998)10:4<529::aid-ajhb13>3.0.co;2-a] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/1997] [Accepted: 09/08/1997] [Indexed: 01/28/2023] Open
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Vik T, Vatten L, Markestad T, Ahlsten G, Jacobsen G, Bakketeig LS. Morbidity during the first year of life in small for gestational age infants. Arch Dis Child Fetal Neonatal Ed 1996; 75:F33-7. [PMID: 8795353 PMCID: PMC1061147 DOI: 10.1136/fn.75.1.f33] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Postneonatal morbidity during infancy was studied in 284 small for gestational age (SGA) and 359 non-SGA term infants. None of these babies had congenital malformations and they were born to para 1 and para 2 mothers. SGA infants had an increased risk (OR: 1.7, 95% confidence interval: 1.1-2.6) of being admitted to hospital compared with non-SGA infants. The principal cause was respiratory tract infections. Increased hospitalisation among SGA infants was a factor only if the mother was a smoker-that is, smoked cigarettes at the time of conception. Among subgroups of SGA babies, there was an increased risk for infants of non-repeaters (women without a previous SGA child) (OR: 2.4, 95% CI: 1.4-3.8) and for infants with symmetric (OR: 2.0, 95% CI: 1.2-3.3) body proportions compared with non-SGA infants. The results suggest that, beginning in early pregnancy, growth retardation may have long term consequences for subsequent infant morbidity, particularly if the mother is smoker.
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Affiliation(s)
- T Vik
- Department of Pediatrics, University Hospital, University of Trondheim, Norway
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Wiley AS. Neonatal size and infant mortality at high altitude in the western Himalaya. AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 1994; 94:289-305. [PMID: 7943187 DOI: 10.1002/ajpa.1330940302] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A prospective study was undertaken in Ladakh, India, a high-altitude region of the Himalaya, to investigate the effects of small average birth size on neonatal mortality. While such studies exist from high-altitude regions of the New World and shed light on the adaptive status of high-altitude-dwelling populations there, this is the first to examine this relationship in the Himalaya. In a sample of 168 newborns, birthweight and other anthropometric measurements were reduced relative to Andean and Tibetan newborns. Logistic regression and hazard analysis showed that neonatal biological characteristics such as weight, fatness, and circumferences were important predictors of survival probabilities of infants, especially in the neonatal period. Low Rohrer's Ponderal Index (PI) was particularly strongly related to poor survival outcome. Males and females showed no significant differences in mortality risk. Data derived from reproductive histories revealed that neonatal mortality accounted for 70-80% of total infant mortality in Ladakh. Compared to other high-altitude studies, small newborn size in Ladakh was associated with much higher mortality risks; mortality risk rose dramatically with birthweights below the mean (2,764 grams), which characterized 50% of all newborns. It is argued that newborns in Ladakh are subject to strong directional selective forces that favor higher birthweights that incur lower risks of neonatal mortality, while Andean infants are subject to relatively mild selection pressure at both ends of the birthweight distribution. Given the overall small size at birth of Ladakhi newborns and the poor survival outcomes of newborns below the mean, it is suggested that this population is less well adapted in a biological sense to the stresses inherent in this high-altitude environment than are Andean populations, perhaps due to the relatively recent colonization of the area and the substantial genetic admixture that has occurred in the past.
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Affiliation(s)
- A S Wiley
- Department of Anthropology, University of Iowa, Iowa City 52242
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