Category Archives: Maternal and Infant Health
Overly Clean Homes Can Increase Child’s Risk of Asthma, Allergies
Living in an overly clean home can actually increase an infant’s risk of developing allergies or asthma as they grow older, as their bodies are not given the chance to develop appropriate responses, according to a new study in the Journal of Allergy and Clinical Immunology. The researchers behind the study were surprised by the results, as they had been looking deeper into data that found that exposure to roach, mouse and pet droppings and other allergens increased asthma risk. "What we found was somewhat surprising and somewhat contradictory to our original predictions," said study co-author Robert Wood, MD, chief of the Division of Allergy and Immunology at the Johns Hopkins Children's Center in Baltimore, according to HealthDay. "It turned out to be completely opposite—the more of those three allergens you were exposed to, the less likely you were to go on to have wheezing or allergy." Approximately 40 percent of the allergy- and wheeze-free children in the study were raised in homes with high amounts of allergens and bacteria, while only 8 percent who suffered from both conditions had been exposed to allergens and bacteria while infants. Read more on pediatrics.
Study: Prenatal Medicaid Policy Reduces Smoking, But Doesn’t Improve Preterm Birthweights
While a Medicaid policy that fast-tracks applications of pregnant women helps reduce smoking during pregnancy, it has no significant effect on improving preterm birth rates or low birth weights, according to a new study in the journal Health Affairs. The study specifically looked at Medicaid’s presumptive eligibility and unborn-child option, which provides coverage for prenatal care. “Although the prevalence of prenatal smoking in the United States has declined in recent decades, it is nearly twice as high among low-income women enrolled in Medicaid than it is in the U.S. population as a whole,” said Marian Jarlenski, PhD, lead author of the paper. “Our research shows that Medicaid’s presumptive eligibility policy led to a nearly 8 percentage-point decrease in smoking during pregnancy, but neither policy significantly improved rates of preterm birth or babies born small for their gestational age.” Read more on maternal and infant health.
CDC: Watercress Tops ‘Powerhouse’ Fruits and Vegetables List
With a “nutrient density score” or 100.00, watercress tops the U.S. Centers for Disease Control and Prevention’s (CDC) new list of “powerhouse” fruits and vegetables. The list of 41 foods was created as a tool for nutrition education and dietary guidance. The study defined “powerhouse” as foods most strongly associated with reduced chronic disease risk, which are often green leafy, yellow/orange, citrus and cruciferous items. Chinese cabbage, chard, beet green and spinach rounded out the top five. The full list is available here. Read more on nutrition.
FDA Initiative Gives Developers Easy Access to Public Health Data
A new online initiative from the U.S. Food and Drug Administration (FDA), openFDA, will give mobile application creators, web developers, data visualization artists and researchers access to the agency’s vast public health datasets in order to streamline the creation of their own applications. The structured, computer-readable format allows researchers to determine what types of data they want to search and how they want to present that data to end-users. “The openFDA initiative leverages new technologies and methods to unlock the tremendous public data and resources available from the FDA in a user-friendly way,” said Walter S. Harris, the FDA’s chief operating officer and acting chief information officer. “OpenFDA is a valuable resource that will help those in the private and public sectors use FDA public data to spur innovation, advance academic research, educate the public, and protect public health.” Read more on technology.
Study: 24 Million U.S. Youth Exposed to E-cigarette Advertisements
Unlike with traditional cigarettes, the U.S. Food and Drug Administration (FDA) does not regulate the marketing of e-cigarettes unless they are advertised as a smoking cessation aid. As a result, e-cigarette companies currently market their products to an audience that includes 24 million youth, according to a new study in the journal Pediatrics. Researchers determined that, from 2011 to 2013, youth exposure to e-cigarette advertisements climbed 256 percent and young adult exposure climbed 321 percent. They also determined that approximately 76 percent of the youth exposure came from advertisements on cable networks. Read more on tobacco.
Study: Global Investment in Midwives Needed to Save the Lives of Mothers, Newborns
Investments in midwifery could save the lives of millions of mothers and newborns, according to a new report from the United Nations Population Fund (UNFPA), the International Confederation of Midwives (ICM) and the World Health Organization (WHO). The report determined that 73 African, Asian and Latin American countries experienced 96 percent of the world’s maternal deaths, 91 percent of stillbirths and 93 percent of newborn deaths, with lack of access to midwives a significant contributing factor. Those countries have only 42 percent of the world’s midwives, nurses and doctors.
- Among the report’s recommendations:
- Increased access to preventive and supportive care from a collaborative midwifery team
- Immediate access to emergency services when needed
- Completing post-secondary education
- And, from a broader perspective, women should delay marriage, have access to healthy nutrition and receive four pre-birth care visits
"Midwives make enormous contributions to the health of mothers and newborns and the well-being of entire communities. Access to quality health care is a basic human right. Greater investment in midwifery is key to making this right a reality for women everywhere," said Babatunde Osotimehin, UNFPA Executive Director, in a release. Read more on maternal and infant health.
Census: Bicycle Commuting Up 60 Percent in Past Decade
U.S. cities across the country are seeing increases in bicycle commuters, according to a recent report from the U.S. Census Bureau. The report found that the total number of people who use a bike to get to work jumped by approximately 60 percent in the past decade, to about 786,000 during the 2008-2012 period, making the largest percentage increase of all commuting modes tracked by the 2000 Census and the 2008-2012 American Community Survey. Portland, Ore. had the highest bicycle-commuting rate at 6.1 percent; the overall national rate was 0.6 percent. "In recent years, many communities have taken steps to support more transportation options, such as bicycling and walking," said Brian McKenzie, a Census Bureau sociologist and the report's author, in a release. "For example, many cities have invested in bike share programs, bike lanes and more pedestrian-friendly streets." Read more on physical activity.
May 19 is ‘Hepatitis Testing Day’
Approximately 5.3 million Americans live with chronic viral hepatitis, although many don’t even realize they’re infected, according to the U.S. Department of Health and Human Services. Today, May 19, marks the third national Hepatitis Testing Day, founded to work to increase the number of people who know their hepatitis B and hepatitis C status; what severe—or even fatal—complications they may face if they’re infected; and their risk of spreading it to others. The U.S. Centers for Disease Control and Prevention (CDC) offers an online Hepatitis Risk Assessment, which utilizes brief questions to determine risk, and then prints out recommendations based on CDC’s testing and vaccination guidelines to discuss with their health care provider. Read more on prevention.
Current, Former Smokers May Have Harder Time Becoming Pregnant
Current and former smokers may face more difficulty when trying to become pregnant, according to a new study in the journal Fertility and Sterility. Researchers at the Boston University School of Public Health (BUSPH) analyzed the chances of getting pregnant among 686 current smokers, 741 former smokers and 2,346 women who never smoked, finding that among the former smokers with the highest level of exposure, the chance of getting pregnant was reduced on average by 26 percent per menstrual cycle. “Pregnant women are already encouraged to quit smoking because of the risks to the mother and baby. Some women might not be aware that current regular smoking also harms female fertility, as concluded by the U.S. Surgeon General based on observational studies and animal studies,” said Rose Radin, a doctoral student in the BUSPH Department of Epidemiology and the lead author of the study, in a release. “Our study also found that current regular smokers take longer to get pregnant than never smokers.” Read more on tobacco.
Future of Public Health is an ongoing series focused on the emerging faces in the world of public health. We spoke with Margo Klar, MPH, a PhD candidate in the Department of Epidemiology at the University of Florida’s College of Public Health & Health Professions, about what helped lead her to the field, her Bill and Melinda Gates Foundation-funded work in maternal health, and where she hopes to go from here.
NewPublicHealth: What encouraged you to pursue a degree and career in public health?
Margo Klar: As an undergraduate at the University of California, Irvine (UCI) I majored in Chemical Engineering and worked in an environmental engineering lab. My undergraduate research focused on the effects of urban runoff on water quality, which we tracked from inland California to the ocean. During my last quarter at UCI, I took a biomedical engineering course. As a part of the class, we were asked to invent a new sleep apnea device. I really enjoyed that creative process and it opened my eyes to the fields of biomedical engineering and medicine.
After graduating, I began looking at applying to medical schools. I went back to school and took anatomy and biology prerequisites. My anatomy teacher once said, “In the United States we worry about problems with our feet, in other countries people don't have feet.” This really resonated with me. While researching medical school programs, I learned about Master of Public Health programs. I decided the MPH would be a great stepping-stone and improve my application to medical school. I was accepted into the Yale School of Public Health in the department of Environmental Health Science. Not only did I receive the training necessary to evaluate health and look for ways to improve global health, I was also able to direct my own thesis research project. I wrote my master’s thesis on an indoor cookstove improvement project for Proyecto Mirador, LLC in rural Honduras. I collected health data and examined indoor air quality improvement and reduction of firewood use as a result of cookstove replacement. This was a terrific learning experience.
NPH: You’ve received a Grand Challenges Explorations grant from the Bill and Melinda Gates Foundation to develop ceramic umbilical cord scissors. What drove you to pursue maternal and child health coming from an environmental background?
Klar: My mentor at Yale, Catherine Weikart Yeckel, PhD thought I should take a look at the Grand Challenges Explorations grant through the Gates Foundation. Essentially this funding mechanism releases a set of topics every six months to which they fund somewhere between 80 to 100 grants to the amount of $100,000 for two years of work. After the first proof of concept phase is complete, a second phase application can be submitted for up to $1 million.
Dr. Yeckel encouraged me to take a look at the maternal and child health topic. Essentially, I Googled top reasons for neonatal mortality in developing countries- neonatal tetanus and infection as a result of poor birthing hygiene and the way the umbilical cord is cut, was among the top causes. I really did not, at the time, have a strong interest in maternal and child health. I had an interest in problem solving, mainly because it’s been something, which has been a personal strength throughout my education. Thanks to my engineering background, I can look at a problem and come up with a solution to try to mitigate it. So, essentially I just applied my problem solving skills to the maternal and child health topic.
Study: Kids’ Cereals Average 40 Percent More Added Sugar than Adult Cereals
One bowl of kids’ cereal every morning would total as much as 10 pounds of sugar in a year, according to a new study from the Environmental Working Group (EWG). The organization assessed the sugar content of 1,500 cereals. While almost all had added sugar, the levels were higher in the 181 cereals specifically marketed to children—an average of 40 percent higher. “When you exclude obviously sugar-heavy foods like candy, cookies, ice cream, soft and fruit drinks, breakfast cereals are the single greatest source of added sugars in the diets of children under the age of eight,” said nutritionist and EWG consultant Dawn Undurraga, co-author of the organization’s new report, Children’s Cereals: Sugar by the Pound, in a release. “Cereals that pack in as much sugar as junk food should not be considered part of a healthy breakfast or diet. Kids already eat two to three times the amount of sugar experts recommend.” Read more on nutrition.
HHS, EU Making Progress in Fight Against Antimicrobial Resistance
This week the U.S. Department of Health and Human Services (HHS) and the European Commission released a progress report of the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR), a joint effort to combat antimicrobial resistance. In 2009, TATFAR identified and adopted 17 recommendations; the progress report includes one new recommendation to go along with 15 existing recommendations.
Notable TATFAR activities from 2011-2013 include:
- Adoption of procedures for timely international communication of critical events that might indicate new resistance trends with global public health implications
- Publication of a report on the 2011 workshop, “Challenges and solutions in the development of new diagnostic tests to combat antimicrobial resistance” to the TATFAR website
- Joint presentations to the scientific community to increase awareness about the available funding opportunities on both sides of the Atlantic
There are an estimated 25,000 deaths in Europe and 23,000 deaths in the United States linked to drug-resistant infections each year. Such infection also cost the United States and the European Union billions of dollars annually in avoidable health care costs and productivity losses. Read more on global health.
Women with Unintended Pregnancies Take the Shortest Maternity Leaves
Women with unintended pregnancies also take the shortest maternity leaves, according to a recent study from the University of Maryland School of Public Health published in the journal Women’s Health Issues. “We know that it’s better for women to take time off after childbirth to take care of their physical and mental health,” said Rada K. Dagher, MD, assistant professor of health services administration. “Returning to work soon after childbirth may not be good for these women or for their children.” Dagher’s previous research has indicated that six months of maternity leave is optimal for reducing a woman’s risk of postpartum depression. In addition to policies that enable women to take longer maternity leaves, she said there is also a need to counsel both women and men who are at risk for unintended pregnancies about effective contraceptive methods. Read more on maternal and infant health.
New Study Shows Latinos of Different Origins Can Have Different Diseases, Risk Factors
A review of a recent study, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) that enrolled about 16,415 Hispanic/Latino adults, finds diversity among Latinos not only in ancestry, culture and economic status, but also in prevalence of certain diseases, risk factors and lifestyle habits. The study was done among Latinos living in San Diego, Chicago, Miami, and the Bronx, N.Y., who self-identified with Central American, Cuban, Dominican, Mexican, Puerto Rican, or South American origins.
- The percentage of people who reported having asthma ranged from 7.4 (among those of Mexican ancestry) to 35.8 (among those of Puerto Rican ancestry).
- The percentage of individuals with hypertension ranged from 20.3 (South American) to 32.2 (Cuban).
- The percentage of people eating five or more servings of fruits/vegetables daily ranged from 19.2 (Puerto Rican origin) to 55.0 (Cuban origin). Also, men reported consuming more fruit and vegetables than women.
- Women reported a much lower consumption of sodium than men among all Hispanic groups represented in the study.
- About 1 in 3 individuals had pre-diabetes, also fairly evenly distributed among Hispanic groups.
- Only about half of individuals with diabetes among all Hispanic groups had it under control.
A second study among the same population will start in October 2014 to reassess certain health measurements and understand the relationship between the identified risk factors during the first visit and future disease in Hispanic populations. Read more on health disparities.
Study: Acetaminophen During Pregnancy Tied to Increased Risk for ADHD, HKDs in Kids
Children whose mothers used acetaminophen during pregnancy are at higher risk for developing attention-deficit/hyperactivity disorder (ADHD)–like behavioral problems or hyperkinetic disorders (HKDs), according to a new study in JAMA Pediatrics. Researchers analyzed data on 64,322 children and mothers enrolled in the Danish National Birth Cohort from 1996 to 2002, finding that approximately 56 percent of the mothers reported acetaminophen use during pregnancy. Their children were 37 percent more likely to be diagnosed with an HKD, 29 percent more likely to be prescribed ADHD medications and 13 percent more likely to exhibit ADHD-like behaviors at age 7. Approximately five to six percent of babies born today will develop ADHD symptoms at some point in their lives. Jorn Olsen, MD, one of the study's authors and a professor of epidemiology at UCLA and at Aarhus University in Denmark, noted that the risk was relatively modest, but that “for women who are pregnant and who have not taken these drugs, I think that the take-home message would be a lot of the use of these particular drugs during pregnancy is not really necessary," according to Reuters. Read more on maternal and infant health.
Stigma Remains Powerful Barrier Impeding Mental Health Care for Many
The stigma surrounding mental health continues to remain a very real and very serious barrier keeping many people from seeking the health care they need, according to a new study in the journal Psychological Medicine. The analysis, from researchers at King’s College London and funded in part by the U.S. National Institutes of Health, combined the results of 144 studies including more than 90,000 people from around the world. Approximately 25 percent of people are estimated to have mental health problems, but only 75 percent of those in the United States and Europe seek treatment; delays in treatment are linked to worse outcomes for many mental health disorders, such as psychosis, bipolar disorder, major depression and anxiety disorders. The study pointed specifically to “treatment stigma” (the stigma associated with using mental health services or receiving mental health treatment) and “internalized stigma” (shame, embarrassment) as the most significant barriers, as well as concerns about confidentiality, wanting to handle the problem by themselves and not believing they needed help. "We now have clear evidence that stigma has a toxic effect by preventing people seeking help for mental health problems,” said Professor Graham Thornicroft, from the college’s Institute of Psychiatry and the study’s lead author. “The profound reluctance to be ‘a mental health patient’ means people will put off seeing a doctor for months, years, or even at all, which in turn delays their recovery." Read more on mental health.
HHS: 2.2M Enrolled for Coverage Under Affordable Care Act Through December
Despite a glitch-filled October 1 launch that saw only about 27,000 people enroll in the first month, by December 28 an estimated 2.2 million Americans had enrolled for health coverage available through the Affordable Care Act, according to the latest data from the U.S. Department of Health and Human Services. The state and federal online marketplaces enrolled nearly 1.8 million in December alone. Of the 2.2 million enrollees:
- 54 percent are female and 46 percent are male
- 30 percent are age 34 and under
- 24 percent are between the ages of 18 and 34
- 60 percent selected a Silver plan, while 20 percent selected a Bronze plan
- 79 percent selected a plan with Financial Assistance
Read more on the Affordable Care Act.
Task Force Recommends All Pregnant Women Be Screened for Gestational Diabetes
The U.S. Preventive Services Task Force is now recommending that all pregnant women be screened for gestational diabetes after 24 weeks of pregnancy. Gestational diabetes can increase the risk of pregnancy complications (such as preeclampsia) and labor complications, due to the baby growing larger than normal. Newborns are also at higher risk of low blood sugar levels after being exposed to the mother’s high blood sugar. Early diagnosis and treatment—lifestyle changes, blood sugar monitoring and insulin—can reduce the risks for both mother and child. "The number of women who have gestational diabetes is rising, and gestational diabetes has effects not only on the mother, but also on the baby," said task force chairwoman Virginia Moyer, MD, vice president for maintenance of certification and quality at the American Board of Pediatrics. "We want to prevent adverse outcomes for both of them." Read more on maternal and infant health.
West Virginia Closer to Restoring Safer Tap Water After Chemical Leak
About 35,000 people in the area of Charleston, West Virginia, can now drink their tap water safely after it was declared usable again, according to West Virginia American Water. More than 300,000 customers were told their water was unsafe to drink and or use for washing after it was discovered last week that as much as 7,500 gallons of 4-methylcyclohexane methanol, or crude MCHM, from Freedom Industries had leaked into the Elk River. Officials estimate it will take a few more days before the entire system is once again safe. MCHM-tainted water can cause nausea, vomiting, dizziness, diarrhea, rashes and reddened skin; 231 people visited emergency departments with symptoms and 14 were admitted. Read more on water and air quality.
CDC Report Finds Health Disparities, Inequalities Persist across the U.S. Population
The U.S. Centers for Disease Control and Prevention (CDC) has released a new report examining the disparities in mortality and disease risk as they relate to income, education level, sex, race, ethnicity, employment status and sexual orientation. CDC Health Disparities and Inequalities Report — United States, 2013 is the second CDC report to take this wide look at the U.S. population. Among its key findings:
- The overall birth rate for teens 15-19 years old dropped 18 percent from 2007 to 2010, although it varied widely from state to state
- People who are Hispanic, are low wage earners, were born outside of the United States, have no education beyond high school, or are male are more likely to work in an occupation in which workers are more likely than average to be injured or become ill
- Binge drinking is most common for people ages 18-34, men, non-Hispanic whites and people with higher household incomes
“It is clear that more needs to be done to address the gaps and to better assist Americans disproportionately impacted by the burden of poor health,” said Chesley Richards, MD, MPH., director of CDC’s Office of Public Health Scientific Services, which produced the report. “We hope that this report will lead to interventions that will allow all Americans, particularly those most harmed by health inequalities, to live healthier and more productive lives.” Read more on health disparities.
HUD Grants to Help Transform Distressed Communities into Thriving Communities
The U.S. Department of Housing and Urban Development (HUD) is granting approximately $4.37 million to help nine areas transform their public or other HUD-assisted housing and distressed neighborhoods into thriving communities. Fifty- two communities had applied for the Choice Neighborhoods Planning Grants. The agency’s Choice Neighborhoods Initiative supports locally-driven economic developments to create renewed, sustainable communities, with a focus on creating energy-efficient, mixed-income housing that has easy access to high-quality services, education programs, early learning programs, public assets and public transportation. Full details on each community can be found here. Read more on housing.
Study: Certain Health Behaviors Tied to Complication-free Pregnancies
Women who engage in certain healthy behaviors—and avoid certain unhealthy ones—are more likely to have complication-free pregnancies, according to a new study in the journal BMJ. An analysis of health data on more than 5,600 women found that eating fruit, having a healthy weight, having lower blood pressure, having a job, and stopping drug and alcohol abuse at 15-20 weeks of gestation "may increase the likelihood of normal pregnancy outcomes," according to Lucy Chappell, of the Women's Health Academic Center of King's College London. The most common pregnancy-related complications are babies who were too small for their gestational age, high blood pressure, preterm birth and preeclampsia. Read more on maternal and infant health.
FDA Takes Another Step to Reduce Consumption of Trans Fats
The U.S. Food and Drug Administration has taken another step to reduce American’s consumption of trans fats with a preliminary determination that partially hydrogenated oils (PHOs) are not “generally recognized as safe” for use in food. PHOs are the primary dietary source of artificial trans fat in processed foods. Up next is a 60-day comment period to collect more information and input on exactly what it would take for food manufacturers to reformulate products so that they do not include PHOs. “While consumption of potentially harmful artificial trans fat has declined over the last two decades in the United States, current intake remains a significant public health concern,” said FDA Commissioner Margaret A. Hamburg, M.D. “The FDA’s action today is an important step toward protecting more Americans from the potential dangers of trans fat. Further reduction in the amount of trans fat in the American diet could prevent an additional 20,000 heart attacks and 7,000 deaths from heart disease each year—a critical step in the protection of Americans’ health.” Read more on food safety.
Lack of Light Disrupts Sleep Cycles During Hospital Stays, Increases Patient Discomfort
Hospital stays may be even more uncomfortable for most patients than necessary because of an overall lack of adequate light, according to a new study in the Journal of Advanced Nursing. The small study found that lower levels of daytime light exposure were connected to worse mood, as well as more fatigue and pain, in patients. The poor light interfered with their bodies’ ability to adopt a normal sleep-wake cycle. Researchers found the lowest levels of daytime light exposure were tied to worse mood and more fatigue and pain among patients, compared to those whose rooms were better-lit during the day. "Until now, no one has looked at the associations among light and outcomes such as sleep, mood and pain experienced in the hospital," said Esther Bernhofer, lead author of the study and a nurse researcher at the Cleveland Clinic's Nursing Institute. "This study forms a basis for testing future lighting interventions to improve sleep-wake patterns, mood and pain in hospitalized adults.” Read more on mental health.
Study: No Link Between IVF, Increased Risk of Cancer in Kids
Despite years of concerns, a new study on in vitro fertilization (IVF) found no link between the conception technique and an increased risk of cancer in children. The findings were published in the New England Journal of Medicine. Researchers analyzed data on more than 106,000 children born through assisted reproduction between 1992 and 2008, finding the risk of them developing cancer was "the same as naturally conceived children," according to lead researcher Alastair Sutcliffe, MD, a specialist in general pediatrics at the University College London. More than 5 million children have been born through IVF since the first successful birth in 1978. "This study is extremely reassuring and should relieve anybody's anxiety about IVF," concluded Lawrence Grunfeld, MD, an associate clinical professor of obstetrics, gynecology and reproductive science at the Mount Sinai Icahn School of Medicine, in New York City. Read more on cancer.
Stakeholder Health, formerly known as the Health Systems Learning Group, is a learning collaborative made up of 43 organizations, including 36 nonprofit health systems, that have met for close to two years to share innovative practices aimed at improving health and economic viability of communities.
The idea for the learning collaborative came from a series of meetings at the White House Office and U.S. Department of Health & Human Services Centers for Faith-Based & Neighborhood Partnerships. The Stakeholder Health administrative team is based at Methodist Le Bonheur Healthcare Center for Excellence in Faith and Health in Memphis, Tenn., and at Wake Forest Baptist Health System in Winston-Salem, N.C. The Robert Wood Johnson Foundation provided a grant to share the group’s findings and lessons learned.
Earlier this year, Stakeholder Health released a monograph to help identify proven community health practices and partnerships. Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health & Equity and Chief Wellness Officer at the Henry Ford Health System was a key contributor to the monograph.
NewPublicHealth recently spoke to Wisdom about Stakeholder Health’s objectives, goals and emerging successes, which she also presented on at the American Public Health Association’s annual meeting in Boston.
NewPublicHealth: What are examples of implementation of the Stakeholder Health recommendations at the Henry Ford Health System?
Kimberlydawn Wisdom: There are several. Stakeholder Health talks quite a bit about transformative partnerships and the importance of those transformative partnerships. And we have some stellar examples here in southeast Michigan of transformative partnerships, and one that I’d like to point to in particular is an effort we established called Sew Up the Safety Net, which addresses decreasing the infant mortality rate in our region, which is appallingly high.
We’ve developed a partnership with three other competing health systems within the Detroit region. So while on one level we are very strong competitors, on another level, we’ve actually joined our strategies and resources together in order to address the infant mortality challenge that we have in our communities. We also have private partners and public partners that are involved with us at various levels, but I think having that unprecedented partnership with competing health systems and getting real work done is something that we’re very proud of and work very hard to maintain.