{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T05:14:03Z","timestamp":1787894043305,"version":"build-2784847793"},"reference-count":44,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,2,14]],"date-time":"2022-02-14T00:00:00Z","timestamp":1644796800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,2,14]],"date-time":"2022-02-14T00:00:00Z","timestamp":1644796800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Reprod Health"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.<\/jats:p><\/jats:sec>","DOI":"10.1186\/s12978-022-01355-4","type":"journal-article","created":{"date-parts":[[2022,2,14]],"date-time":"2022-02-14T13:03:11Z","timestamp":1644843791000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["\u201cI got to catch my own baby\u201d: a qualitative study of out of hospital birth"],"prefix":"10.1186","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8513-4910","authenticated-orcid":false,"given":"Mickey","family":"Sperlich","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cynthia","family":"Gabriel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2022,2,14]]},"reference":[{"issue":"2","key":"1355_CR1","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1111\/birt.12411","volume":"46","author":"MF MacDorman","year":"2019","unstructured":"MacDorman MF, Declercq E. Trends and state variations in out-of-hospital births in the United States, 2004\u20132017. Birth. 2019;46(2):279\u201388.","journal-title":"Birth"},{"issue":"1","key":"1355_CR2","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1111\/jmwh.12172","volume":"59","author":"M Cheyney","year":"2014","unstructured":"Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health. 2014;59(1):17\u201327.","journal-title":"J Midwifery Womens Health"},{"issue":"11","key":"1355_CR3","first-page":"1","volume":"58","author":"MF MacDorman","year":"2010","unstructured":"MacDorman MF, Menacker F, Declercq E. Trends and characteristics of home and other out-of-hospital births in the United States, 1990\u20132006. Natl Vital Stat Rep. 2010;58(11):1\u20134.","journal-title":"Natl Vital Stat Rep"},{"issue":"10","key":"1355_CR4","doi-asserted-by":"publisher","first-page":"56","DOI":"10.3389\/fpsyg.2019.00056","volume":"25","author":"M Greenfield","year":"2019","unstructured":"Greenfield M, Jomeen J, Glover L. \u201cIt can\u2019t be like last time\u201d\u2014choices made in early pregnancy by women who have previously experienced a traumatic birth. Front Psychol. 2019;25(10):56.","journal-title":"Front Psychol"},{"issue":"2","key":"1355_CR5","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1016\/j.jmwh.2008.09.006","volume":"54","author":"D Boucher","year":"2009","unstructured":"Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health. 2009;54(2):119\u201326.","journal-title":"J Midwifery Womens Health"},{"issue":"7068","key":"1355_CR6","doi-asserted-by":"publisher","first-page":"1309","DOI":"10.1136\/bmj.313.7068.1309","volume":"313","author":"TA Wiegers","year":"1996","unstructured":"Wiegers TA, Keirse MJ, van der Zee J, Berghs GA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ. 1996;313(7068):1309\u201313.","journal-title":"BMJ"},{"issue":"3","key":"1355_CR7","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1111\/j.1523-536X.2009.00322.x","volume":"36","author":"EK Hutton","year":"2009","unstructured":"Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003\u20132006: a retrospective cohort study. Birth. 2009;36(3):180\u20139.","journal-title":"Birth"},{"issue":"3","key":"1355_CR8","doi-asserted-by":"publisher","first-page":"380","DOI":"10.1016\/j.midw.2011.05.006","volume":"28","author":"E Hadjigeorgiou","year":"2012","unstructured":"Hadjigeorgiou E, Kouta C, Papastavrou E, Papadopoulos I, M\u00e5rtensson LB. Women\u2019s perceptions of their right to choose the place of childbirth: an integrative review. Midwifery. 2012;28(3):380\u201390.","journal-title":"Midwifery"},{"key":"1355_CR9","doi-asserted-by":"publisher","first-page":"94","DOI":"10.1097\/00006199-197903000-00012","volume":"28","author":"RP Lederman","year":"1979","unstructured":"Lederman RP, Lederman E, Work BA, McCann DS. Relationship of psychological factors in pregnancy to progress in labor. Nursing Res. 1979;28:94\u20137.","journal-title":"Nursing Res"},{"key":"1355_CR10","doi-asserted-by":"publisher","first-page":"242","DOI":"10.1016\/j.jogn.2020.12.006","volume":"50","author":"CM Epstein","year":"2021","unstructured":"Epstein CM, Houfek J, Rice MJ, Weiss SJ. Integrative review of early life adversity and cortisol regulation in pregnancy. J Obstet Gynecol Neonatal Nurs. 2021;50:242\u201355.","journal-title":"J Obstet Gynecol Neonatal Nurs"},{"issue":"5","key":"1355_CR11","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1016\/j.jmwh.2005.04.024","volume":"50","author":"JS Seng","year":"2005","unstructured":"Seng JS, Low LK, Ben-Ami D, Liberzon I. Cortisol level and perinatal outcome in pregnant women with posttraumatic stress disorder: a pilot study. J Midwifery Womens Health. 2005;50(5):392\u20138.","journal-title":"J Midwifery Womens Health"},{"issue":"1","key":"1355_CR12","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1016\/j.jogn.2017.10.008","volume":"47","author":"JS Seng","year":"2018","unstructured":"Seng JS, Li Y, Yang JJ, King AP, Low LM, Sperlich M, Rowe H, Lee H, Muzik M, Ford JD, Liberzon I. Gestational and postnatal cortisol profiles of women with posttraumatic stress disorder and the dissociative subtype. J Obstet Gynecol Neonatal Nurs. 2018;47(1):12\u201322.","journal-title":"J Obstet Gynecol Neonatal Nurs"},{"issue":"4","key":"1355_CR13","doi-asserted-by":"publisher","first-page":"295","DOI":"10.1007\/s00737-011-0218-2","volume":"14","author":"JS Seng","year":"2011","unstructured":"Seng JS, Kohn-Wood LP, McPherson MD, Sperlich M. Disparity in posttraumatic stress disorder diagnosis among African American pregnant women. Arch Womens Ment Health. 2011;14(4):295\u2013306.","journal-title":"Arch Womens Ment Health"},{"key":"1355_CR14","doi-asserted-by":"publisher","first-page":"530","DOI":"10.1016\/j.jad.2021.08.079","volume":"295","author":"PM Sanjuan","year":"2021","unstructured":"Sanjuan PM, Fokas K, Tonigan JS, Henry MC, Christian K, Rodriguez A, Larsen J, Yonke N, Leeman L. Prenatal maternal posttraumatic stress disorder as a risk factor for adverse birth weight and gestational age outcomes: a systematic review and meta-analysis. J Affect Disord. 2021;295:530\u201340.","journal-title":"J Affect Disord"},{"key":"1355_CR15","doi-asserted-by":"publisher","first-page":"361","DOI":"10.2147\/IJWH.S55561","volume":"7","author":"R Zielinski","year":"2015","unstructured":"Zielinski R, Ackerson K, Low LK. Planned home birth: benefits, risks, and opportunities. Int J Womens Health. 2015;7:361.","journal-title":"Int J Womens Health"},{"key":"1355_CR16","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1111\/jmwh.12142","volume":"59","author":"D Cook","year":"2014","unstructured":"Cook D, Avery M, Frisvold M. Formulating evidence-based guidelines for certified nurse-midwives and certified midwives attending home births. J Midwifery Womens Health. 2014;59:153\u20139.","journal-title":"J Midwifery Womens Health"},{"issue":"24","key":"1355_CR17","doi-asserted-by":"publisher","first-page":"2741","DOI":"10.1001\/jama.1980.03310240033019","volume":"244","author":"CA Burnett","year":"1980","unstructured":"Burnett CA, Jones JA, Rooks J, Chen CH, Tyler CW, Miller CA. Home delivery and neonatal mortality in North Carolina. JAMA. 1980;244(24):2741\u20135.","journal-title":"JAMA"},{"issue":"8","key":"1355_CR18","doi-asserted-by":"publisher","first-page":"930","DOI":"10.2105\/AJPH.77.8.930","volume":"77","author":"WF Schramm","year":"1987","unstructured":"Schramm WF, Barnes DE, Bakewell JM. Neonatal mortality in Missouri home births, 1978\u201384. Am J Public Health. 1987;77(8):930\u20135.","journal-title":"Am J Public Health"},{"key":"1355_CR19","volume-title":"Uncertain terms: negotiating gender in American culture","author":"FD Ginsburg","year":"2001","unstructured":"Ginsburg FD, Tsing AL. Uncertain terms: negotiating gender in American culture. Boston: Beacon Press; 2001."},{"key":"1355_CR20","first-page":"1651","volume":"94","author":"A Hickman","year":"2009","unstructured":"Hickman A. Born (not so) free: legal limits on the practice of unassisted childbirth or freebirthing in the United States. Minn L Rev. 2009;94:1651.","journal-title":"Minn L Rev"},{"issue":"6","key":"1355_CR21","doi-asserted-by":"publisher","first-page":"474","DOI":"10.1016\/0091-2182(95)00061-5","volume":"40","author":"ER Declercq","year":"1995","unstructured":"Declercq ER, Paine LL, Winter MR. Home birth in the United States, 1989\u20131992: a longitudinal descriptive report of national birth certificate data. J Nurse-Midwifery. 1995;40(6):474\u201382.","journal-title":"J Nurse-Midwifery"},{"issue":"9","key":"1355_CR22","doi-asserted-by":"publisher","first-page":"1545","DOI":"10.2105\/AJPH.2005.065680","volume":"95","author":"TJ Rosenberg","year":"2005","unstructured":"Rosenberg TJ, Garbers S, Lipkind H, Chiasson MA. Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: differences among 4 racial\/ethnic groups. Am J Public Health. 2005;95(9):1545\u201351.","journal-title":"Am J Public Health"},{"issue":"6","key":"1355_CR23","doi-asserted-by":"publisher","first-page":"707","DOI":"10.1111\/jmwh.12490","volume":"61","author":"JL Alhusen","year":"2016","unstructured":"Alhusen JL, Bower KM, Epstein E, Sharps P. Racial discrimination and adverse birth outcomes: an integrative review. J Midwifery Womens Health. 2016;61(6):707\u201320.","journal-title":"J Midwifery Womens Health"},{"issue":"2","key":"1355_CR24","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1111\/birt.12043","volume":"40","author":"E Montgomery","year":"2013","unstructured":"Montgomery E. Feeling safe: a metasynthesis of the maternity care needs of women who were sexually abused in childhood. Birth. 2013;40(2):88\u201395.","journal-title":"Birth"},{"issue":"1","key":"1355_CR25","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12884-015-0626-9","volume":"15","author":"E Montgomery","year":"2015","unstructured":"Montgomery E, Pope C, Rogers J. The re-enactment of childhood sexual abuse in maternity care: a qualitative study. BMC Pregnancy Childbirth. 2015;15(1):1\u20137.","journal-title":"BMC Pregnancy Childbirth"},{"key":"1355_CR26","doi-asserted-by":"crossref","unstructured":"Diamond-Brown LA. Women\u2019s motivations for \u201cchoosing\u201d unassisted childbirth: A compromise of ideals and structural barriers. In Reproduction, Health, and Medicine 2019 Nov 22. Emerald Publishing Limited.","DOI":"10.1108\/S1057-629020190000020010"},{"key":"1355_CR27","first-page":"192","volume-title":"Assessing psychological trauma and PTSD","author":"J Wolfe","year":"1997","unstructured":"Wolfe J, Kimerling R. Gender issues in the assessment of posttraumatic stress disorder. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford Press; 1997. p. 192\u2013238."},{"issue":"4","key":"1355_CR28","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1097\/00006199-196807000-00014","volume":"17","author":"BG Glaser","year":"1968","unstructured":"Glaser BG, Strauss AL, Strutzel E. The discovery of grounded theory; strategies for qualitative research. Nurs Res. 1968;17(4):364.","journal-title":"Nurs Res"},{"issue":"19","key":"1355_CR29","doi-asserted-by":"crossref","first-page":"160940692092818","DOI":"10.1177\/1609406920928188","volume":"29","author":"HA Qureshi","year":"2020","unstructured":"Qureshi HA, \u00dcnl\u00fc Z. Beyond the paradigm conflicts: a four-step coding instrument for grounded theory. Int J Qual. 2020;29(19):1609406920928188.","journal-title":"Int J Qual"},{"key":"1355_CR30","unstructured":"Padgett DK. Qualitative methods in social work research. Sage publications; 2016 May 25."},{"key":"1355_CR31","volume-title":"Qualitative inquiry and research design: choosing among five approaches","author":"JW Creswell","year":"2007","unstructured":"Creswell JW. Qualitative inquiry and research design: choosing among five approaches. 2nd ed. Thousand Oaks: Sage Publications; 2007.","edition":"2"},{"key":"1355_CR32","doi-asserted-by":"crossref","unstructured":"Shanley LK. Unassisted childbirth. ABC-CLIO; 2012 Feb 22.","DOI":"10.5040\/9798216028949"},{"issue":"5","key":"1355_CR33","first-page":"1","volume":"11","author":"K McDonald","year":"2011","unstructured":"McDonald K, Amir LH, Davey MA. Maternal bodies and medicines: a commentary on risk and decision-making of pregnant and breastfeeding women and health professionals. BMC Public Health. 2011;11(5):1\u20138.","journal-title":"BMC Public Health"},{"key":"1355_CR34","volume-title":"Exploring evidence for disrespect and abuse in facility-based childbirth","author":"D Bowser","year":"2010","unstructured":"Bowser D, Hill K. Exploring evidence for disrespect and abuse in facility-based childbirth. Boston: USAID-TRAction Project, Harvard School of Public Health; 2010."},{"key":"1355_CR35","doi-asserted-by":"publisher","first-page":"S49","DOI":"10.1016\/j.ijgo.2015.02.005","volume":"131","author":"S Miller","year":"2015","unstructured":"Miller S, Lalonde A. The global epidemic of abuse and disrespect during childbirth: history, evidence, interventions, and FIGO\u2019s mother\u2013baby friendly birthing facilities initiative. Int J Gynecol Obstet. 2015;131:S49-52.","journal-title":"Int J Gynecol Obstet"},{"key":"1355_CR36","volume-title":"Against health: how health became the new morality","year":"2010","unstructured":"Metzl J, Kirkland A, Kirkland AR, editors. Against health: how health became the new morality. New York: NYU Press; 2010."},{"issue":"12","key":"1355_CR37","doi-asserted-by":"publisher","first-page":"840","DOI":"10.1016\/j.annepidem.2012.10.001","volume":"22","author":"KA Ertel","year":"2012","unstructured":"Ertel KA, James-Todd T, Kleinman K, Krieger N, Gillman M, Wright R, Rich-Edwards J. Racial discrimination, response to unfair treatment, and depressive symptoms among pregnant black and African American women in the United States. Ann Epidemiol. 2012;22(12):840\u20136.","journal-title":"Ann Epidemiol"},{"issue":"5","key":"1355_CR38","doi-asserted-by":"publisher","first-page":"561","DOI":"10.1016\/j.midw.2011.11.002","volume":"28","author":"M Jackson","year":"2012","unstructured":"Jackson M, Dahlen H, Schmied V. Birthing outside the system: perceptions of risk amongst Australian women who have freebirths and high risk homebirths. Midwifery. 2012;28(5):561\u20137.","journal-title":"Midwifery"},{"issue":"2","key":"1355_CR39","first-page":"1","volume":"9","author":"M Bayly","year":"2018","unstructured":"Bayly M, Downe P. \u201cMost often people would tell me I was crazy\u201d: defending against deviance ascribed to alternative birth choices. MIRCI. 2018;9(2):1.","journal-title":"MIRCI"},{"issue":"1","key":"1355_CR40","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12978-019-0729-2","volume":"16","author":"S Vedam","year":"2019","unstructured":"Vedam S, Stoll K, Taiwo TK, Rubashkin N, Cheyney M, Strauss N, McLemore M, Cadena M, Nethery E, Rushton E, Schummers L. The giving voice to mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):1\u20138.","journal-title":"Reprod Health"},{"issue":"232","key":"1355_CR41","doi-asserted-by":"publisher","first-page":"270","DOI":"10.1016\/j.socscimed.2019.05.008","volume":"1","author":"LB Attanasio","year":"2019","unstructured":"Attanasio LB, Hardeman RR. Declined care and discrimination during the childbirth hospitalization. Soc Sci Med. 2019;1(232):270\u20137.","journal-title":"Soc Sci Med"},{"issue":"16","key":"1355_CR42","doi-asserted-by":"publisher","first-page":"4296","DOI":"10.1073\/pnas.1516047113","volume":"113","author":"KM Hoffman","year":"2016","unstructured":"Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci USA. 2016;113(16):4296\u2013301.","journal-title":"Proc Natl Acad Sci USA"},{"issue":"38","key":"1355_CR43","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1016\/j.midw.2016.03.010","volume":"1","author":"L Holten","year":"2016","unstructured":"Holten L, de Miranda E. Women\u2019s motivations for having unassisted childbirth or high-risk homebirth: an exploration of the literature on \u2018birthing outside the system.\u2019 Midwifery. 2016;1(38):55\u201362.","journal-title":"Midwifery"},{"issue":"1\u20132","key":"1355_CR44","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1177\/1744987118809450","volume":"24","author":"C Feeley","year":"2019","unstructured":"Feeley C. Freebirthing: a case for using interpretative hermeneutic phenomenology in midwifery research for knowledge generation, dissemination and impact. J Res Nurs. 2019;24(1\u20132):9\u201319.","journal-title":"J Res Nurs"}],"container-title":["Reproductive Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12978-022-01355-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12978-022-01355-4\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12978-022-01355-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,9,18]],"date-time":"2024-09-18T14:15:46Z","timestamp":1726668946000},"score":1,"resource":{"primary":{"URL":"https:\/\/reproductive-health-journal.biomedcentral.com\/articles\/10.1186\/s12978-022-01355-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,2,14]]},"references-count":44,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["1355"],"URL":"https:\/\/doi.org\/10.1186\/s12978-022-01355-4","relation":{},"ISSN":["1742-4755"],"issn-type":[{"value":"1742-4755","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,2,14]]},"assertion":[{"value":"9 July 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"25 January 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 February 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was reviewed and approved by the Health Sciences and Behavioral Sciences Institutional Review Board at the University of Michigan (ID #HUM00014720).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"43"}}