Produção Nacional
Revisado por pares
Women's Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil
2017; Wiley; Volume: 43; Issue: 2 Linguagem: Inglês
10.1111/padr.12074
ISSN1728-4457
AutoresLetícia J. Marteleto, Abigail Weitzman, Raquel Zanatta Coutinho, Sandra Valongueiro Alves,
Tópico(s)Intimate Partner and Family Violence
ResumoPopulation and Development ReviewVolume 43, Issue 2 p. 199-227 ARTICLEFree Access Women's Reproductive Intentions and Behaviors during the Zika Epidemic in Brazil Letícia J. Marteleto, Letícia J. MarteletoSearch for more papers by this authorAbigail Weitzman, Abigail WeitzmanSearch for more papers by this authorRaquel Zanatta Coutinho, Raquel Zanatta CoutinhoSearch for more papers by this authorSandra Valongueiro Alves, Sandra Valongueiro AlvesSearch for more papers by this author Letícia J. Marteleto, Letícia J. MarteletoSearch for more papers by this authorAbigail Weitzman, Abigail WeitzmanSearch for more papers by this authorRaquel Zanatta Coutinho, Raquel Zanatta CoutinhoSearch for more papers by this authorSandra Valongueiro Alves, Sandra Valongueiro AlvesSearch for more papers by this author First published: 05 June 2017 https://doi.org/10.1111/padr.12074Citations: 35AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat The epidemic caused by the Zika virus (ZIKV), beginning in 2015, is a major public health shock for Brazil, confronting reproductive-age women with an array of potentially dire risks for pregnancy and for the health of their children. As these risks have become more widely known, we would expect to see responses on the part of vulnerable women in changed childbearing intentions and in sexual and contraceptive behavior. In this study we investigate these responses. In particular, we examine the interplay of women's desires, behaviors, and healthcare access and use during the first 18 months of the epidemic, drawing on rich new qualitative data. The ZIKV epidemic has several defining features. First, the virus is transmissible via a mosquito (the Aedes aegypti) that is already familiar to most Brazilians because of its long history transmitting other viruses, including dengue fever and chikungunya (Petersen et al. 2016). This familiarity may affect the ways in which people understand and respond to the vector. Second, ZIKV is transmissible not only via mosquitoes, but also via sexual intercourse, blood transfusions, and amniotic fluid (ibid.).1 The fact that it is transmissible via amniotic fluid means that pregnant women can transmit the virus to their fetuses (Brasil et al. 2016; Brito 2015; Petersen et al. 2016). Moreover, infection at any point during pregnancy can have deleterious effects on fetal development (Brasil et al. 2016). Third, the symptoms of ZIKV infection can range in severity from rashes and fevers to temporary paralysis (Guillain-Barré Syndrome; Petersen et al. 2016). Among fetuses, ZIKV infection can lead to congenital Zika syndrome, of which microcephaly is a possible outcome (França et al. 2016; Johansson et al. 2016; Miranda-Filho et al. 2016; Petersen et al. 2016).2 Fourth, despite its wide range of potential symptoms, ZIKV infection can often be asymptomatic (Johansson et al. 2016), allowing it to go unnoticed and/or to be unknowingly transmitted. Finally, there is as yet no vaccine or treatment for the virus (Marston et al. 2016; Thomas et al. 2016). Together, these features of the epidemic imply that the only way to guarantee against Zika-related birth defects until a vaccine is developed, the epidemic subsides, and/or an effective treatment becomes available is to avoid becoming pregnant or to terminate a pregnancy. In this article, we provide an overview of the Brazilian context and describe how and why the ZIKV epidemic may affect reproductive processes. We then use new focus group data collected in two regions of Brazil with different onsets of the ZIKV epidemic and ZIKV and microcephaly rates to explore how the epidemic is affecting women's fertility intentions and contraceptive use. We pay special attention to how women's socioeconomic status and geographic location are related to their responses to the epidemic. Focus groups are especially well suited for capturing the complexity of individual motivations and behaviors because exchanges between participants often provoke the detailed expression and/or qualification of different perspectives (Morgan and Krueger 1993). To conclude, we highlight the implications of our observations for researchers and policymakers seeking to better understand and address how the ZIKV epidemic is affecting reproductive decision-making and disparities in reproductive health. The Brazilian context In the decades before the ZIKV epidemic, Brazil's fertility fell dramatically, from 5.8 births per woman in the 1970s (Berquó and Cavenaghi 2004) to 1.9 by 2010 (Cavanaghi and Berquó 2014). Because fertility was already below replacement level, many women may have wanted to prevent pregnancy even before the epidemic began. If so, then the epidemic could exert little influence on women's already predominantly low fertility desires. However, unintended fertility remains high in Brazil, where approximately 50 percent of all births are deemed unintended (Le et al. 2014). This large unintended birth rate reveals an important disconnect between the fertility desires and behaviors of many women. Thus, even if women wish to prevent pregnancy during the epidemic, it is unlikely that all of them will be able to do so successfully. Some women who do become pregnant may seek an abortion, despite the fact that abortion is highly restricted in Brazil (Aiken et al. 2016). These abortions may pose additional health risks because many are unsafe (Fusco and Andreoni 2012; Grimes et al. 2006), and they may be especially risky if performed in the second or third trimester. Because unintended pregnancy disproportionately occurs among women of lower socioeconomic status (Prietsch et al. 2011; Theme-Filha et al. 2016), women with greater economic resources may be more successful in preventing unwanted pregnancy during the epidemic and beyond. Appendix Table 1 highlights fertility patterns by socioeconomic status and geographic region in Brazil.3 Overall fertility and adolescent fertility levels are highest among women with low socioeconomic status (Cavenaghi and Berquó 2014). Moreover, women with lower status have a greater number of children and tend to have them earlier in their reproductive years than women with higher status (Camarano et al. 2014; Cavenaghi and Berquó 2014). For example, in 2010, the highest age-specific fertility rates among women in households with less than 1 minimum wage4 occurred at ages 20–24; among their counterparts in households with more than 2 minimum wages, the highest age-specific fertility rates occurred at ages 30–34. This pattern suggests that a greater share of younger women with lower status were likely to view their childbearing as completed when the ZIKV epidemic began than women of the same age with higher socioeconomic status. At the same time, evidence also suggests that women with higher socioeconomic status tend to delay pregnancy (Camarano et al. 2014; Cavenaghi and Berquó 2014), which may mean that more women with higher status had not yet completed their childbearing at the epidemic's onset. Moreover, because economic development has disproportionately occurred in the Southern regions of Brazil (Diniz 2002) and poverty levels are higher in the Northern regions (IPEA 2010), reproductive health disparities persist across space. For instance, adolescent fertility rates are significantly higher in the lesser developed North and Northeast than in the South and Southeast (Appendix Table 1). Likewise, higher fertility rates are observed in the North than in the South. For example, in 2010 the total fertility rates in the North and Northeast were 2.47 and 2.06, respectively, while they were below replacement levels in the South and Southeast (1.78 and 1.70, respectively, Appendix Table 1). Underlying these socioeconomic and geographic disparities in fertility are parallel disparities in contraceptive use. Our calculations show that among non-pregnant women in unions with 9 years of schooling or more in 2006, 89.3 percent used modern contraceptive methods at ages 15–19 and 87.3 percent at ages 20–24. In contrast, among women with less than 3 years of schooling, only 61.1 percent and 76.7 percent used modern contraception at these respective ages. Rates of modern contraceptive use were lowest in the North and Northeast in the 1990s, but gaps declined by the mid-2000s.5 Higher rates of contraceptive failure, discontinuation, and switching are also found in the Northeast (Leite and Gupta 2007). Despite disparities in reproductive health, Brazil's unified health system (Sistema Único de Saúde-SUS) is designed to provide universal and equitable health care to all citizens (Costa 2016a; Macinko and Harris 2015). Brazil's SUS system6 provides most health procedures and prescribed medications free of charge, including contraception. A branch of the health care offered by SUS is formed by community-based primary care called Estratégia Saúde da Família (Family Health Strategy), which provides comprehensive primary health care7 for a large proportion of Brazil's population (62 percent in 2014) (Macinko and Harris 2015). Importantly for this research, ZIKV was first detected in Northeast Brazil (Diniz 2016; Pan American Health Organization 2015; Zanluca et al. 2015), and the region was initially hit hardest by the epidemic (Brasil 2017a; Oliveira et al. 2017). For instance, in November and December 2016 (epidemiological weeks 45/2015 to 52/2016), 1,049 municipalities had reported ZIKV cases in the Northeast compared to only 381 in the Southeast (Brasil 2017b). Figure 1 shows that in the state of Pernambuco alone, 106 municipalities had confirmed ZIKV cases in this period; in Minas Gerais, only 16 municipalities had confirmed ZIKV cases. Moreover, the Northeast presents the highest number of confirmed microcephaly cases8 in the country (1,730 cases out of the total of 2,347). A combination of lower economic development, high temperatures, stagnant water, and sanitation problems are possible explanations for why Brazil's Northeastern region was affected first by the ZIKV epidemic (Ali et al. 2017; Diniz 2016; Zanluca et al. 2015). Figure 1Open in figure viewerPowerPoint Relative and absolute number of municipalities with confirmed cases of ZIKV by state in the period between epidemiological weeks 45/2015 and 52/2016: Brazil, 2015–2016 SOURCE: Brasil 2017b. Risk perceptions and reproductive intentions The presence of Zika and the threats it poses to developing fetuses may lead some women to want to prevent or delay9 pregnancy and childbearing. In fact, early in the epidemic, some officials in the Brazilian Ministry of Health encouraged women to postpone pregnancy (Romero 2015) because doing so was the only legal way to avoid Zika-related birth defects until more was understood about the virus and the prevention of intrauterine transmission. There are several reasons why the epidemic may lead some women to want to avoid a pregnancy. First is the possibility of becoming infected during pregnancy and transmitting the virus to the developing fetus. The health belief model (Rosenstock 1974) suggests that the motivation to adapt one's behaviors to mitigate health-related risks is often contingent on simultaneously believing that one is at risk of infection, that infection poses grave health consequences, that specific actions will reduce the risk of infection, and that the benefits of preventing infection outweigh the costs (Rosenstock 1974; Rosenstock, Strecher, and Becker 1994). Applied to the ZIKV epidemic, this model would suggest that in order for women to want to postpone pregnancy they must believe they are at risk of ZIKV infection, understand the potential in utero consequences of infection, believe that abstinence and/or contraception will successfully prevent pregnancy, and believe that not becoming pregnant is worth any monetary, physical, or psychological costs incurred from abstinence and/or contraception. This last belief may be less common among women who desired more children before the epidemic began, especially if these women are reaching the end of their reproductive years. For these women, the potential cost of delaying pregnancy may mean an inability to conceive at a later date. A second and related reason is that the epidemic may be affecting social norms and values. Both the theory of planned behavior (Ajzen 1991) and the theory of reasoned action (Fishbein and Ajzen 2011) suggest that individuals’ intentions are related to their attitudes, beliefs, and perceived norms, which are derived from their social surroundings. Thus, if public officials’ discouragement of pregnancy during the early stages of the epidemic has increased stigma against pregnant women and especially against infected pregnant women, then this stigma may heighten women's desire to avoid pregnancy. Likewise, increased attention to congenital Zika syndrome, particularly microcephaly, both among the media and among women's peers, may also affect women's perceptions of risk and attitudes toward becoming pregnant during the epidemic, which may in turn affect their pregnancy intentions. Assuming that at least some women want to postpone pregnancy, the theory of planned behavior and the theory of reasoned action also suggest that this desire should result in deliberate actions to prevent becoming pregnant, such as using contraception more frequently or switching to a more effective form of contraception (Moreau et al. 2013; Reinecke, Schmidt, and Ajzen 1996; Sutton, McVey, and Glanz 1999). Similarly, the cognitive social model of fertility intentions (Bachrach and Morgan 2013) suggests that the desire to avoid pregnancy may lead to both deliberate and automatic reactions that increase efforts to prevent pregnancy. Preliminary evidence indicates a slight decline in live births, starting in the second half of 2016, underscoring the possibility that at least some Brazilian women are changing their fertility behavior during the period of the ZIKV epidemic.10 Figure 2 shows the absolute numbers of vaginal and cesarean-section deliveries occurring in hospitals. These numbers declined in December 2016 after remaining stable for the previous two years.11 Correspondingly, Figure 3 shows the total number of live births in Pernambuco12 (a state with high ZIKV incidence). In this state, the number of live births declined by 10 percent between 2015 and 2016, starting in August 2016, a little more than a year after the epidemic began. Figure 2Open in figure viewerPowerPoint Absolute number of hospitalizations due to deliveries (all types) by month and year, Brazil 2014–2016 SOURCE: Ministério da Saúde 2017. Data available for tabulation at www.datasus.gov.br. Accessed March 14, 2017. Figure 3Open in figure viewerPowerPoint Number of live births by month and year, 2015–2016: Pernambuco, Brazil SOURCE: Sinasc/GMVEV/DG-IAEVE/SEVS/SES-PE. Preliminary data available through the Microcephaly Epidemic Research Group. Accessed March 28, 2017. Distal determinants of reproductive responses to the ZIKV epidemic To prevent or delay pregnancy, women must either limit their sexual activity or use effective forms of contraception consistently (Bongaarts 1978). However, women's consistent use of contraception often varies with their social context. For instance, socioeconomic status shapes women's ability to obtain and afford reproductive services (Campbell, Sahin-Hodoglugil, and Potts 2006; Dennis and Grossman 2012) and also influences which individuals women interact with on a regular basis, which over time can affect their attitudes toward contraception (Bachrach and Morgan 2013). Socioeconomic status may also shape women's use of contraception by determining the type of reproductive health services to which they have access (Potter et al. 2003). Recent research in Recife, for example, suggests that nurses intentionally do not provide information about emergency contraception to women in order to prevent the method from gaining popularity (Spinelli et al. 2014). If women believe that the quality of care at public clinics is low or that clinics are crowded (Barnes-Josiah, Myntti, and Augustin 1998), they may avoid using public health services even when these are the only services they can afford. Likewise, women may fear a lack of privacy at public rather than private clinics (Hatzenbuehler, Phelan, and Link 2013). This lack of privacy may contribute to a fear of stigmatization when women are seeking services for unwanted or unplanned pregnancies or for treatment of sexually transmitted infections. Analytic strategy Data We conducted eight focus groups in Belo Horizonte, Minas Gerais (Southeast), and eight focus groups in Recife, Pernambuco (Northeast) approximately 18 months after the epidemic began in Brazil. Each focus group consisted of six to eight women between the ages of 18 and 49 years (N = 114). This large age range was intended to capture women both toward the beginning and the end of their reproductive years. We stratified focus groups by socioeconomic status,13 conducting half with women of low status and half with women of high status, which we proxied with the neighborhood of recruitment (described below). We hypothesized that the manner in which the ZIKV epidemic affects the reproductive intentions of women differs by socioeconomic status. Stratifying focus groups by socioeconomic status was also intended to allow participants to identify more readily with one another's experiences and therefore to express themselves more freely (Knodel 1993). Participants included both pregnant and non-pregnant women, with the majority not pregnant at the time of participation. Belo Horizonte and Recife represent distinct demographic, economic, and epidemiological settings in Brazil, yet both are urban state capitals with great influence on their regional economies. Recife, the capital of Pernambuco, is one of the locations where the first cases of ZIKV and microcephaly were diagnosed in Brazil. In 2016, microcephaly cases in Pernambuco constituted 18.9 percent of all cases nationally (Brasil 2017b). In contrast, microcephaly cases in Minas Gerais represented only 0.8 percent of cases nationally in the same year (ibid.). The early onset of the ZIKV epidemic and the high microcephaly rate in Pernambuco suggest differences in both the likelihood of infection and the likelihood of contact with infected individuals according to geographic location. While not a perfect proxy, geographic location suggests variation in the social environment related to Aedes aegypti mosquitoes, ZIKV, microcephaly, and congenital Zika syndrome. These disparities in the onset of the ZIKV epidemic also reflect broader disparities between the two states. The Municipal Human Development Index (IDHM) for 2010, for example, was 0.772 in Recife and 0.810 in Belo Horizonte (Brasil 2017d). A larger proportion of households lack infrastructure in Recife, with increased exposure to mosquitoes; in 2010, 11 percent of Recife households had open sewage, compared to only 1.3 percent in Belo Horizonte households (Brasil 2012). In contrast to Belo Horizonte, Recife has an ideal environment for the reproduction of the Aedes aegypti, owing to its hot temperatures and high humidity (at least 70 percent) throughout the year. Recife also has a chronic problem of water supply and distribution, which is worsened in poor neighborhoods, where people have to save water inside their houses to drink, cook, clean, and use for personal hygiene. In each city, we recruited women from two adjacent neighborhoods selected on the basis of four criteria. First, we ranked all neighborhoods and regions in each municipality by their LIRAa index, that is, the Aedes aegypti larval infestation index (LIRAa—Levantamento de Índice Rápido do Aedes aegypti). The LIRAa index maps localities according to Aedes aegypti infestation. Not surprisingly, Recife has overall higher LIRAa indices than Belo Horizonte (LIRAa 2015, 2016). Of the eight focus groups we conducted in each municipality, four were conducted in areas with low to medium relative levels of Aedes aegypti larvae infestation and four in areas with medium to high relative levels of larvae infestation (ibid.). The second criterion was differing proximities to bodies of water. In Belo Horizonte we selected only areas with close proximity to bodies of water so that these areas are comparable to Recife, which is a city characterized by mangroves. The third selection criterion was that all areas we selected presented contrasting physical infrastructures, that is, high-rise apartments and single-story homes. The fourth criterion was the presence of segregated but adjacent high and low socioeconomic status residences. Within each area, two focus groups were conducted in neighborhoods with high socioeconomic status and two others in neighborhoods with low socioeconomic status. The fourth criterion should result in the participation of women whose ability to prevent unintended pregnancies differs substantially. To generate an overall sample that was diverse in terms of race/ethnicity, age, and socioeconomic status, we recruited participants from a central location—outside of grocery and convenience stores—by passing out flyers containing basic information about the study. Participants were remunerated US$15 (R$50) for their participation—a sum large enough to pay for their transportation costs and one meal on the day of their participation. Focus groups were conducted in rented, safe spaces within the neighborhoods from which women were recruited. All focus groups were led by the same interviewer and were audio-recorded with participants’ oral consent. Immediately following each focus group, the interviewer recorded field notes that conveyed her perceptions of the group's dynamic, body language, and anything else that could not be audio-recorded. Once all focus groups were completed, the audio-recordings (including field notes) were transcribed. Methods The same interview protocol was followed for all focus groups, consisting of open-ended questions about participants’ pregnancy intentions and birth histories; perceptions of ZIKV symptoms; ZIKV transmission; where they receive information about ZIKV; demand for and access to contraception; and what kind of advice they would offer to women who became pregnant during the epidemic. Questions about the effects of ZIKV on women's reproductive plans and behaviors, including abortion, were asked in the latter half of the interview to minimize the possibility of biasing responses. Focus group transcripts were coded and analyzed by two researchers. Coding of the data and thematic analysis were performed manually; software was used to organize overarching themes, highlight codes and excerpts, and quantify codes and their combinations. A literature review on risk perception and reproductive health informed the initial codebook, which included such codes as “sources of information about ZIKV,” “strategies of protection against infection,” “use and type of contraceptives,” and “ZIKV affecting pregnancy by postponement.” Development of the codebook was an iterative process; as new themes emerged (e.g., belief in the severity of ZIKV), a corresponding code was created and added to the codebook and then applied to all previous respondents, an approach widely used in qualitative research (Weiss 1994; Coffey and Atkinson 1996). Many of the codes were accompanied by sub-codes that represented distinct responses within a given code category. In the case of sources of information, for example, sub-codes included “TV,” “Townhall,” “Flyer/folder (cartilha),” “Health agents who visit their homes,” “Children's school,” “Hospital/Posto (waiting room banner),” “On the bus,” “Don't trust word of mouth,” “Internet,” “Radio,” “Newspaper,” “Scientific literature,” “Magazine,” and “Had a class about the topic at school.” Finally, the program combined like-coded passages into an “overview grid” (Knodel 1993), allowing us to relate different data points to one another across comparative contexts. A key strength of this approach is that it highlighted systematic points of convergence and divergence among women from different socioeconomic and geographic backgrounds. Results Reproductive intentions during the ZIKV epidemic We begin by examining whether the ZIKV epidemic has affected the reproductive intentions of Brazilian women. In all groups, regardless of socioeconomic status (SES) or geographic location, women expressed fear of contracting ZIKV. When asked whether they or their friends who want to have (more) children intend to postpone pregnancy because of ZIKV, the majority of both low- and high-SES women mentioned their intentions to postpone pregnancy, regardless of whether they lived in cities with low (Belo Horizonte) or high (Recife) ZIKV prevalence. Women who reported not wanting more children mentioned they would postpone pregnancy if hypothetically they (still) wanted (more) children: Respondent: If I wanted to have children now, I certainly wouldn't do it. Exactly because I don't want to risk being bitten by a mosquito, right?Moderator: But has it crossed your mind to have children at this moment and you postponed because of Zika?Respondent: Yes. That was in the beginning of the year. I said “now, no way.” Running the risk, no. (BH, High SES)Respondent: So, I thought about getting pregnant and now I don't think as much, so I will wait until everything is solved. This is a tragedy and could happen with anyone and I wouldn't like it to happen to me and to my family, so this is something that changed in my mind. I avoid getting pregnant now much more than before. (BH, Low SES)Respondent: I think about fear and about not wanting to get pregnant now. If I had a plan of having a child in one year, it wouldn't be one year anymore, it would be at least 4 years just because of Zika. (Recife, High SES)Moderator: Do you know anyone who does not want to have children because of Zika?Respondent: I do, my niece. Because she is afraid, right?Moderator: And how long will she wait to get pregnant?Respondent: She said three more years because she wants the outbreak to pass. (Recife, Low SES) When discussing how long women intended to postpone pregnancy because of ZIKV, responses varied from specific periods, like 2 or 3 years, to more abstract answers, such as: “when they find a cure,” “when they create a vaccine,” or “until doctors learn more about the epidemic and the mechanisms by which it affects the baby.” Women also reported their own and their friends’ intentions to postpone pregnancy until the dry months, reasoning that the lower mosquito proliferation during the dry months made it temporarily safer for them to become pregnant. Seasonality might have also affected women's pregnancy intentions, because once the number of ZIKV cases declined during the dry months and the media stopped constantly providing the public with ZIKV information, women reported feeling safe about pregnancy again. Intentions regarding pregnancy postponement differed by women's socioeconomic status, reflecting that high-SES women in Brazil have a first pregnancy later than low-SES women and therefore have a shorter amount of time in which to achieve their desired family size. The median age at first pregnancy14 in Northeast Brazil is 19.9 for women with less than high school education and 26.7 for women with at least a high school diploma. In Southeast Brazil the corresponding median ages at first pregnancy are 20.8 and 27.6. In our focus groups, we found that age was a key factor that explained a short period of postponement or no postponement during the ZIKV epidemic for several high-SES women, with high-SES women discussing at length how the “age factor” was a determinant for their own or their friends’ decision whether or not to postpone pregnancy. Notably, these discussions about age were not as frequent among low-SES women, who tended to have children at a much younger age: Respondent: My sister is 36 and got pregnant at the end of last year. She couldn't wait longer. She was already trying for a long time. (BH, High SES)Respondent: I have a niece who is trying to get pregnant. And with the age factor, she is crazy to become a mother. (BH, High SES)Moderator: Why do you think [she got pregnant with the risk of getting Zika]?Respondent: Because of her age. She said “I am 35 and I want to have my daughter. With or without a Zika outbreak.” (Recife, High SES) While all women reported a fear of contracting ZIKV, concerns were stronger among women trying to get pregnant or desiring (more) children than among women who had achieved their desired family size and had no intention to become pregnant. Because most low-SES women have children early in Brazil, concerns over ZIKV were lower among low-SES groups. Specifically, low-SES women stated that they would be more concerned about ZIKV if they were “trying to get pregnant” or if they “wanted more children.” At the same time, in discussions about their own and their friends’ birth histories, low-SES women reported that most of their (and their friends’) pregnancies, particularly the first ones, occurred at a young age and were unplanned: Respondent: I'm going to tell you something. I was very sad. I took my pre-natal classes with 15 women, and I was the only one who wanted to get pregnant. All of them
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