Divergent trends in maternal cigarette smoking during pregnancy: United States 1990-99

While examination of causes for trends in smoking have largely focused on how changes have occurred with maternal age and, less commonly, time period, little is known as to how age, period and birth cohort interact on trends in the prevalence of smoking during pregnancy. We performed a population-based, retrospective cohort study based on the vital statistics records comprised of White (n=24,499,629) and Black (n = 5,096,625) women delivering in the United States in 1990-99. Smoking prevalence rates were derived by seven 5-year maternal age groups (15-19 to 45-49 years), two time periods (1990-94 and 1995-99), and eight 5-year maternal birth cohorts (1945-49 to 1980-84) after adjusting for the confounding effects of gravidity, education, marital status, and lack of prenatal care through multivariable logistic regression models. The prevalence of smoking was 17.3% among Whites, and 13.5% among Blacks, with substantial variations by age, time period, and birth cohort. The rate declined with increasing age among Whites during the 1990-94 and 1995-99 periods. Among Blacks, the rates increased steeply with advancing age up to 25-29 years and began to decline thereafter. Smoking rates declined among both Whites and Blacks with increasing birth cohort within each age strata. These rates were highest among multigravid women (gravida > or = 2), and lowest among primigravid women. The rates among Whites declined with increasing maternal age for each gravida. Among Blacks, smoking rates for each gravida increased with advancing age up to 25-29 years, and plateaued among older women. Variation in smoking prevalence by age, time period, and birth cohort provides impetus for designing interventions to reduce smoking. Such studies should not only consider cross-sectional trends, but also the divergent patterns by age and cohort among women of different race/ethnic groups and gravidity.     

Smoking prevalence of pregnant women compared to women in the general population of Washington State.

We used two readily available sources of information to identify subgroups of pregnant Washington State women with high smoking rates. We compared smoking rates in pregnant women and women in general using information from the Washington State birth certificate collection system and the Washington State Behavioral Risk Factor Surveillance System. Smoking rates are substantially higher in young mothers 18-24 years of age than in comparable age cohorts in the general population of women in the state. In contrast, mothers 25 years of age and older smoke at lower rates than their age cohort in the general population. For multiparous women of all ages, smoking prevalence is related to age at first birth. Married women, whether pregnant or not, smoked less than unmarried women.     

Risk indicators for talipes equinovarus in Washington State, 1987-1989

To identify risk indicators for talipes equinovarus, we compared 175 case children with talipes equinovarus of unknown etiology identified through the Washington State Birth Defect Registry with 1,470 control children sampled from resident live births. Infant gender, maternal smoking, death of a preterm sibling, and marital status were independently related to talipes equinovarus in an analysis based on information from birth certificate records. The findings differed by infant gender. The prevalence odds ratio for maternal smoking was 2.6 (95% confidence interval: 1.6-4.0) in males and 1.4 (95% confidence interval:0.6-3.2) in females.     

The Washington State Intergenerational Study of Birth Outcomes: methodology and some comparisons of maternal birthweight and infant birthweight and gestation in four ethnic groups

A statewide database of vital records and hospital discharge summaries of obstetric and neonatal admissions for Washington State in 1987-95 was linked to the birth certificates of mothers born in the state. A total of 46,000 births to mothers of four racial/ethnic groups were studied: Whites, African-Americans, Native Americans and Hispanics. For all four groups inverse associations were found between maternal birthweight and infant low birthweight and preterm birth. The birthweight distribution of African-American mothers was displaced markedly downwards compared with the Whites; this difference in maternal birthweight is offered as a partial explanation of the greater prevalence of suboptimal pregnancy outcomes in the former. In contrast, the maternal birthweight distributions of Whites, Native Americans and Hispanics are similar; differences in pregnancy outcomes are probably more related to maternal preconceptional and postnatal factors in these groups as well as differences in pregnancy-related factors. Mothers' birthweight may have clinical value in identifying high-risk pregnancies.     

High incidence of sudden infant death syndrome among Northern Indians and Alaska Natives compared with Southwestern Indians: Possible role of smoking

Epidemiologic studies of sudden infant death syndrome (SIDS) in the United States have found a particularly high incidence among American Indians and Alaska Natives compared with whites. This report shows that there is a remarkable difference in the incidence of SIDS between Northern Indians and Southwestern Indians. From 1984 through 1986, the incidence of SIDS was 4.6 per 1,000 live births among Indians and Alaska Natives in the Northern region of the United States, while the incidence among Southwestern Indians was 1.4 per 1,000 live births (risk ratio = 3.4; 95 percent confidence interval = 2.4-4.8). Among whites living in the same regions, the incidence of SIDS was 2.1 and 1.6 per 1,000 live births, respectively. The incidence among Native Americans in the Northern region was high in all five Indian Health Service Areas. Differences in socioeconomic status, maternal age, birth weight, and prenatal care did not appear to explain the higher incidence of SIDS among Northern Indians compared with Southwestern Indians. However, the prevalence of maternal cigarette smoking during pregnancy is exceptionally high among Northern Indians and Alaska Natives, while it is low among Southwestern Indians. This difference in smoking habits may explain, at least in part, the excess risk of SIDS among Indians in the Northern region. This report points to the need for effective smoking cessation programs for Native Americans, targeting in particular women of reproductive age.     

Maternal smoking during pregnancy and the prevalence of autism spectrum disorders, using data from the autism and developmental disabilities monitoring network

Background: Reported associations between gestational tobacco exposure and autism spectrum disorders (ASDs) have been inconsistent.Objective: We estimated the association between maternal smoking during pregnancy and ASDs among children 8 years of age.Methods: This population-based case–cohort study included 633,989 children, identified using publicly available birth certificate data, born in 1992, 1994, 1996, and 1998 from parts of 11 U.S. states subsequently under ASD surveillance. Of these children, 3,315 were identified as having an ASD by the active, records-based surveillance of the Autism and Developmental Disabilities Monitoring Network. We estimated prevalence ratios (PRs) of maternal smoking from birth certificate report and ASDs using logistic regression, adjusting for maternal education, race/ethnicity, marital status, and maternal age; separately examining higher- and lower-functioning case subgroups; and correcting for assumed under-ascertainment of autism by level of maternal education.Results: About 13% of the source population and 11% of children with an ASD had a report of maternal smoking in pregnancy: adjusted PR (95% confidence interval) of 0.90 (0.80, 1.01). The association for the case subgroup autistic disorder (1,310 cases) was similar: 0.88 (0.72, 1.08), whereas that for ASD not otherwise specified (ASD-NOS) (375 cases) was positive, albeit including the null: 1.26 (0.91, 1.75). Unadjusted associations corrected for assumed under-ascertainment were 1.06 (0.98, 1.14) for all ASDs, 1.12 (0.97, 1.30) for autistic disorder, and 1.63 (1.30, 2.04) for ASD-NOS.Conclusions: After accounting for the potential of under-ascertainment bias, we found a null association between maternal smoking in pregnancy and ASDs, generally. The possibility of an association with a higher-functioning ASD subgroup was suggested, and warrants further study.     

Prenatal Smoking in Two Consecutive Pregnancies: Georgia, 1989–1992

Objective: To explore the patterns of prenatal smoking among women whose first and second pregnancies ended in live births. Methods: We used population-based data to explore prenatal smoking among 14,732 white and 8968 black Georgia residents whose first and second pregnancies ended in live births during 1989–1992. Smoking status was obtained from birth certificates linked for individual mothers. Because of demographic differences, we analyzed white and black women separately. Results: Approximately 15% (2253) of white women and 4% (318) of black women smoked during their first pregnancy. Of those smokers, 69% (1551) of white women and 58% (184) of black women also smoked during their second pregnancy. For both white and black nonsmokers during the first pregnancy, low education was the most significant predictor of smoking during the second pregnancy, after adjusting for consistency of the father's name on the birth certificate, prenatal care, birth interval, mother's county of residence, and birth outcome. Conclusions: The prevalence of smoking in this study may be low because of underreporting of prenatal smoking on birth certificates. The majority of women who smoked during their first pregnancy also smoked during their second, suggesting that these women exposed their first infant to tobacco smoke both in utero and after delivery. Practitioners should offer smoking cessation programs to women during, as well as after, pregnancy. Pediatricians should educate parents on the health risks to young children of exposure to environmental tobacco smoke and refer smoking parents to smoking cessation programs.     

Maternal smoking and Down syndrome: the confounding effect of maternal age

Inconsistent results have been reported from studies evaluating the association of maternal smoking with birth of a Down syndrome child. Control of known risk factors, particularly maternal age, has also varied across studies. By using a population-based case-control design (775 Down syndrome cases and 7,750 normal controls) and Washington State birth record data for 1984-1994, the authors examined this hypothesized association and found a crude odds ratio of 0.80 (95% confidence interval 0.65-0.98). Controlling for broad categories of maternal age (<35 years, > or =35 years), as described in prior studies, resulted in a negative association (odds ratio = 0.87, 95% confidence interval 0.71-1.07). However, controlling for exact year of maternal age in conjunction with race and parity resulted in no association (odds ratio = 1.00, 95% confidence interval 0.82-1.24). In this study, the prevalence of Down syndrome births increased with increasing maternal age, whereas among controls the reported prevalence of smoking during pregnancy decreased with increasing maternal age. There is a substantial potential for residual confounding by maternal age in studies of maternal smoking and Down syndrome. After adequately controlling for maternal age in this study, the authors found no clear relation between maternal smoking and the risk of Down syndrome.     

Maternal smoking and the risk of polyhydramnios.

BACKGROUND. Washington State birth certificates were used to conduct a population-based case-control study to assess the possible association of maternal smoking with polyhydramnios. METHODS. All singleton births complicated by polyhydramnios (n = 557) were identified from the vital records for the years 1984 to 1987. For comparison, 1671 records were randomly selected for the same years from singleton births uncomplicated by polyhydramnios. RESULTS. Women who reportedly smoked prenatally were found to be at increased risk for polyhydramnios (relative risk [RR] = 1.7, 95% confidence interval [CI] = 1.5-2.1, adjusted for marital status, maternal age, and parity). When women with conditions known to be associated with polyhydramnios were excluded, the risk for those who smoked prenatally remained elevated (RR = 1.8, 95% CI = 1.1-2.3). CONCLUSION. Overdistention of the uterus from polyhydramnios may cause a variety of pregnancy complications. The observed association of smoking with polyhydramnios may be a further indication for public health interventions aimed at preventing smoking during pregnancy.     

The association of maternal growth and socio-economic measures with infant birthweight in four ethnic groups

BACKGROUND: Both maternal socio-economic status (SES) and growth measures are themselves interrelated and are also related to infant birthweight. The objective of this study is to compare the relative importance of such maternal measures as determinants of birthweight of female infants-the prospective mothers of the next generation. METHODS: The study base was derived from a population-based multiethnic intergenerational cohort: the Washington State Intergenerational Cohort. Infants of mothers from four ethnic groups were included: non-Hispanic Whites, African Americans, Native Americans, and Hispanics. We generated simple, partial, and multiple correlation coefficients to investigate the association between birthweight and the maternal growth and SES measures. RESULTS: While there were slight differences among the ethnic groups, generally each of three maternal pre-conceptional growth measures-birthweight, stature, and pre-pregnant weight-was a stronger predictor of female infant birthweight than were each of the five maternal SES factors-age, parity, marital status, educational attainment, and prenatal care onset. After accounting for the proportion of variation in birthweight explained by the maternal growth measures and maternal smoking, the addition of the five SES variables added relatively little to the prediction of infant birthweight. The maximal multiple correlation coefficients (R2) yield values ranging from 9.5% to 12.8%. CONCLUSIONS: A mother's growth before pregnancy is a stronger predictor of infant birthweight than is her current socio-economic circumstance. Since the mother's growth must have been influenced by the socio-economic circumstances of her family of upbringing, this further highlights the intergenerational contribution on a woman's reproductive success.     

Fetal alcohol syndrome prevention in Washington State: evidence of success

Fetal alcohol syndrome (FAS) is a permanent birth defect syndrome caused by maternal consumption of alcohol during pregnancy. It is characterised by growth deficiency, central nervous system damage/dysfunction, and a unique cluster of minor facial anomalies. To assess the effectiveness of fetal alcohol syndrome prevention efforts, one must be able to estimate accurately the prevalence of fetal alcohol syndrome over time in population-based samples. With the establishment of the Washington State Fetal Alcohol Syndrome Diagnostic and Prevention Network of clinics, the development of the Fetal Alcohol Syndrome Facial Photographic Analysis Software, the creation of the Fetal Alcohol Spectrum Disorders (FASD) 4-Digit Diagnostic Code, the establishment of the Foster Care Fetal Alcohol Syndrome Screening Program, and the collection of Pregnancy Risk Assessment Management System data on maternal use of alcohol during pregnancy, the tools, methods and infrastructure for assessing the effectiveness of fetal alcohol syndrome primary prevention efforts in Washington State are in place. A cross-sectional study was conducted to determine whether the prevalence of fetal alcohol syndrome among children in a foster care population, born between 1993 and 1998, decreased with the documented decrease in prevalence of maternal use of alcohol during pregnancy from 1993 and 1998 in Washington State. The prevalence of maternal drinking during pregnancy in Washington State declined significantly (P < 0.001) from 1993 to 1998 as did the prevalence of fetal alcohol syndrome among foster children born 1993-98 (P < 0.03). These observations support the likelihood that fetal alcohol syndrome prevention efforts in Washington State are working successfully.     

Peer Reviewed: Age and Racial/Ethnic Disparities in Prepregnancy Smoking Among Women Who Delivered Live Births

Introduction

Prenatal smoking prevalence remains high in the United States. To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessation interventions to women who are most likely to smoke before pregnancy. Our objective was to identify groups with the highest prepregnancy smoking prevalence by age within 6 racial/ethnic groups.

Methods

We analyzed data from 186,064 women with a recent live birth from 32 states and New York City from the 2004-2008 Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women. We calculated self-reported smoking prevalence during the 3 months before pregnancy for 6 maternal racial/ethnic groups by maternal age (18-24 y or ≥25 y). For each racial/ethnic group, we modeled the probability of smoking by age, adjusting for education, Medicaid enrollment, parity, pregnancy intention, state of residence, and year of birth.

Results

Younger women had higher prepregnancy smoking prevalence (33.2%) than older women (17.6%), overall and in all racial/ethnic groups. Smoking prevalences were higher among younger non-Hispanic whites (46.4%), younger Alaska Natives (55.6%), and younger American Indians (46.9%). After adjusting for confounders, younger non-Hispanic whites, Hispanics, Alaska Natives, and Asian/Pacific Islanders were 1.12 to 1.50 times as likely to smoke as their older counterparts.

Conclusion

Age-appropriate and culturally specific tobacco control interventions should be integrated into reproductive health settings to reach younger non-Hispanic white, Alaska Native, and American Indian women before they become pregnant.     

Relation of Maternal Low Birth Weight to Infant Growth Retardation and Prematurity

Objectives: This study sought to determine the relationship between maternal birth weight, infant intrauterine growth retardation, and prematurity. Methods: Stratified and logistic regression analyses were performed on a dataset of computerized Illinois vital records of African American (N = 61,849) and White (N = 203,698) infants born between 1989 and 1991 and their mothers born between 1956 and 1975. Results: Race-specific rates of small-for-gestational age (weight-for-gestational age <10th percentile) and preterm (<37 weeks) infants rose as maternal birth weight declined. The adjusted (controlling for maternal age, education, marital status, parity, prenatal care utilization, and cigarette smoking) odds ratio (95% confidence interval) of small-for-gestational age for maternal low birth weight (<2500 g) among African Americans and Whites were 1.7 (1.1.4–1.9) and 1.8 (1.7–2.0), respectively. The adjusted odds ratio (95% confidence interval) of prematurity for maternal low birth weight (<2500 g) among African Americans and Whites were 1.6 (1.3–1.9) and 1.3 (1.0–1.6), respectively. The racial disparity in the rates of small-for-gestational age and prematurity persisted independent of maternal birth weight: adjusted odds ratio equaled 2.2 (2.1–2.4) and 1.5 (1.4–1.7), respectively. Conclusions: Maternal low birth weight is a risk factor for infant intrauterine growth retardation and prematurity among African Americans independent of maternal risk status during pregnancy; it is a risk factor for infant intrauterine growth retardation among Whites. Maternal low birth weight fails to explain the racial disparity in the rates of small-for-gestational age and premature infants.     

Smoking behavior among urban and rural Native American adolescents in California

BACKGROUND: Previous studies have documented a high prevalence of tobacco use among Native American adolescents. However, little is known about the smoking behavior of Native American adolescents who live in urban areas. This study used statewide data from California to examine the smoking behavior and related psychosocial risk factors among Native American adolescents living in urban and rural counties. METHODS: The Independent Evaluation of the California Tobacco Control Program conducted three population-based statewide surveys of 10th-grade California public school students in 1996, 1998, and 2000. Past-month smoking and psychosocial correlates were examined among 22,440 respondents, including 1060 Native Americans. RESULTS: Native Americans had a 32% excess risk of past-month smoking compared with other ethnic groups. Smoking prevalence did not differ between urban (27.7%) and rural (29.3%) Native Americans. Native Americans reported higher access to cigarettes and exposure to smoking peers than other groups. Those psychosocial variables explained some, but not all, of the excess risk of smoking among Native Americans. CONCLUSIONS: Effective smoking prevention and cessation interventions are needed for Native American adolescents in urban and rural areas of California.     

Accuracy of prenatal smoking data from Washington State birth certificates in a population-based sample with cotinine measurements

PurposeTo assess the accuracy of smoking data in contemporary U.S. birth certificates.MethodsWe compared data on prenatal smoking as reported on Washington State birth certificates to cotinine measured in archived newborn screening dried blood spots for 200 infants born in 2007 (100 randomly selected from births to self-reported nonsmokers and 100 born to self-reported smokers). We estimated the sensitivity of the birth certificate data to identify prenatal smokers and the precision with which self-identified third trimester smokers report smoking levels.ResultsInfants born to two (2%) mothers who reported they did not smoke during the pregnancy had whole blood cotinine concentrations consistent with active smoking by the mother (sensitivity 85%). Sensitivity of the birth certificate to identify reported smokers who continued to smoke throughout pregnancy was similar (89%). Among self-identified third trimester smokers whose infants' specimens were collected shortly after delivery, Spearman rho between infant cotinine and maternal-reported cigarettes/day in the third trimester was 0.54.ConclusionsBirth certificates may represent a viable option for assessing prenatal smoking status, and possibly smoking cessation and level among smokers, in epidemiologic studies sufficiently powered to overcome a moderate amount of exposure measurement error.     

Linking birth records to hospital admission records enhances the identification of women who smoke during pregnancy

Objective : Birth records and hospital admission records are valuable for research on maternal smoking, but individually are known to under‐estimate smokers. This study investigated the extent to which combining data from these records enhances the identification of pregnant smokers, and whether this affects research findings such as estimates of maternal smoking prevalence and risk of adverse pregnancy outcomes associated with smoking. Methods : A total of 846,039 birth records in New South Wales, Australia, (2001–2010) were linked to hospital admission records (delivery and antenatal). Algorithm 1 combined data from birth and delivery admission records, whereas algorithm 2 combined data from birth record, delivery and antenatal admission records. Associations between smoking and placental abruption, preterm birth, stillbirth, and low birthweight were assessed using multivariable logistic regression. Results : Algorithm 1 identified 127,612 smokers (smoking prevalence 15.1%), which was a 9.6% and 54.6% increase over the unenhanced identification from birth records alone (prevalence 13.8%), and delivery admission records alone (prevalence 9.8%), respectively. Algorithm 2 identified a further 2,408 smokers from antenatal admission records. The enhancement varied by maternal socio‐demographic characteristics (age, marital status, country of birth, socioeconomic status); obstetric factors (multi‐fetal pregnancy, diabetes, hypertension); and maternity hospital. Enhanced and unenhanced identification methods yielded similar odds ratios for placental abruption, preterm birth, stillbirth and low birthweight. Conclusions : Use of linked data improved the identification of pregnant smokers. Studies relying on a single data source should adjust for the under‐ascertainment of smokers among certain obstetric populations.     

Association Between Changes in Smoking Habits in Subsequent Pregnancy and Infant Birth Weight in West Virginia

West Virginia has one of the highest prenatal smoking prevalence rates in the nation. While overall national prenatal smoking rates have been declining, the prevalence rates in West Virginia continue to climb. Smoking in pregnancy has been associated with deleterious health outcomes in infants, including decreased birth weight. Yet, minimal research has been done on changes in smoking behaviors over time and the association of the changes in infant birth weights. The aim of the current study is to examine the change in prenatal smoking status of West Virginia women and the associated changes in infant birth weights. Population-based secondary data analysis was conducted using West Virginia birth certificates for all singleton infant siblings born between 1989 and 2006, linked based on mother. Infants born to women who smoked during pregnancy had significantly lower birth weights than infants born to non-smokers. Repeated measures analysis used to examine the changes with time showed that women who smoked during their first pregnancy but refrained from smoking during their subsequent pregnancy had significantly increased birth weight for the second infant, and conversely, infants born to women who initiated smoking with the subsequent pregnancy had significantly decreased birth weight compared to the previous infant. Findings of the study may be used to inform and to guide the development of population focused interventions to decrease maternal prenatal smoking in first and in subsequent pregnancies in an effort to improve infant birth weight outcomes.     

Smoking Cessation during Pregnancy and Relapse after Childbirth: The Impact of the Grandmother’s Smoking Status

Objectives Smoking during pregnancy can result in negative effects in exposed children. It is well established that the smoking status of husbands is a major predictor of smoking among pregnant women. It was investigated whether the smoking status of the women's parents and parents-in-law has an impact on smoking cessation during pregnancy and relapse after birth above the smoking status of the husband. Method An initial sample of 458 women and their husbands was assessed prospectively during a 17-month period after birth regarding smoking habits. Five months after birth the women and their husbands reported the smoking status of their own parents. Results Smoking during pregnancy was related to the smoking status of the women's husband and mother. Women with a husband and mother who smoke were more likely to continue smoking. Relapse after smoking cessation during pregnancy was related to the smoking status of the husband and the mother-in-law. The smoking status of the women's father and father-in-law was not related to smoking cessation or relapse. Conclusion The smoking status of the pregnant women's mothers and mothers-in-law is related to fetal and newborn's nicotine exposure. The findings suggest benefits of taking the smoking status of pregnant women's mothers and mothers-in-law into account in smoking prevention programs for pregnant women and mothers with infants.     

Race, family income, and low birth weight.

The relations among race, family income, and low birth weight were examined using information obtained from the National Longitudinal Survey of Youth, which conducted yearly interviews with a nationally representative sample of young women identified in the late 1970s. Data were available for these women and their offspring from 1979 through 1988. Maternal education, maternal age, age/parity risk, marital status, and smoking during pregnancy served as covariates in cross-sectional and longitudinal analyses. The risk of low birth weight among births to black women and white women who were poor was at similarly high levels regardless of whether poverty was determined prior to study entrance or during the study period. Longitudinal analyses showed an exceptionally large increase in risk of low birth weight among children born to women whose prior pregnancy ended in a low-birth-weight infant. These two findings emphasize the importance of factors antecedent to the pregnancy in the genesis of low birth weight.     

Smoking Status and Factors Associated with Smoking of First-Time Mothers During Pregnancy and Postpartum: Findings from the Healthy Beginnings Trial

This study aimed to investigate smoking status and factors associated with smoking among first-time mothers and their partners during pregnancy and postpartum. A prospective cohort study with 201 first-time mothers was conducted using data from the Healthy Beginnings Trial, undertaken in one of the most socially and economically disadvantaged areas of south-western Sydney, Australia in 2007–2010. Smoking status of the mothers and their partner and smoke-free home status were assessed at 30–36 weeks of pregnancy, and also at 6, 12 and 24 months postpartum. Multivariable two-level logistic random-intercept models were conducted. Smoking rates of the first-time mothers were 17.6 % during pregnancy and 22.5 % postpartum. The likelihood of being a current smoker among the mothers significantly increased after giving birth, with an adjusted odds ratio of 3.96 (95 % CI 1.3–12.1) at 6 months, 6.19 (95 % CI 1.84–30.9) at 12 months, and 6.58 (95 % CI 1.86–23.23) at 24 months postpartum. Mothers’ smoking status was significantly inversely associated with educational level and positively associated with their partner’s smoking status. In addition, mothers who breastfed their child were significantly less likely to be a smoker, with an adjusted odds ratio of 0.10 (95 % CI 0.02–0.68). Although pregnancy may act as a motivator to quit smoking, it is of concern that maternal smoking rate increased after giving birth. Smoking cessation programs should not only focus on smoking in pregnancy, but also address other risk factors, particularly in postpartum women and their partners.