 is Courtney Stiro-Massaro. She is a certified nurse midwives and family nurse practitioner also with her MPH, residing in Boston. She is a C&M at Boston Medical Center and assistant professor of OBGYN at the Boston University School of Medicine. She received her MPH from two main schools of public health and tropical medicine and she completed her RN and MSN. The certification is C&M and FMP at Vanderbilt in Nashville. She has been providing full support midwifery care at Boston Medical Center and it's affiliated Community Health Center since 2014. Welcome Courtney and thank you for stepping in as a replacement speaker for us. You have the floor Courtney. Well welcome everybody and I'm sorry for those of you who wanted to hear about BMI and pregnancy but I hope that you all find this presentation nonetheless interesting even though it wasn't your intended topic. So the objectives for today are to discuss pre-eclampsia rates internationally and nationally, review the negative health and fetal effects of pre-eclampsia, understand the USTFPS's recommendation for prevention of pre-eclampsia and pregnancy, explain aspirin's mechanism for action and helping to prevent pre-eclampsia and discuss how participants might start screening for possible aspirin use in their pregnancy as well as barriers that we at the Medical Center have come across to try and help you not have to go through those similar barriers. And this project was supported by a very generous grant from the March of Dimes. So a little bit of background just to make sure everybody's on the same page. Pre-eclampsia is the onset of hypertension, a blood pressure of 140 over 90 and proteinuria and this is after 20 weeks of pregnancy. Most of the time it's high blood pressure and proteinuria but sometimes there's just the high blood pressure and other symptoms including thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema or cerebral or visual disturbances. And then delivery is the cure for pre-eclampsia. And I should have said when I started if people have questions please write them in the comment box. I'll try to pay attention as I'm talking and so we can go through questions then and if I forget then we'll just go through them at the end. So there are a number of effects for pre-eclampsia on both the mother and the fetus and baby. So there are acute effects and chronic effects. From an acute effect we have eclampsia, stroke, DIC, health syndrome, liver hemorrhage and rupture, pulmonary edema and aspiration, ARDS, acute renal failure and death. From a chronic point of view we also have an increased risk of chronic hypertension, diabetes, renal failure, excuse me, chronic artery disease and neurological deficits. So there are a number of effects both short-term and long-term that are very, very important for moms who have pre-eclampsia. So if there's something that we can do, i.e. taking prenatal aspirin, lotus aspirin in pregnancy to help prevent pre-eclampsia, something that's very important. And Celine, you had asked what do you think about the new American norms? Those norms I believe are not pregnancy-specific. So I think ACOG and ACNM are continuing to maintain the definition of pre-eclampsia as 140 over 90. Those may be adjusted as of now to my knowledge they are not. So the definition of pre-eclampsia kind of maintains the same. And then as far as effects on the fetus, pre-eclampsia is the leading cause of iatrogenic preterm birth and low birth weight. In the United States, 15% of preterm births are due to preeclampsia. So this is a very important issue both from a maternal point of view and from a fetal point of view. And there are other effects including interuterine growth restriction, small for gestational age, oligo-hydramio, placental abrasion, low apgras scores at birth, NICU admissions, stillbirth, neonatal death, an increase in blood pressures in childhood and adulthood. So again, not only are fetuses more at risk for being born preterm, which has long lasting effects on them as babies and children, but many other effects. So a little bit about the epidemiology. Internationally, about 4.6 of deliveries are related to preeclampsia or due to preeclampsia and 1.4% are due to eeclampsia. And 15 to 10 to 15, excuse me, percent of maternal deaths worldwide are associated with preeclampsia and eeclampsia. The WHO estimates about 18% of pregnancies are complicated with hypertensive disorders and that includes not just preeclampsia but gestational hypertension and others. And then from the United States point of view, approximately 3% of pregnancies are complicated by preeclampsia. And 12% of deaths are likely attributed to preeclampsia and eeclampsia. And although morbidity is more common than mortality, it's still both are still very important. And it's estimated that more than one-third of severe obstetric complications are related to preeclampsia. And severe obstetric complications are defined as severe preeclampsia, eeclampsia, severe hemorrhage, severe sepsis, or uterine rupture. So we can see that amongst that large list of very severe complications preeclampsia can account for a third of those severe complications. And in the United States, and I believe internationally as well, rates of hypertension and pregnancy are increasing. So this is why this is a very important topic. And why I'm glad you guys are joining me. And then Selene to get to your question, a little bit about race differences. And this is within the United States, but I again believe that it holds true to some extent internationally. The incidence of preeclampsia in a study that looked at data from 2014 to 2012 showed that the rate for black women was 6.4% compared to 3.75% among white women, which was a statistically significant result. Black women in the same study were 2.8 times more likely to die from complications of hypersensitive diseases than white women. Black women additionally were 2.4 times more likely to have an intrauterine field demise compared to white women. So we can see that within the United States there are huge discrepancies between white and black women. And Hispanic as well, but the discrepancy between white and black is certainly much more severe. And in another study from 1979 to 2006 looking at that data, black rates of preeclampsia increased more than whites. So for blacks the rate was 40.1 per 100,000 deliveries and for whites it was 28.6. So again, another study showing the distinct rates of differences between black and white. And this is just a visual, a chart, or visual from the previous study and just shows again the significant difference between black and white women in the United States. And that, you know, in the 70s there was a difference and then it seemed to kind of, the black rate seemed to decrease and not by any degree catch up with, but have a less stark difference between black and white. And you can see that just recently, let me use my technology, the huge difference. I mean this is black rates and either white rates. And you can see that there's a dramatic difference between those women and their rates of preeclampsia. And so because preeclampsia does cause 15% or is a result of 15% of the pre-tembers talking about infant mortality is also something that I think is important. And we can see here that in the United States our maternal mortality rate for 2015 was 5.8 per 100,000 live birds. And if you look down at the bottom, this is, the figure shows different countries throughout the world based on their infant mortality rate. And the United States is between the Slovakia, excuse me, yes, Slovakia and Russia. So maybe not, maybe we're not doing the best in the road, no offense to the Russians or the Slovaks. Whereas we see that in Boston, the city where I live and the city where I work, the infant mortality for white women is 1.7. Meaning that we have the white women have the infant mortality rate of those women in cinnamon, i.e. very, very good. Whereas our black maternal mortality rate in Boston is 8.1, excuse me, which puts us right in between Chile and Costa Rica. So you can see that although the United States is not doing very well overall, white women in Boston are doing exceedingly well, or excuse me, white infants in Boston are doing exceedingly well from their mortality rate, i.e. they are dying very, very rarely. Whereas black infants in Boston are dying a rate higher than the United States and a rate that is astronomically inappropriate in my opinion. So a little bit about what we can do to try and help not only women get, not get preeclampsia, excuse me, but also decrease this infant mortality rate related to preeclampsia. And the USPSTF, which is the United States Preventative Service Task Force released recommendations a number of years ago recommending that aspirin, 81 milligrams is what they recommended, be used as preventative medicine after 12 weeks of gestation in women who are high risk for preeclampsia. And this will get into more of the data but has been shown to help decrease the rate of preeclampsia. So the USPSTF has kind of two different, well they have three actually, peers of risk factors. There's women who have a high risk for preeclampsia and who should be on prenatal aspirin if they only have if they have one or more risk factor. And those high risk factors include a history of preeclampsia, having multi-field gestation, chronic hypertension, type 1 or type 2 diabetes, renal disease and autoimmune disease. So again, women with any of those risk factors, one risk factor should be on this aspirin. And then the moderate risk factors is a little bit more debatable or excuse me, not debatable, but a little bit more left up to the provider's judgment. And the moderate risk factors include obesity, a family history of preeclampsia, specifically having a mom or a sister who's had preeclampsia. So if you're demographic aspects including being African American, low socioeconomic status, being over 35, or having had a history of low birth weight, small for gestational age or previous adverse pregnancy outcomes and a 10-year pregnancy, more than a 10-year pregnancy interval. The USPSTF says that women who have moderate risk factors, if you have several moderate risk factors, then they should be on aspirin and pregnancy. And several is a word that although Webster defines it as more than two, that was a point of contention or offered a lot of debate in our practice as far as several was two, several was three. And my take on it is the USPSTF said several to leave it up to the provider's recommendation or the provider's choice, that the provider needs to determine whether or not they find the various risk factors that a patient might have worthy of putting them on aspirin. And then, sorry, the third factor, the third level is just low dose, women who have no risk. And those women do not need to be on, the recommendation is for them not to be on an aspirin during pregnancy. So a little bit about the pathology of aspirin, why we think this works. And one of the things is to acknowledge that first off, we don't have a very good sense of why pre-eclampsia, why women get pre-eclampsia. But one of the thoughts is that it has to do with their body's kind of reaction to the placenta in that pathophysiology. So aspirin has been shown to help so, excuse me, women who are at risk for high blood pressure or hypertensive diseases often have their deficient of prestacean, which is a vasodilator, and they also have excess thromboxin, which is a vasoconstrictor in a platelet aggregate, excuse me. And so that can cause hypertensive disorders in pregnancy. And so prenatal aspirin, aspirin being a anti-platelet aggregate, has been shown to help high risk women to decrease that risk of preeclampsia. And you may be wondering why I'm saying prenatal aspirin, why I keep referring to women should be taking prenatal aspirin instead of low dose aspirin or aspirin 81 milligrams. And this was a concerted effort amongst the providers in the hospital where I work, who are working on our aspirin or low dose aspirin or prenatal aspirin program. We very specifically wanted aspirin to be associated with pregnancy in America, or at least in Boston, sometimes people call it baby aspirin or 81 milligrams aspirin. And so we just, we wanted to take away those, that wording and have aspirin be related to pregnancy. We wanted patient providers and pharmacists to understand that the aspirin is being used to it's being prescribed for risk reduction in pregnant women, excuse me. And so that linking pregnancy risk reduction to aspirin we found that prenatal aspirin seemed like a very good way in order to do that. Additionally, some initial studies in Europe have shown that higher doses, higher doses than 81 milligrams might be necessary. And so we felt that rather than saying 81 milligrams of aspirin leaving it something, leaving it more neutral, so that there could be a little could be a possibility of changes if necessary in the future. So prenatal aspirin's benefits, there are a number of them. The US PSPS in their analysis said that aspirin, prenatal aspirin reduces the risk of preeclampsia by at least 10%. The less conservative estimates say it can be up to 24%. So that's a huge, huge dramatic decrease in women getting preeclampsia. There's also a reduced risk of preterm births by 14%. It reduces the risk of intrauterine growth restriction by 20%. A newer meta analysis of many women, 20,000 women who initiated prenatal aspirin before 16 weeks showed that it prevented preeclampsia, prevented severe preeclampsia, and also prevented fetal growth restriction. For a preeclampsia point of view, the risk ratio was down to 0.57. Severe preeclampsia, the risk ratio was 0.47. And for fetal growth restriction, the risk ratio was 0.56. So again, with both of these studies, we can see and many other analysis that have been published since then. The benefit of prenatal aspirin in pregnancy. And so cost benefits, you know, cost is always very important looking at how much each intervention costs and saves. And so the cost of preeclampsia, at least in 2012, was $2.8 billion to the United States health care system. This included 1.03 billion in maternal costs and 1.5 billion in infant costs for infant costs, excuse me. A more recent study in 2015 looked at the savings studies. We implemented the USPSPS guidelines. It would save the United States $3.77 million in direct medical costs. So we estimated that approximately it's $5 or $10 for a woman to get prenatal aspirin for their entire pregnancy. And the cost, the savings, excuse me, are many, many millions of dollars, which our health care system certainly could need. And then a little bit about safety, because I think that's one of the things as we started to implement this in our hospital. There were a lot of concerns from OBGYNs, midwives, pediatricians, pharmacists about the safety of prenatal aspirin. And from a maternal point of view, aspirin is, prenatal aspirin use of pregnancy is not associated with an increased of placental abruption or postpartum hemorrhage. Additionally, aspirin is not associated with first trimester defects, first defects, excuse me, is not associated with birth defects when used in the first trimester. And it is not associated with premature closure of the ductus arteriosus, intraventricular hemorrhage, or neonatal bleeding. So it is something that is very safe in pregnancy, which is. And then a little bit about the timing. There was a study that looked at the best time for taking prenatal aspirin. And it looked at kind of three different times upon waking up, eight hours after waking and at bedtime. And the results showed that at bedtime it was the most beneficial time to take prenatal aspirin. So that's at least in our practice when we recommend women to try and take their prenatal aspirin. And then a word about compliance, which is something that I think many of us struggle with our patients not taking the medicines that we recommend quite to the extent that we would like. And a recent study has shown that greater than 90% compliance is important in decreasing preterm preeclampsia rates. So it is something that is necessary for patients to be taking at a regular basis. And in this study compliance was positively associated with a family history preeclampsia. But interestingly, negative associated with smoking, maternal age less than 25, Afro-Caribbean or South Asian racial origin, or a history of preeclampsia in a previous pregnancy. And I found that to be very interesting because it seems like if your mom had preeclampsia then you're more likely to take your prenatal aspirin. But if you had preeclampsia you are not necessarily more likely to take it. And the researchers don't really go into it but it was just an aspect of the study that I found interesting and worthy of paying attention to given that I typically assume that if my patients have had preeclampsia before they would be more likely to really want to prevent it in their next pregnancy. But at least in this study that was shown not to be the case. So a little bit about the health belief model of self-efficacy. How we can kind of help our patients or why our patients might actually want to take prenatal aspirin. And this is a model that was developed in the 1950s. And so patients need to perceive that they have susceptibility to the problem, that there are consequences to the problem. And if they have that they perceive that there is a threat. Additionally they need to perceive that there is benefit to the action. And they need to understand their barriers to the action. And that allows them to have expectations of the intervention's effectiveness. And both those perceived threats and the expectation of intervention outreach to their self-efficacy. And specifically from a prenatal aspirin point of view what that means is that patients need to have a perceived susceptibility that they might have preterm birth. They might be susceptible to getting hypertensive diseases or hypertensive diseases in pregnancy. They also need to understand or have an appreciation of the consequences of hypertensive disease and preterm birth. And that leads to their perception of the danger. And then they also need to perceive the benefits of aspirin for risk reduction and acknowledge their barriers to being able to take prenatal aspirin. And that then affects their expectation and action's effectiveness. And again all of this leads to their self-determination towards aspirin for risk reduction of hypertensive diseases in pregnancy and preterm birth. So then a little bit about Boston Medical Center and the hospital where I work and where we're going to talk a little bit in the next couple minutes about the interventions that we have done to try and increase our aspirin use in pregnancy. So Boston Medical Center is New England's largest safety net hospital. 50% of families have an income less than $20,000. 30% of our patients are non-English speaking and 68% of patients speak in a language other than English in the home. And 68% of patients also identify as black or Hispanic or black. And within our labor and delivery so our pregnancy the patients that we see who are pregnant, 70% of those patients so we take care of 70% of the black and Latino women in Boston. So one of the reasons why the race disparities are so important for me and for the hospital where I work and the providers where I work is because of this difference. We see the vast majority of the black women and the women who are at high risk for developing preeclampsia in the city of Boston. And so again we went over this but I just want to put BMC is kind of epidemiology to me into play. So internationally we have about 4.6% of deliveries related to preeclampsia, 1.4 related to preeclampsia, and 10 to 15% of maternal deaths associated with preeclampsia and eclampsia. That's nationally. Excuse me, that's internationally. Nationally in the United States approximately 3% of pregnancies are complicated with preeclampsia. At BMC however a recent study showed that approximately 30% of our pregnancies are complicated with some type of hypertension disease preeclampsia gestational hypertension and or intrauterine growth restriction. So compared to the national and international data that's a dramatic increase and a much higher rate of those diseases. And approximately 40% of our preterm births are due to preeclampsia gestational hypertension or intrauterine growth restriction. So it just shows again the level of need and the level of importance within our patient population for making sure that we as providers are screening and prescribing prenatal aspirin and then our patients are taking it. And so we developed a intervention, a quality improvement initiative to try to increase prenatal aspirin prescriptions to 90% and use to 90% in high-risk women in Boston Medical Center. And so there are kind of four primary drivers within which we were trying to implement this quality improvement. First was to screen. To have our patients try and arrive in the first trimester if possible and for providers to screen appropriately. The next thing that was necessary was providers then not after they screened to prescribe and for providers to identify the risks. And then for the other thing, we developed a new graphic which is our electronic medical system to allow the script to be written. Initially when we started this project, whenever a provider would prescribe prenatal aspirin, a pop-up would say, oh, this patient is pregnant, that's unsafe. Are you sure you want to continue? And so providers would have to click through and say, yes, I do. I understand that it is safe. And then the patients need to take the medicine. So they need to go to the pharmacy. They need to be aware of the benefits. And the family needs to be supportive of the patients taking the medicine. And then they need to maintain. They need to maintain taking their prenatal aspirin. They may pick it up, but if they don't take it, then as we already talked about, their compliance, the effects are much finished. So providers need to check in with their patients to make sure that they're taking it. Patients need to continue throughout their pregnancy to believe that it is helpful and so therefore need to take it. Other prescribers need to not discontinue it. And so as we kind of just talked about in our previous slide, our stakeholders include providers, pharmacists, patients, and their family. Those are the ones that we identified. And so from a provider point of view, we did a number of focus groups to kind of get a sense before we started our intervention, before we started our project on how providers felt about prescribing prenatal aspirin. And these focus groups included physicians and midwives who are the main two groups of providers who care for pregnant women, both prenatally and non-laboratory. And so amongst our providers there was an agreement that the high-risk women, the high-risk categories of the USPSTS guidelines, everyone felt very comfortable prescribing prenatal aspirin to those women. There were some concerns about certain moderate risk factors. And again, the debate of is several two, is several three, what does several mean? There were also some concerns about the secondary effects of aspirin that have yet to be studied. Although as I previously mentioned, the studies that we currently have show that prenatal aspirin is safe in pregnancy. There were some concerns that maybe five years down the road, ten years down the road, or one year down the road, there might be some effects that we don't yet know about that we could be unintentionally harming our patients or their patients. And then also from a midwifery point of view, there was that struggle of thinking of pregnancy as normal and believing that pregnancy is normal and that the woman was doing great and her body was doing everything necessary, balancing that with the need for prenatal aspirin and the fact that although your pregnancy is normal, this is something that might need to be taken in order to try and help make it even more safe. And then interestingly, there was also a question by one provider about if withholding prenatal aspirin, if not giving it to patients, was a problem because we know that it's worthwhile and how could we withhold it when we knew that it was beneficial. And so again, we also talked to pharmacists to get a better sense of what they were thinking and their opinions. And they had a number of self-reported hesitations about prescribing prenatal aspirin, including bleeding, harm to the fetus, the risk versus benefit, and just a general lack of knowledge. And 73% of the pharmacists that we pulled or talked to said that they were unaware of the USPSTS guidelines that prenatal aspirin was something that was recommended and something that was safe in pregnancy. Again, we can see from this slide the question asked if a pregnant patient came to my pharmacy with a prenatal aspirin prescription, I would feel comfortable prescribing her prescription and you can see that the vast majority of people either strongly disagree, disagree, or are neutral and that it really is only 23%, it's a very small number of those pharmacists who feel, who would agree or strongly agree to this statement. So it showed us that we had a lot of work to do with the pharmacists. And it was interesting because initially when we started off our project, we honestly hadn't really taken into account the pharmacists importance in helping us make sure that our patients get the prenatal aspirin. We just had assumed that if a provider prescribed the medicine that the pharmacist would dispense it. And clearly we learned very quickly that that is not the case that a lot of the pharmacists had a very difficult time felt unsafe prescribing prenatal aspirin or dispensing, excuse me, the prenatal aspirin to their patients. And then we looked at patients and we had focus groups with the patients and the patients said that their providers had told them that they shouldn't use aspirin. One woman said that in her last pregnancy she had a migraine and her doctor told her to use Tylenol and definitely not use aspirin. And we have another instances of just quotes from patients who said the doctor told me not to use aspirin or that they thought that it was contraindicated. So that's one part of our barriers that we were trying to overcome that have patients realize that, you know, yes, Tylenol is something great for a headache, but aspirin, prenatal aspirin in this aspect is something different than analgesia or other pain medicines. And then there was also the barrier of patients beliefs. A Haitian woman said that she was told that she shouldn't take aspirin when she was pregnant. An Ethiopian woman said that in her country she was told that aspirin can increase the rate of miscarriage. Another woman from El Salvador said that aspirin is not safe because it can act as a contraception. So we see that from a patient point of view we not only have their perception of what their providers are telling them that aspirin might not be safe in pregnancy, but also maybe what they culturally believe or what they hear at home. And so those are other barriers that we saw to overcome. And then looking at their opinions just a little bit more, we see that you know, low dose aspirin is safe in pregnancy when patients were asked that. 27% agreed or strongly agreed, but the remaining 83% did not. They either were neutral or they disagreed. And then for those who were asked about, low dose aspirin can prevent hypertensive diseases in pregnancy, 32% agreed or strongly disagreed. But again, there is a large number of women who were either neutral or strongly disagreed who, when prescribed prenatal aspirin, maybe without the appropriate counseling, would not fill the prescription, would not maintain their taking of the prescription. And so this is kind of a busy chart, I apologize, but it looks at the interventions that we did. So in the bottom, or the top left-hand corner, we see pharmacists. So as I said, we kind of initially hadn't had pharmacists in our wheel and very quickly brought them in and realizing that they were a very important partner within helping our program to succeed. And so we developed educational materials for them, including continuing education lectures. We sent out a newsletter to those who worked at Boston Medical Center and we developed pharmacist algorithms. So the pharmacist would feel safe understanding why prenatal aspirin was safe in pregnancy and helped them to be involved in that risk reduction. And interestingly with CDS Health, we when providers were prescribing prenatal aspirin and prenatal vitamins, those providers would then get a very polite fact from CDS Health, which for non-Americans is just a very large pharmaceutical company in the United States, or pharmaceutical store, saying, I think you probably made a mistake, you prescribed prenatal aspirin and prenatal vitamin to this patient. And if this is not a mistake, please let us know. And so it was something that we were able to reach out to CDS and they were wonderful in sharing our concerns about this fact and we presented them with data and UTSTS and they now have taken that, they have removed that kind of warning label. And so we at least at Boston Medical Center have not been getting that fact anymore, which speaks to the power which speaks to the fact that it was wonderful that they listened to us and were able to adjust their guidelines and their warnings based on new evidence. And then from a patient point of view, we developed educational cards, educational videos, and posters and clinics, which I'll show briefly in the next couple slides as we talked about before. We did focus groups to get a sense, focus groups and surveyed, excuse me, to get a sense of what the patients were feeling and their comfort level with aspirin and their knowledge with aspirin. And in addition, we also developed inpatient counseling for women who had pregnancy induced hypertension, preclampsia gestational hypertension and IUGR, so that those women who had had maybe a preterm birth, who had been induced for preclampsia would know that for their next delivery, for their next pregnancy, excuse me, that they would need to be on prenatal aspirin to try and help decrease their risk of it coming again. And then from a provider point of view, we had focus groups, we did, we do presentations, we have quarterly QI presentations, presentations like this. We also have monthly newsletters, which we send out to our providers. And then we standardize within our electronic medical record. Not only we removed that epic flag that was saying, oh, aspirin is not safe in pregnancy, but we also developed what's called a dot phrase, which just allows patient or provider, excuse me, to have type in one little phrase, and then it pops up all of the risk factors. So providers don't have to remember if chronic hypertension is a moderate risk factor or a high risk factor. It's all there and very easy. And then from a community point of view, we've also been working with a number of groups in Boston who are helping to improve birth outcomes for at-risk women because it seemed like a very logical extension of our program, not only for our hospital, but within the community. And we've asked Google to change their listing of the order of prenatal aspirin sites. Initially when we started this program, if you googled aspirin in pregnancy, it would come up a number of less evidence-based sites. And so we're working with them to try and have the more evidence-based sites come up first so that when patients Google it, that they can have the best information readily available to them. And so this is an example of our education cards that we give to our patients. And it just goes over what you need to know about high blood pressure, who may or may not be at risk for high blood pressure, the different risk factors. And then the safety and the benefits of aspirin in pregnancy, prenatal aspirin in pregnancy. And this is our algorithm for our providers. And we have this displayed around clinic and they've all been emailed it. And it just helps them go through of, you know, risk factors if the patient qualifies for prenatal aspirin and help them to very clearly just kind of walk through the risks and how to go about making sure that they're taking their aspirin. And then the posters, we have a very large Spanish and Haitian Creil speaking populations as well as our English populations. So currently we have posters in Spanish and Haitian Creil and English. And this is just an example on our left. We have a poster in Creil and a poster in a right in Spanish and we have displayed those in our clinic and our ultrasound areas just to help patients if the provider hasn't talked to them about it, helps them to learn about it, but also helps them feel more comfortable. One of the physicians that is the lead in this initiative is an MFM and she was doing an ultrasound and she was counseling patients, a patient about prenatal aspirin and the patient was like, oh yeah, I know about this. I saw the poster in the waiting room. I'm totally on board. And so it was a wonderful way for us to see that our posters had helped the patient feel comfortable about accepting the prenatal aspirin prescription before the provider had even been able to counsel them about it. And then we do have a website at www.prenatalaspirin.com. Our posters are there, our education cards are there, the provider risk assessment. We also have a wonderful video that we made about prenatal aspirin and pregnancy. Well, we certainly think it's wonderful and we hope you think it's wonderful. And as I said, our resources are in Spanish, English, and Haitian Creole right now just because those are the main populations that we, non-English speaking populations that we have at Boston Medical Center. And then just a little bit about our data, how we're doing. You know, it's been a lot of up and down about the... Courtney? Courtney, just to say that we're actually only got two minutes left of the whole session. So you'll need to kind of speed up a bit or come to a conclusion. Well, so to conclude, it's been a long process but we are working on continuing to increase the number of last months that we have. We have 100% a rate of prescription for the high risk for prenatal aspirin. So it's something that we're very proud of. So yes, questions. Well, Courtney, thank you for a very key topic. Looking, it seems to be the major question from the audience was about the posters. Would the posters be available for reproduction? Probably by other practices to use. Are they available to modify or are there any special permissions better that? Because I do see one or two, you know, things in the new population system. That is an exception. I forgot to include my email address embarrassingly on the presentation. We'll type it into the chat box right now. And if people are interested in the posters or the educational part, please just let me know. And I will see what I can do about getting you access to those. Thank you very much for a wonderful presentation, Courtney. And I see you have given us your email address for those of you who are interested in getting additional information about this very key topic. Which I think impacts every single one of us in our practices. Thank you all for your time.