Home Births

Number: 0329


Aetna considers planned deliveries at home and associated services not medically appropriate.

Note: However, coverage of home births will be considered when mandated by law under plans subject to state mandates.

See also CPB 0127 - Home Uterine Activity Monitoring.


According to the policy statement on home delivery of the American College of Obstetricians and Gynecologists (ACOG), labor and delivery, while a physiological process, clearly presents hazards to both the mother and fetus before and after birth.  These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation. 

Guidelines for Perinatal Care published by the American Academy of Pediatrics and ACOG state that the hospital, including a birthing center within the hospital complex, or a freestanding birthing center, provides the safest setting for labor, delivery, and the postpartum period.  The use of other settings is not encouraged.  Further, any facility providing obstetrical care should have the services listed as essential components for a level I hospital.  This includes the availability of blood and fresh-frozen plasma for transfusion; anesthesia, radiology, ultrasound, electronic fetal heart rate monitoring and laboratory services available on a 24-hour basis; resuscitation and stabilization of all inborn neonates; nursery; and other services that are not available in the home setting.

Malloy (2010) stated that home births attended by certified nurse midwives (CNMs) make up an extremely small proportion of births in the United States (less than 1.0 %) and are not supported by ACOG.  The author examined the safety of CNM attended home deliveries compared with certified nurse midwife in-hospital deliveries in the United States as measured by the risk of adverse infant outcomes among women with term, singleton, vaginal deliveries.  United States linked birth and infant death files for the years 2000 to 2004 were used for the analysis.  Adverse neonatal outcomes including death were determined by place of birth and attendant type for in-hospital CNM, in-hospital "other" midwife, home certified nurse midwife, home "other" midwife, and free-standing birth center CNM deliveries.  For the 5-year period, there were 1,237,129 in-hospital CNM attended births; 17,389 in-hospital "other" midwife attended births; 13,529 home CNM attended births; 42,375 home "other" midwife attended births; and 25,319 birthing center CNM attended births.  The neonatal mortality rate per 1,000 live births for each of these categories was, respectively, 0.5 (deaths = 614), 0.4 (deaths = 7), 1.0 (deaths = 14), 1.8 (deaths = 75), and 0.6 (deaths = 16).  The adjusted odds ratio (OR) (95 % confidence interval [CI]) for neonatal mortality for home CNM attended deliveries versus in-hospital CNM attended deliveries was 2.02 (1.18 to 3.45).  The author concluded that deliveries at home attended by CNMs and "other midwives" were associated with higher risks for mortality than deliveries in-hospital by CNMs.

Kennare et al (2010) examined differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births.  The experimental design was a opulation-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991 to 2006.  Analysis included logistic regression adjusted for predictor variables and standardized perinatal mortality ratios.  Main outcome measures included perinatal death, intra-partum death, death attributed to intra-partum asphyxia, Apgar score less than 7 at 5 mins, use of specialized neonatal care, operative delivery, perineal injury and post-partum hemorrhage.  Planned home births accounted for 0.38 % of 300,011 births in South Australia.  They had a perinatal mortality rate similar to that for planned hospital births (7.9 versus 8.2 per 1,000 births), but a 7-fold higher risk of intra-partum death (95 % CI: 1.53 to 35.87) and a 27-fold higher risk of death from intra-partum asphyxia (95 % CI: 8.02 to 88.83).  Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labor.  Low Apgar scores were more frequent among planned home births, and use of specialized neonatal care as well as rates of post-partum hemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant.  Planned home births had lower cesarean section and instrumental delivery rates, and a 7 times lower episiotomy rate than planned hospital births.  The authors concluded that perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

In a meta-analysis, Wax and colleagues (2010) reviewed the medical literature on the maternal and newborn safety of planned home versus planned hospital birth.  These investigators included English-language peer-reviewed publications from developed Western nations reporting maternal and newborn outcomes by planned delivery location.  Outcomes' summary OR with 95 % CI were calculated.  Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery.  These women were less likely to experience lacerations, hemorrhage, and infections.  Neonatal outcomes of planned home births revealed less frequent prematurity, low birth weight, and assisted newborn ventilation.  Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.  The authors concluded that less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.  Limitations of this study included those inherent in the included studies, self-selection of women for home birth, and insufficient data for some outcomes.

The ACOG Committee on Obstetric Practice's opinion on planned home birth (2011) noted that although the Committee believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.  Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.  Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a 2-fold to 3-fold increased risk of neonatal death when compared with planned hospital birth.  More importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a CNM, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Although ACOG does not support planned home births given the published medical data, it emphasizes that women who decide to deliver at home should be offered standard components of prenatal care, including group B Strep screening and treatment, genetic screening, as well as HIV screening.  It is also important for women thinking about a planned home birth to consider if they are healthy and considered low-risk and to work with a CNM, certified midwife, or physician who practices in an integrated and regulated health system; have ready access to consultation; and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency.  Furthermore, the recommendations state that a prior cesarean delivery is an absolute contraindication to planning a home birth due to the risks, including uterine rupture.  Women who want to try for a vaginal birth after cesarean are advised to do so only in a hospital where emergency care is immediately available.  Attempting a home birth also is not advised for women who are post-term (greater than 42 weeks gestation), carrying twins, or have a breech presentation because all carry a greater risk of perinatal death.

The American Academy of Pediatrics (2013) states that hospitals and birthing centers are the safest places for U.S. women to deliver, and expectant mothers should be informed of the increase in neonatal mortality and complications that come with home births. However, the AAP says, clinicians must respect the right of women to make a medically informed decision about delivery. The AAP's statement concurs with the 2011 statement from the American College of Obstetricians and Gynecologists. The AAP notes that planned home birth in the United States appears to be associated with a two- to threefold increase in neonatal mortality. The AAP states that evidence also suggests that infants born at home in the United States have an increased incidence of low Apgar scores and neonatal seizures. Some women who plan to deliver at home will need transfer to a hospital before delivery because of unanticipated complications. This percentage varies widely among reports, from approximately 10% to 40%.

Olsen and Clausen (2012) stated that observational studies of increasingly better quality and in different settings suggested that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications.  These investigators updated a Cochrane review first published in 1998.  They evaluated the effects of planned hospital birth compared with planned home birth in selected low-risk women, assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary.  They searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 30, 2012) and contacted editors and authors involved with possible trials.  Randomized controlled trials comparing planned hospital birth with planned home birth in low-risk women as described in the objectives were selected for analysis.  The 2 review authors assessed trial quality and extracted data, and contacted study authors for additional information.  Two trials met the inclusion criteria but only 1 trial involving 11 women provided some outcome data and was included.  The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn.  The authors concluded that there is no strong evidence from randomized trials to favor either planned hospital birth or planned home birth for low-risk pregnant women.  However, the trials showed that women living in areas where they are not well-informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.  As the quality of evidence in favor of home birth from observational studies seems to be steadily increasing, it might be as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new randomized controlled trials.

Chervenak et al (2013) addressed the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility.  Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women's rights.  These investigators provided a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.  They started with patient safety and showed that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients.  They documented that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d'etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth.  These researchers then argued that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth.  They explained why obstetricians should not participate in or refer to randomized clinical trials of planned home versus planned hospital birth.  The authors called on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.

Tura et al (2013) stated that although promising progress has been made towards achieving the Millennium Development Goal four through substantial reduction in under-five mortality, the decline in neonatal mortality remains stagnant, mainly in the middle and low-income countries.  As an option, health facility delivery is assumed to reduce this problem significantly.  However, the existing evidences show contradicting conclusions about this fact, particularly in areas where enabling environments are constraint.  Thus, this review was conducted with the aim of determining the pooled effect of health facility delivery on neonatal mortality.  The reviewed studies were accessed through electronic web-based search strategy from PUBMED, Cochrane Library and Advanced Google Scholar by using combination key terms.  The analysis was done by using STATA-11.  I(2) test statistic was used to assess heterogeneity.  Funnel plot, Begg's test and Egger's test were used to check for publication bias.  Pooled effect size was determined in the form of relative risk in the random-effects model using DerSimonian and Laird's estimator.  A total of 2,216 studies conducted on the review topic were identified.  During screening, 37 studies found to be relevant for data abstraction.  From these, only 19 studies fulfilled the preset criteria and included in the analysis.  In 10 of the 19 studies included in the analysis, facility delivery had significant association with neonatal mortality; while in 9 studies the association was not significant.  Based on the random effects model, the final pooled effect size in the form of relative risk was 0.71 (95 % CI: 0.54 to 0.87) for health facility delivery as compared to home delivery.  The authors concluded that health facility delivery is found to reduce the risk of neonatal mortality by 29 % in low and middle income countries.  Moreover, they stated that expansion of health facilities, fulfilling the enabling environments and promoting their utilization during childbirth are essential in areas where home delivery is a common practice.

In a retrospective analysis, Catling-Paull et al (2013) reported maternal and neonatal outcomes for Australian women planning a publicly funded home birth from 2005 to 2010.  Data for 2005 to 2010 (or from the commencement of a program to 2010) were requested from the 12 publicly funded home birth programs in place at the time.  Main outcome measures were maternal outcomes (mortality; place and mode of birth; perineal trauma; type of management of the third stage of labor; post-partum hemorrhage; transfer to hospital); and neonatal outcomes (early mortality; Apgar score at 5 minutes; birth weight; breast-feeding initially and at 6 weeks; significant morbidity; transfer to hospital; admission to a special care nursery).  Nine publicly funded home birth programs in Australia provided data accounting for 97 % of births in these programs during the period studied.  Of the 1,807 women who intended to give birth at home at the onset of labor, 1,521 (84 %) did so; 315 (17 %) were transferred to hospital during labor or within 1 week of giving birth.  The rate of stillbirth and early neonatal death was 3.3 per 1,000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1,000 births.  The rate of normal vaginal birth was 90 %.  The authors concluded that the findings of this study provided the first national evaluation of a significant proportion of women choosing publicly funded home birth in Australia; however, the sample size did not have sufficient power to draw a conclusion about safety.  They stated that more research is needed to ascertain the safety of alternative places of birth within Australia.

Cheng et al (2013) noted that more women are planning home birth in the United States, although safety remains unclear.  These investigators examined outcomes that were associated with planned home compared with hospital births.  They conducted a retrospective cohort study of term singleton live births in 2008 in the United States.  Deliveries were categorized by location: hospitals or intended home births.  Neonatal outcomes were compared with the use of the χ(2) test and multi-variable logistic regression.  There were 2,081,753 births that met the study criteria.  Of these, 12,039 births (0.58 %) were planned home births.  More planned home births had 5-minute Apgar score less than 4 (0.37 %) compared with hospital births (0.24 %; adjusted OR, 1.87; 95 % CI: 1.36 to 2.58) and neonatal seizure (0.06 % versus 0.02 %, respectively; adjusted OR, 3.08; 95 % CI: 1.44 to 6.58).  Women with planned home birth had fewer interventions, including operative vaginal delivery and labor induction/augmentation.  The authors concluded that planned home births were associated with increased neonatal complications but fewer obstetric interventions.  They stated that the  trade-off between maternal preferences and neonatal outcomes should be weighed thoughtfully.

A recent study reported greater risk of infant death for home deliveries.  Grunebaum and colleagues (2013) performed this study by analyzing of Centers for Disease Control and Prevention (CDC) data and found that babies delivered at home were almost 4 times more likely to die than babies delivered in hospitals.  The absolute risk of infant death at birth or within 28 days after delivery was 12.6 per 10,000 midwife-assisted home births compared to 3.2 per 10,000 hospital births assisted by midwives, according to findings presented at the Society for Maternal-Fetal Medicine meeting.  It is important to note that this study included only planned home births, and under-counted the actual risk of death at home birth in 3 separate ways:

  • Transfers to the hospital during attempted home birth ended up in the hospital group and were not counted in the home birth death rate.
  • Intra-partum stillbirths were not included in these data, so home birth deaths were under-counted even further.
  • The authors of this study examined all races, but white women account for more than 90 % of women choosing home birth, and the neonatal death rate for white women is much lower than that for all races.

Blix and colleagues (2014) stated that there is concern about the safety of homebirths, especially in women transferred to hospital during or after labor.  The scope of transfer in planned home births has not been assessed in a systematic review.  These investigators described the proportions and indications for transfer from home to hospital during or after labor in planned home births.  The databases PubMed, Embase, Cinahl, Svemed+, and the Cochrane Library were searched using the MeSH term "home childbirth".  Inclusion criteria were as follows: the study population was women who chose planned home birth at the onset of labor; the studies were from Western countries; the birth attendant was an authorized mid-wife or medical doctor; the studies were published in 1985 or later, with data not older than from 1980; and data on transfer from home to hospital were described.  Of the 3,366 titles identified, 83 full text articles were screened, and 15 met the inclusion criteria.  Two of the authors independently extracted the data.  Because of the heterogeneity and lack of robustness across the studies, there were considerable risks for bias if performing meta-analyses.  A descriptive presentation of the findings was chosen.  A total of 15 studies were eligible for inclusion, containing data from 215,257 women.  The total proportion of transfer from home to hospital varied from 9.9 % to 31.9 % across the studies.  The most common indication for transfer was labor dystocia, occurring in 5.1 % to 9.8 % of all women planning for home births.  Transfer for indication for fetal distress varied from 1.0 % to 3.6 %, post-partum hemorrhage from 0 % to 0.2 % and respiratory problems in the infant from 0.3 % to 1.4 %.  The proportion of emergency transfers varied from 0 % to 5.4 %.  The authors concluded that future studies should report indications for transfer from home to hospital and provide clear definitions of emergency transfers.

Grunebaum et al (2014) examined neonatal mortality in relation to birth settings and birth attendants in the United States from 2006 through 2009.  Data from the CDC-linked birth and infant death dataset in the United States from 2006 through 2009 were used to assess early and total neonatal mortality for singleton, vertex, and term births without congenital malformations delivered by mid-wives and physicians in the hospital and mid-wives and others out of the hospital.  Deliveries by hospital mid-wives served as the reference.  Mid-wife home births had a significantly higher total neonatal mortality risk than deliveries by hospital mid-wives (1.26 per 1,000 births; relative risk [RR], 3.87 versus 0.32 per 1,000; p < 0.001).  Mid-wife home births of 41 weeks or longer (1.84 per 1,000; RR, 6.76 versus 0.27 per 1,000; p < 0.001) and mid-wife home births of women with a first birth (2.19 per 1,000; RR, 6.74 versus 0.33 per 1,000; p < 0.001) had significantly higher risks of total neonatal mortality than deliveries by hospital mid-wives.  In mid-wife home births, neonatal mortality for first births was twice that of subsequent births (2.19 versus 0.96 per 1,000; p < 0.001).  Similar results were observed for early neonatal mortality.  The excess total neonatal mortality for mid-wife home births compared with mid-wife hospital births was 9.32 per 10,000 births, and the excess early neonatal mortality was 7.89 per 10,000 births.  The authors concluded that the findings of this study showed a significantly increased total and early neonatal mortality for home births and even higher risks for women of 41 weeks or longer and women having a first birth.  These significantly increased risks of neonatal mortality in home births must be disclosed by all obstetric practitioners to all pregnant women who express an interest in such births.

An UpToDate review on “Planned home birth” (Declercq and Stotland, 2015) stated that “Large cohort studies using intent-to-treat analysis of midwife-attended, planned, out-of-hospital birth of low-risk women in developed countries have reported reduced rates of cesarean birth, perineal lacerations, and medical interventions, and similar rates of maternal and early perinatal morbidity and mortality compared to planned hospital birth.  However, there may be a higher rate of late neonatal mortality with planned home birth”.

CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes not covered for indications listed in the CPB (not all-inclusive):
59400 - 59430 Vaginal delivery, antepartum and postpartum care [not covered for planned deliveries at home]
59510 - 59525 Cesarean delivery [not covered for planned deliveries at home]
59610 - 59622 Delivery after previous cesarean delivery [not covered for planned deliveries at home]
99199 Unlisted special service, procedure or report [not covered for planned deliveries at home]
99461 Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center [not covered for planned deliveries at home]
HCPCS codes not covered for indications listed in the CPB (not all-inclusive):
G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0300 Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes
S8415 Supplies for home delivery of infant
S9123 - S9124, T1000 - T1003, T1030 - T1031 Nursing care in the home [not covered for planned deliveries at home]
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
O09.00 - O9a.53 Complications mainly related to pregnancy, normal delivery and other indications for care in pregnancy, labor, and delivery, complications occurring mainly in the course of labor and delivery, and complications of the puerperium [not covered for planned deliveries at home]
Z34.00 - Z34.93 Encounter for supervision of normal first pregnancy [not covered for planned deliveries at home]
Z37.0 - Z37.9 Outcome of delivery [not covered for planned deliveries at home]
Z38.1, Z38.4
Liveborn infants according to place of birth and type of birth (born outside of the hospital) [not covered for planned deliveries at home]
Z39.0 - Z39.2 Encounter for maternal postpartum care and examination

The above policy is based on the following references:
    1. Bastian H, Keirse MJ, Lancaster PAL. Perinatal death associated with planned home birth in Australia: Population based study. BMJ. 1998;317(7155):384-388.
    2. Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database Syst Rev. 1998;(3):CD000352.
    3. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: AAP; 2007.
    4. American College of Obstetricians and Gynecologists (ACOG). Statement on Home Delivery. Washington, DC: ACOG; September 1999.
    5. American College of Obstetricians and Gynecologists (ACOG). Home births double risk of newborn death. ACOG Press Release. Washington, DC: ACOG; July 31, 2002.
    6. Pang JW, Heffelfinger JD, Huang GJ, et al. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol. 2002;100(2):253-259.
    7. McKenna P, Matthews T. Safety of home delivery compared with hospital delivery in the Eastern Region Health Authority in Ireland in the years 1999-2002. Ir Med J. 2003;96(7):198-200.
    8. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Home births. College Statement. Statement No. C-Obs 2. East Melbourne, VIC: RANZCOG; November 2006.
    9. American College of Obstetricians and Gynecologists (ACOG). Home births in the United States. ACOG Statement of Policy. Washington, DC: ACOG; approved May 4, 2007.
    10. Wax JR, Pinette MG, Cartin A, Blackstone J. Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births. Am J Obstet Gynecol. 2010;202(2):152.e1-e5.
    11. Malloy MH. Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol. 2010;30(9):622-627.
    12. Kennare RM, Keirse MJ, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991-2006: Differences in outcomes. Med J Aust. 2010;192(2):76-80.
    13. Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: A metaanalysis. Am J Obstet Gynecol. 2010;203(3):243.e1-e8.
    14. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 476: Planned home birth. Obstet Gynecol. 2011;117(2 Pt 1):425-428.
    15. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012;9:CD000352.
    16. Chervenak FA, McCullough LB, Brent RL, et al. Planned home birth: The professional responsibility response. Am J Obstet Gynecol. 2013;208(1):31-38.
    17. American Academy of Pediatrics, Committee on Fetus and Newborn. Planned home birth. Policy Statement. Pediatrics. 2013;131(5):1016-1020.
    18. Tura G, Fantahun M, Worku A. The effect of health facility delivery on neonatal mortality: Systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013 ;13:18.
    19. Catling-Paull C, Coddington RL, Foureur MJ, Homer CS; Birthplace in Australia Study; National Publicly-funded Homebirth Consortium. Publicly funded homebirth in Australia: A review of maternal and neonatal outcomes over 6 years. Med J Aust. 2013;198(11):616-620.
    20. Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4):325.e1-e8.
    21. Grunebaum A, Sapra K, Chervenak F. Term neonatal deaths resulting from home births: An increasing trend. Annual Meeting of the Society for Maternal and Fetal Medicine, New Orleans, LA, February 7, 2013. Oral Concurrent Sessions 5, Clinical Obstetrics. Abstract 57. Am J Obstet Gynecol. 2014;210 (1 Supp):S38.
    22. Blix E, Kumle M, Kjærgaard H, et al. Transfer to hospital in planned home births: A systematic review. BMC Pregnancy Childbirth. 2014;14:179.
    23. Grunebaum A, McCullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol. 2014;211(4):390.e1-e7.
    24. Declercq E, Stotland NE . Planned home birth. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed January 2015.

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