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European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103 

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Coronary perfusion pressure and compression quality in maternal cardiopulmonary 

resuscitation in supine and left-lateral tilt positions: A prospective, crossover study using 
mannequins and swine models 
Satoshi Dohia,*, Kiyotake Ichizukaa, Ryu Matsuokab, Kohei Seoa, Masaaki Nagatsukaa, Akihiko 
Sekizawab 
a Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan b Department of 
Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan 
A R T I C L E I N F O 
Article history: Received 4 January 2017 Received in revised form 14 June 2017 Accepted 12 July 2017 
Keywords: Aortocaval compression Maternal cardiopulmonary resuscitation (CPR) Supine position Swine model (LWD strain) 
Left uterine displacement 
A B S T R A C T 
Objective: The risk of maternal and fetal mortality is high if cardiopulmonary arrest occurs during pregnancy. To assess the best 
position for maternal cardiopulmonary resuscitation (CPR), a prospective randomized crossover study was undertaken, involving 
basic life support mannequin-based simulation (BLS-MS) and a swine model of pulseless electrical activity (an unstable cardiac 
state) incorporating a fetal mannequin (PEA-FM). Study design: The BLS-MS (performed by certified rescuers) served to 
evaluate the quality of chest compressions in 30 left lateral tilt (LLT) and supine positions. Based on a 5-point scale, each rescuer 
subjectively graded their experience. The PEA-FM model was used to compare coronary perfusion pressure readings during CPR 
in supine, supine with left uterine displacement, 30 LLT, and 30 right lateral tilt positions. Compression rate and correctness of 
hand position, compression depth, and recoil were measures of compression quality (BLS-MS). Results: Compared with LLT 
position, supine position enabled correct hand position (rate: 0.99 vs 0.88; p < 0.05) and compression depth (rate: 0.76 vs 0.36; p 
< 0.001) significantly more often. Moreover, BLS- MS rescuers found chest compressions significantly easier to perform with 
the mannequin in supine (vs LLT) position (difficulty score: 1.75 vs 3.95; p < 0.001). In the PEA-FM study arm, supine position 
with left uterine displacement and right lateral tilt positions had the highest and lowest recorded coronary perfusion pressure 
readings, respectively. Conclusion: Supine position with left uterine displacement is optimal for maternal CPR. © 2017 The 
Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC- ND license 
(http://creativecommons.org/licenses/by-nc-nd/4.0/). 
Introduction 
Cardiopulmonary  arrest  in  pregnant  women  carries  a  high  risk  of  maternal  and  fetal  mortality  [1,2],  placing  the  survival  of 
both  in  jeopardy.  First responders have approximately 4 min to initiate cardiopulmonary resuscitation (CPR) for maternal cardiac 
arrest,  thereafter  calling  for  emergency  caesarian  section  [3].  Because  of  the  toll  already  exacted  on  cardiac,  respiratory, 
gastrointestinal,  and  reproductive  systems  in  pregnant  women,  reduced  chest  compliance  and  residual  capacity,  as  well  as 
diminished cardiac output (owing to uterine compression of the inferior vena cava) 
constitute important challenges for resuscitative efforts during pregnancy [1,4]. 
Other studies of pregnant women have indicated that left lateral tilt position (LLT) improves maternal hemodynamic parameters; 
however, adopting a full lateral position for maternal CPR may substantially decrease the effectiveness of chest compressions and 
affect the feasibility of caesarean delivery [5– 7]. Soar et al. have reported that the ability to provide effective chest compressions 
 declines as the angle of LLT increases, with mannequins tending to roll at angles >30 [8]. However, upon investigating the 
hemodynamic effects of right lateral tilt (RLT) and LLT (5 and 10) in pregnant women, Ellington et al. discovered no significant 
difference in maternal blood flow [9]. Matorras et al. also saw no obvious benefit for LLT in instances of emergency * 
Corresponding author at: Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, 35-1 
Chigasaki-chuo, Tsuzuki-ku, Yokohama-city, Kanagawa, Japan. 
E-mail address: satoshi.dohi1018@gmail.com (S. Dohi). 
caesarean  delivery,  finding  maternal  parameters  (blood  pressure,  heart  rate)  similar  for  partial  left  lateralization  and  supine 
position [10]. Finally, a more recent mannequin study by Butcher et al. has 
http://dx.doi.org/10.1016/j.ejogrb.2017.07.019 0301-2115/© 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an 
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/). 
 
shown  comparable  effectiveness  of  chest  compressions  in  both  supine/uterine  displacement  and  lateral tilt positions, suggesting 
that  either  method  may  be  suitable  for maternal CPR [11]. These studies demonstrate the lack of a definitive protocol for CPR in 
an  obstetric  setting.  Because  related  clinical  trials  involve  ethical  and  practical  concerns,  development  of  suitable  preclinical 
models of maternal cardiac arrest and resuscitation is essential for instituting effective CPR interventions in pregnant women. 
The  present  study  entailed  use  of  a  basic  life  support  mannequin  simulation  (BLS-MS)  to  evaluate  CPR  effectiveness, 
comparing  30  LLT  tilt and supine positions. A 5-point question- naire then served to score the ease of performing CPR. Position- 
dependent  changes  in  coronary  perfusion  pressure  (CPP),  a  major  indicator  of  CPR  effectiveness  [12],  were  also  assessed.  For 
this  purpose,  a  novel  swine  model  of  maternal  CPR  was  devised,  incorporating pulseless electrical activity (PEA) cardiac arrest 
and a fetal mannequin (PEA-FM). 
Materials and methods 
Study design 
This  prospective  randomized  crossover  study  was  conducted  at Yokohama Advanced Cardiovascular Life Support (BLS-MS 
arm)  and  Kobe  Medical  Device  Development  Center  (PEA-FM arm) between 2008 and 2012. To measure CPR parameters such 
as  compression  rate  and  hand  position,  certified  rescuers  performed  chest  compressions  on  a mannequin placed in either supine 
or  30  LLT  position,  using  an  adjustable  bed  (comparable  to  an  operating  room  table)  as  platform.  The  degree  of  tilt  was 
protractor-verified  in  each  instance.  Participants  provided  their  own  assessments  of  the  difficulty  encountered  during  each 
procedure. The medical 
S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103 99 
Fig. 1. Preparation of swine model for maternal CPR. A–C: Fetal mannequin placed intra-abdominally in sedated pig and 
positioned against inferior vena cava, inserting a Swan-Ganz catheter to monitor arterial and central venous pressures; D: Fetal 
mannequin, consisting of full-body pregnancy simulation fetus with amnion (LM-105; Koken Co Ltd, Tokyo, Japan). 
Abbreviations: CPR, cardiopulmonary resuscitation. 
ethical review board of Kanazawa University approved the study protocol. 
To  measure  CPP  at  different  positions,  fetal  mannequins  were  placed  within  abdominal  cavities  of  four  pigs,  subsequently 
inducing  PEA  cardiac  arrest  in  these  animals.  The  Animal  Experiment  Committee  of  the  Intervention  Technical  Center  for  the 
use of laboratory animals in the Kobe Medical Device Development Center granted approval for this aspect of the study. 
BLS-MS participants, protocol, and outcome measures 
Twenty  rescuers  !  18  years  old  and  certified  as  competent  in  American  Heart  Association  (AHA)  basic  life  support  (BLS) 
volunteered for this investigation. All participants provided written informed consent, and all completed the study success- fully. 
On  a  random  assignment  basis,  each  BLS  rescuer  performed  simulated  chest  compressions  on  a  mannequin  (Resusci  Anne 
Simulator;  Laerdal  Medical,  Stavanger,  Norway)  placed  in either supine or 30 LLT position, continuing for 2 min in the position 
first  assigned,  resting  for  10  min,  and  then  repositioning  the  mannequin  and  repeating  CPR  for  2  min  in  the  second  assigned 
position.  The  2-  min  intervals  for  CPR  conformed  to  AHA  BLS  guidelines  of  2005  and  2010.  To avoid potential bias, rescuers 
were  blinded  to  the  monitor  screen  displaying  compression  rate  or  hand  position.  Analysis  of  all  collected  data  involved 
proprietary methods (PC Skill Reporting System; Laerdal Medical). 
The  primary  outcome  measure  was  chest  compression  quality  (stipulated  as  a  compression  depth  of  50–60  mm,  hand 
positioned on the lower half of the sternum, and recoil to within 5 mm of baseline chest height) and rate (number of compressions 
executed in 1 min). As a secondary outcome, rescuers scored the ease of 
 
performing CPR with the mannequin in a given position. The questionnaires were completed after BLS-MS execution, applying a 
5-point  Likert-like  scale  (1,  very  easy;  2,  easy;  3,  normal;  4, difficult; 5, very difficult) [13]. The average values of self-reported 
ratings were termed difficulty scores. 
PEA-FM model, CPR protocol, and outcome measures 
Four  female  swine  (LWD strain: Landrace Â Large White Â Duroc three-way cross breeds; age, 3 months; weight, 35–37 kg) 
were  used  to  develop  the  PEA-FM  model.  The  swine  were  purchased  from  a  pathogen-free  farm  in  Japan  and  kept  at  the 
Intervention  Technical  Center  under  controlled  conditions  (tem-  perature,  23 Æ 3 C; humidity, 55 Æ10%), implementing a 12-h 
light-dark  cycle  (lights  on,  7:00–19:00;  lights  off,  19:00–7:00)  and  direct-expansion  air conditioning, with a medium-quality air 
filter. The animals consumed a commercial solid diet (MP-A, Oriental Yeast, Tokyo, Japan; maximum limit, 800 g/day). 
The  pigs  were  sedated  using  intramuscular  ketamine  (Ketalar,  2  mg/kg)  and  xylazine  (10  mg/kg)  as  well  as  inhalatory 
isoflurane  (2–3%)  in  oxygen  (2–3  L/min).  Subsequently,  a  3.5-g  fetal  manne-  quin  consisting  of  a  full-body 
pregnancy-simulating  fetus  with  amnion  (LM-105;  Koken,  Tokyo,  Japan)  was  positioned  within  the  abdominal  cavity  of  each 
pig,  placed  against  the  inferior  vena  cava  (Fig.  1).  PEA  cardiac  arrest  [14],  an  unstable  cardiac  condition  marked  by  sustained 
electrical  activity  and  absence  of  a  palpable  pulse,  was  induced  by  administering  a  bolus of potassium chloride (0.9 mEq/kg) in 
normal  saline  (20  mL)  intravenously.  Precordial  electrodes  continuously  monitored  electrocardiographic  activity.  All  four  pigs 
ultimately  experienced  cardiac  arrest,  signaled  by  ventricular fibrillation on electrocardiogram and loss of arterial blood pressure 
waveforms. 
Subsequently,  2-min  sets  of  chest  compressions  were  delivered  to  the  animals  positioned as follows: supine, supine with left 
uterine  displacement  (LUD),  30  LLT,  and  30  RLT.  In  addition  to  constant  monitoring  of  heart  rate,  Swan-Ganz  catheter 
placement  enabled  ongoing  recording  of  arterial  and  central  venous  pressures.  The  primary  outcome  in  the  PEA-FM  arm  was 
CPP, defined as aortic diastolic pressure minus left ventricular end- diastolic pressure, with readings taken at 0.5, 1.0, 1.5, and 2.0 
min after starting CPR. 
Statistical analysis 
Mean  differences  in  percentage  of  compressions  performed  at  stipulated  depth,  hand  position,  and  recoil,  as  well  as 
differences  in  chest  compression  rates,  were  analyzed  via  Student’s  two-tailed  t-  test,  applying  Kruskal-Wallis  and  Dunn’s 
post-hoc  tests  to  assess  CPP  differences  in  the  animal  model.  All  computations relied on standard software (SAS JMP Pro 11.0; 
SAS Institute, Cary, NC), setting significance at p 0.05. 
Results 
Demographics 
Among  the  BLS-MS  participants  (women,  35%),  age  was  40.8  Æ  7.2  years,  and  median  BLS  experience  was  3  years. 
Thirteen (65%) of the rescuers were registered nurses (Table 1). 
CPR parameters and ease of performing the mannequin CPR simulation (BLS-MS) 
Relative  to  total  number  of  compressions  executed,  the  ratio  of  compressions  executed  at  stipulated  depth  was  significantly 
higher for supine than for 30 LLT position (114.5/150 vs 53.8/ 
100 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103 
Table 1 Characteristics of the participants involved in the mannequin-based CPR simulation (N = 20). 
Variable Value 
Age, years 40.8 Æ 7.2 Sex Male 7 (35) 
Female 13 (65) 
Specialty 
Registered nurse 13 (65) Anesthesiologist 1 (5) Obstetrician 1 (5) EMS technician 3 (15) ER physician 1 (5) Neurosurgeon 1 (5) 
Professional experience, years 16.5 (13.5–20.2) Experience with BLS, years 3 (2–4.2) 
Values expressed as number (percentage), median (interquartile range), or mean Æ standard deviation. CPR, cardiopulmonary 
resuscitation; ER, emergency room; EMS, emergency medicine service; BLS, basic life support. 
150;  p  <  0.001),  as  was  the  ratio  of  compressions  performed  using  correct  hand  position  (149.5/150  vs  131.7/150;  p  <  0.05). 
However,  our  analysis  showed  no  position-specific  differences  in  chest  compression  rate  or  ratio  of  compressions  that recoiled 
correctly  to  total  number  of  compressions  (Table  2).  Questionnaire  scores  also  revealed  that  the  participants  found  chest 
compressions  signifi-  cantly  easier  to  perform  with  the  mannequin  in  supine  (vs  LLT)  position  (difficulty  score,  1.75  [95% 
confidence interval, 1.31–2.19] vs 3.95 [95% confidence interval, 3.68–4.22]; p < 0.001). 
CPP variation in the swine model (PEA-FM) 
In  the  swine  model,  animal  position during CPR significantly affected CPP values at 1.0 and 1.5 min, but not those at 0.5 and 
2.0  min  (Dunn’s  post-hoc test: p < 0.001, p = 0.02, p = 0.10, and p = 0.14, respectively; Fig. 2, Supplementary Fig. 1). At all four 
evaluated  time  points,  supine  position  with  LUD and 30 RLT position generated the highest and lowest CPP values, respectively 
(Dunn’s post-hoc test: p < 0.05). 
Discussion 
Main findings 
The  present  study  indicates  that  rescuers  perform  higher-  quality  chest  compressions  if  subjects  are  in  supine  position,  and 
that CPP normalization proceeds most effectively in supine position with LUD. 
Interpretation 
In  an  obstetric  setting,  optimal  patient  positioning  during  CPR  remains  controversial.  A  mannequin  simulation  study 
previously  performed  by  Kim  et  al.  has  confirmed  that  even  inexperienced  first  responders  can  execute  high-quality  chest 
compressions  with  subjects  in  30  LLT  position  [15].  Furthermore,  although  neither  hand  position  nor  other  measures  of  chest 
compression  technique  (rate,  depth,  or  recoil)  showed  significant  position-specific  differ-  ences, performing chest compressions 
proved  easier  in  supine  (vs  LLT)  position.  All  BLS  rescuers  participating  in  the  present  study,  each  AHA-certified,  also  stated 
preferring  supine  mannequin  position  during  simulated  CPR.  Indeed,  the  stipulated  chest  compression  depth  and  hand  position 
were achieved by rescuers more often when performing simulated CPR supine. 
Upon investigating various methods for producing lateral tilt, Ip et al. found dedicated foam or hard wedges, rather than 
pillows or 
 
 human wedge, superior in conferring lateral tilt during CPR [16]. On the other hand, the mannequin study of Butcher et al. 
demonstrated that chest compressions were equally effective in both supine/uterine displacement and lateral tilt positions, 
maintaining that either method is suitable for CPR [11]. Such observations are perhaps attributable to differences in experience 
levels of rescuers recruited for these studies, and to subtle differences in the models used or study protocols applied. For example, 
unlike the relatively inexperienced first responders involved in the study by Kim et al. [15], the AHA-certified BLS rescuers 
enlisted in this investigation were highly experienced, and therefore more apt to achieve better outcomes. Present findings thus 
underscore the importance of rescue experience in achieving superior CPR outcomes, and support the contention that supine 
position, rather than LLT, yields better-quality chest compressions. Data acquired from the swine model of maternal CPR also 
corroborated that chest compressions are most effective if performed on the animal positioned supine with LUD, while 
conversely suggesting that 30 RLT position may be harmful, given the very low CPPs generated. Maximal CPP has emerged as 
one of the best parameters in predicting return of spontaneous circula- tion, and CPP measurements are generally more predictive 
than aortic pressure alone [17,18]. Lateral positioning also appeared to improve left atrial wedge pressure correlation in a 
positive- pressure ventilation pig model [19], although another study using LLT to relieve presumptive aortocaval compression 
by pregnant 
Table 2 Quality of chest compressions in the mannequin-based simulation. 
Parameter Supine position 
(n = 20) 
p-value 
Correct hand position 0.99 0.88 < 0.05 Correct chest compression depth 0.76 0.36 < 0.001 Correct recoil 1.0 1.0 NS Chest 
compression rate* 120.4 123.1 NS 
Unless otherwise specified, all values are provided as ratios between number of compressions performed in correct capacity and 
total number of compressions. NS, not significant. 
* Compressions/min. 
S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103 101 
Fig. 2. Measurement of CPP during resuscitative chest compressions, executed with animals in different positions. A–D: CPP 
readings at 0.5, 1.0, 1.5, and 2.0 min after pulseless cardiac arrest. Abbreviations: CPP, coronary perfusion pressure; LLT, left 
lateral tilt; LUD, supine position with left uterine displacement; RLT, right lateral tilt; SP, supine position. 
uteri  indicated  that  15  of  LLT  was  ineffective  in  reducing  inferior  vena  cava  compression  [20].  It  is  therefore  prudent  for 
healthcare providers to perform maternal CPR using uterine displacement and not lateral tilt. 
Aortocaval  compression  is  a  key  contributor  to  supine  maternal  hypotension.  The  PEA-FM  model  we  devised simulates the 
condition  of  aortocaval  compression,  so  the  low  CPPs  recorded  in  LLT  attest  to  the  inadequacy  of  lateral  tilt  in  alleviating 
aortocaval  compression.  Such  inference  stems  from  the  fact  that  aortocaval  compression  may  persist,  despite  high lateral tilt, if 
the gravid uterus is immobile and sags over the abdomen [21]. 
Armstrong  et  al.  analyzed  cardiac  indices  of  term  pregnant  women  in  sitting,  lateral,  and  supine  positions  and  found  that 
maternal  stroke  volume  index, heart rate, and systolic blood pressure were higher in lateral position [22]. Although body position 
may  be  critical  in  exacerbating  cardiorespiratory  stress  during  pregnancy,  deficits  in  delivery  of  maternal  CPR  in  simulated 
obstetric  settings  have  been  conspicuous  in  several  studies.  One  such  investigation  revealed  that  compressions were carried out 
correctly  in  just  56%  of  cases,  and  ventilations  in  50%  [23].  Furthermore, critical interventions such as LUD or engaging a firm 
back  support  prior  to  initiating  compressions  were  frequently  neglected  [23].  Poor pregnancy-specific CPR was also reported in 
another  study  [24].  Finally,  Einav  et  al.  have  noted  that  obstetric  specialty  clinicians  in  a  hospital  setting  possessed  limited 
knowledge of current recommendations for treating maternal 
Left lateral tilt position (n = 20) 
 
cardiac  arrest  [25].  All  these  sources  highlight  the  need  for  awareness,  standardization,  continued education, and further studies 
in this high-risk and complex field. 
Strengths and limitations 
Clinical  trials  in  obstetric  settings  involve  ethical  and  practical  concerns.  Studies/guidelines  for  CPR  in  pregnancy therefore 
generally  rely  on  case  series,  extrapolating  from  cardiac  arrest  data  in  non-pregnant  patients  and  from  mannequin  studies. 
Unfortunately,  these  approaches  are inherently limited in terms of reflecting real maternal CPR conditions. The major strength of 
the  present  study  is  the use of a novel PEA-FM model that perhaps more closely mimics maternal CPR. In non-obstetric settings, 
porcine  models  of  cardiac  arrest  and  resuscitation  are  relatively  well  understood  [26].  The  swine  model  has  several  important 
advantages  over  other  animal  models,  and  outcomes  in  the  swine  model  seemingly translate well to clinical circumstances [27]. 
Especially  relevant  to  CPR  is  the  fact that the large chests of pigs can accommodate appropriately forceful precordial chest com- 
pressions  and  electrical  transthoracic  counter  shocks  applied  during  defibrillation.  In  addition,  this  large  mammal  will  tolerate 
extensive  manipulations,  especially  sampling  of  blood  and  intravascular  or  intracardiac  pressure  measurements;  moreover,  the 
serum  chemistries of pigs and humans are quite similar [27,28]. The animal model used here also incorporated a fetal mannequin, 
an  important  feature  closely  simulating  aortocaval  compression  in  pregnant  women.  Hence,  the  three  study  arms  conducted 
(BLS-MS,  PEA-FM,  and  rescuer  questionnaire)  all  generated  data  to support the superiority of supine position for better-quality 
outcomes in maternal CPR. 
The  present  study  has  several  acknowledged  limitations.  Although  the  PEA-FM  model  of  maternity  embodies  certain CPR- 
relevant  anatomic  features, its applicability to pregnant women cannot be completely conceded. Specifically, the fetal mannequin 
was  not  secured  in  place,  creating  a  potential  for  excessive  mobility.  Another  major limitation is that CPP was the sole index of 
CPR  effectiveness  in the animal model. Cerebral perfusion pressure is an equally important measure and would be an appropriate 
addition  to  similar  future  investigations.  More  recently,  near-  infrared  spectroscopic  cerebral  oximetry  has  also  emerged  as  a 
noninvasive  means  of  predicting  return  of  spontaneous  circulation  following  CPR.  Finally,  although  the  lack  of  statistically 
significant  differences  in  CPP  values  at  0.5  and  2.0  min remains unexplained, it may reflect insufficient chest compression soon 
after  initiating  CPR  and  fatigue  before  terminating  CPR  [29,30].  As  determined  by  Ashton  et  al.,  rotating  rescuers  at  1-min 
intervals  is  advisable,  due  to  fatigue  that  develops  within  3  min  of  uninterrupted  CPR.  However,  further  research  is  needed  to 
clarify such issues. 
Conclusions 
Although  maternal  chest  compression  is  feasible  in  30  LLT  position,  correct  compression  depth  may  be  more  difficult  to 
achieve,  due  in  part  to  the surface used. Using mannequin-based simulations, we found that chest compressions were much more 
effective  if  performed  with  the  subject  positioned  supine  on  a  firm  surface,  preferably  with  lateral  uterine  displacement.  Our 
limited  animal  model  also  registered  consistently  lower  CPP  readings  during  CPR in supine and in LLT or RLT positions at 30, 
compared  with  CPP  readings  in  supine  position  plus  LUD.  RLT  position  seemed  especially  inadequate  for  maintaining  CPP 
during chest compressions. 
102 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103 
Funding 
None. 
Conflict of interest 
The author reports no conflict of interest. 
Acknowledgements 
I  am  deeply  grateful  to  Prof.  Takayuki  Kosuge  (Teikyo  University),  Prof.  Hiroshi  Saito  (Showa  University  Northern 
Yokohama  Hospital),  Dr.  Yasuo  Takegoshi  (Fukui  Saiseikai  Hospi-  tal),  Mr.  Yasuo  Hara  (IVTec),  and  Ms.  Kazue  Nara 
(Yokohama  Advanced  Cardiovascular  Life  Support  [ACLS]),  whose  related  comments  and  suggestions  were  of  immeasurable 
value.  I  also  extend  my  gratitude  to  the  BLS  rescuers  of  Yokohama  ACLS. Cactus Communications provided editorial support, 
assisting  in  medical  writing,  table  creation,  production  of  high-resolution  images (per author’s detailed specifications), collating 
the author’s comments, copyediting, fact checking, and referencing. 
Appendix A. Supplementary data 
Supplementary  data  associated  with  this  article  can  be  found,  in  the  online  version,  at  http://dx.doi.org/10.1016/j. 
ejogrb.2017.07.019. 
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