(Abstracted from Obstet Gynecol 2024;143:53–66 Up to 1 in 10 women of reproductive age is affected by endometriosis, a condition that is characterized by endometrial-like tissue manifesting in the pelvis or abdomen external to the uterus. Approximately two-thirds of patients with endometriosis will experience endometriomas or cysts on the ovaries that are visible on ultrasonography; these cysts are correlated with higher pain levels and damage to healthy ovarian tissue.

Dienogest, oral contraceptive pills, gonadotropin-releasing hormone agonists, norethindrone acetate with or without aromatase inhibitors, and danazol reduce ovarian endometrioma size. OBJECTIVE:To estimate the effect of medical management on the size of ovarian endometriomas.DATA SOURCE:Online databases were searched from inception to October 2022, including Ovid MEDLINE, Ovid EMBASE, PubMed, EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Web of Science.METHODS OF STUDY SELECTION:Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we included all English-language, full-text articles that reported on change in endometrioma size (either diameter or volume) after medical interventions. Studies evaluating surgical interventions or postoperative recurrence were excluded. All screening and data extraction were performed independently by two authors. Risk of bias assessment was performed with either the Cochrane Risk of Bias Tool for randomized controlled trials or a modified Newcastle-Ottawa Scale for observational studies.TABULATION, INTEGRATION, AND RESULTS:After removal of duplicates, 9,332 studies were screened, with 33 full-text articles deemed eligible for inclusion. In the meta-analysis, dienogest showed significant reduction in cyst diameter (reduction 1.32 cm, 95% CI, 0.91-1.73, eight studies, n=418 cysts) and volume (mean difference of log-transformed volume 1.35, 95% CI, 0.87-1.83, seven studies, n=282 cysts). Similarly, significant reductions were seen with the oral contraceptive pill (OCP) (1.06 cm, 95% CI, 0.59-1.53, nine studies, n=455), gonadotropin-releasing hormone (GnRH) agonists (1.17 cm, 95% CI, 0.42-1.92, four studies, n=128 cysts), norethindrone acetate (0.6 cm, 95% CI, 0.27-0.94, two studies, n=88 cysts), and danazol (1.95 cm, 95% CI, 1.18-2.73, two studies, n=34 cysts). Norethindrone acetate with aromatase inhibitor was also effective in reducing endometrioma volume (mean difference of log-transformed volume 1.47, 95% CI, 0.16-2.78, two studies, n=34 cysts).CONCLUSION:Medical management with dienogest, OCPs, GnRH agonists, norethindrone acetate, norethindrone acetate with aromatase inhibitor, or danazol can reduce the size of ovarian endometriomas.SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD 42022363319.

OBJECTIVE:To estimate the effect of medical management on the size of ovarian endometriomas. DATA SOURCE:Online databases were searched from inception to October 2022, including Ovid MEDLINE, Ovid EMBASE, PubMed, EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science. METHODS OF STUDY SELECTION:Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we included all English-language, full-text articles that reported on change in endometrioma size (either diameter or volume) after medical interventions. Studies evaluating surgical interventions or postoperative recurrence were excluded. All screening and data extraction were performed independently by two authors. Risk of bias assessment was performed with either the Cochrane Risk of Bias Tool for randomized controlled trials or a modified Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS:After removal of duplicates, 9,332 studies were screened, with 33 full-text articles deemed eligible for inclusion. In the meta-analysis, dienogest showed significant reduction in cyst diameter (reduction 1.32 cm, 95% CI, 0.91-1.73, eight studies, n=418 cysts) and volume (mean difference of log-transformed volume 1.35, 95% CI, 0.87-1.83, seven studies, n=282 cysts). Similarly, significant reductions were seen with the oral contraceptive pill (OCP) (1.06 cm, 95% CI, 0.59-1.53, nine studies, n=455), gonadotropin-releasing hormone (GnRH) agonists (1.17 cm, 95% CI, 0.42-1.92, four studies, n=128 cysts), norethindrone acetate (0.6 cm, 95% CI, 0.27-0.94, two studies, n=88 cysts), and danazol (1.95 cm, 95% CI, 1.18-2.73, two studies, n=34 cysts). Norethindrone acetate with aromatase inhibitor was also effective in reducing endometrioma volume (mean difference of log-transformed volume 1.47, 95% CI, 0.16-2.78, two studies, n=34 cysts). CONCLUSION:Medical management with dienogest, OCPs, GnRH agonists, norethindrone acetate, norethindrone acetate with aromatase inhibitor, or danazol can reduce the size of ovarian endometriomas. SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD 42022363319.

To evaluate the effect of dienogest on endometrioma size.

Background Women in sub-Saharan Africa face numerous barriers to reproductive health and antenatal care (ANC) services. The objective of this study was to identify health provider perspectives regarding the barriers and enablers to reproductive health, ANC, and postnatal care (PNC) services in rural Tanzania. Methods A qualitative study was conducted in four districts of Tanzania and utilized key informant interviews (KIIs) and focus group discussions (FGDs). An interview guide was developed, focusing on individual and community-based factors (barriers and enablers) to accessing ANC and PNC services. Data were collected during December 2017 and May 2018 and analyzed using a thematic approach. Results Two major themes were identified as barriers to women accessing ANC and PNC services. First, factors related to women in the context of their family and community, for example (i) lack of autonomy in a patriarchal society, (ii) lack of knowledge and education regarding healthy pregnancy and pregnancy complications, (iii) lack of financial resources or control over financial resources, (iv) use of traditional birth attendants, (v) lack of male involvement, (vi) cultural beliefs as barriers to accessing family planning and ANC and PNC services. Second, factors present in the health system, for example (i) lack of infrastructure, equipment and health provider resources at health facilities, and (ii) lack of confidentiality and feelings of stigmatization when receiving health services. Reduced stigmatization against women with Human Immunodeficiency Virus (HIV) served as an enabler. Conclusions Overall, this study highlights the need to implement more initiatives in these rural districts to improve ANC and PNC services uptake. It also indicates the need to find strategies to improve male involvement and family support in the local context.

INTRODUCTION: Studies have shown that a high body mass index (BMI), expressed in kg/m2, is an independent risk factor for stillbirth. The purpose of this study was to determine an optimal time of delivery in obese women in order to decrease the risk of stillbirth in this population. METHODS: We conducted a retrospective population-based cohort study using the CDC's Period Linked Birth-Infant Death and Fetal Death data. The study population included all singleton, term births with a recorded pre-pregnancy BMI that occurred between 2014 and 2017, inclusively. The risk of stillbirths in each BMI class was estimated at each gestational week from 37 weeks and onwards. RESULTS: Of the 12,742,980 births in our cohort that met study criteria, 46.8% were to women with a normal BMI, 26.9% were to women who were classified as overweight, 14.5% were to women in obesity class I, 7.3% in obesity class II, and 4.8% in obesity class III. As compared to women at 41 weeks with a normal BMI, there was a higher risk of stillbirth in women of obesity class I at 39 weeks (OR 1.15 95% CI 1.00–1.31), at 38 weeks for obesity class II (OR 1.21 95% CI 1.04–1.41) and at 37 weeks for obesity class III (OR 1.30 95% CI 1.11–1.52). CONCLUSION: As compared to women with a normal BMI, there was a higher risk of stillbirth at term in women with each increase in BMI class. Consideration should be given to early induction among these women to reduce the risk of stillbirth.

Objectives Our objective is to establish whether women with obstructive sleep apnea (OSA) have more adverse outcomes following a cesarean delivery (CD) compared to women without OSA. Methods We performed a retrospective cohort study using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States. All women with a CD between 2006 and 2015 were identified using International Classification of Disease (ICD)-9 coding. Multiple pregnancies and stillbirths were excluded. Women with OSA were matched by maternal age, CD indication and year of admission to women without OSA in a 1:10 ratio. Maternal outcomes following CD were compared between these two groups using conditional logistic regression, adjusted for baseline characteristics. Results Among 2,482,132 births from cesarean deliveries, 2,041 wereto women with OSA. Rates of OSA increased over the 10-year study period, from 23 per 100,000 births in 2006 to 154 per 100,000 in 2015 (p<0.0001). Among women with a CD, women with OSA were more likely to have pregnancies complicated by postpartum hemorrhage (OR 1.5, 95% CI 1.2-1.8), postpartum infection 1.5 (1.2-1.8), wound complications 2.5 (1.9-3.3), venous thromboembolic disease 3.3 (2.2-5.0), chorioamnionitis 1.3 (1.1-1.6), blood transfusion 2.0 (1.7-2.4), cardiac arrest 2.2 (1.5-3.1), post-partum cardiomyopathy 11.8 (2.5-55.2) and assisted ventilation and intubation 33.6 (19.2-58.7). Conclusions OSA in pregnancy with a CD is associated with an increased risk of adverse outcomes. Women with OSA should receive close follow-up in the antenatal and postpartum periods. Our objective is to establish whether women with obstructive sleep apnea (OSA) have more adverse outcomes following a cesarean delivery (CD) compared to women without OSA. We performed a retrospective cohort study using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States. All women with a CD between 2006 and 2015 were identified using International Classification of Disease (ICD)-9 coding. Multiple pregnancies and stillbirths were excluded. Women with OSA were matched by maternal age, CD indication and year of admission to women without OSA in a 1:10 ratio. Maternal outcomes following CD were compared between these two groups using conditional logistic regression, adjusted for baseline characteristics. Among 2,482,132 births from cesarean deliveries, 2,041 wereto women with OSA. Rates of OSA increased over the 10-year study period, from 23 per 100,000 births in 2006 to 154 per 100,000 in 2015 (p<0.0001). Among women with a CD, women with OSA were more likely to have pregnancies complicated by postpartum hemorrhage (OR 1.5, 95% CI 1.2-1.8), postpartum infection 1.5 (1.2-1.8), wound complications 2.5 (1.9-3.3), venous thromboembolic disease 3.3 (2.2-5.0), chorioamnionitis 1.3 (1.1-1.6), blood transfusion 2.0 (1.7-2.4), cardiac arrest 2.2 (1.5-3.1), post-partum cardiomyopathy 11.8 (2.5-55.2) and assisted ventilation and intubation 33.6 (19.2-58.7). OSA in pregnancy with a CD is associated with an increased risk of adverse outcomes. Women with OSA should receive close follow-up in the antenatal and postpartum periods.

The objective of this study was to examine the factors which serve as barriers and enablers to accessing maternal and reproductive health services among women in rural Tanzania. A qualitative study, utilizing focus group discussions (FGDs), was conducted in three districts. An interview guide was developed that focused on individual or community-based factors affecting women's access to reproductive and maternal health services. Data was collected during December 2017 and May 2018, and analyzed using a thematic approach. The barriers included a lack of autonomy, lack of knowledge and education, travel and transportation barriers, lack of financial resources, lack of infrastructure, lack of confidentiality, lack of male involvement, cultural beliefs, and the use of traditional birth attendants. In contrast, the increased autonomy for women and the implementation of government policies were identified as enablers. Innovations need to be identified that address these barriers in order to increase access to maternal and reproductive health services in these districts.

Abstract Objectives To evaluate if induction of labor (IOL) in obese women at 39 weeks of gestation decreases the risk of cesarean delivery (CD). Methods We conducted a retrospective propensity score matched study using the Center for Disease Control’s (CDC’s) Period Linked Birth-Infant Death data. The study population consisted of cephalic singleton births to women with BMI greater or equal to 30.0 kg/m2 who delivered at or beyond 39 weeks between 2013 and 2017. Women with prior CD were excluded. Women who underwent IOL at 39 weeks were propensity score matched 1:5 on the basis of CD risk factors to women who did not undergo IOL at 39 weeks but may have had an IOL at a later gestational age. Conditional logistic regression compared CD rates and maternal outcomes between obese women induced at 39 weeks with those not induced at 39 weeks. Results Our cohort consisted of 197,343 obese women induced at 39 weeks and 986,715 obese women not induced at 39 weeks. Overall, the risk of CD among women who had an IOL at 39 weeks was lower than those without an IOL at 39 weeks, 0.59 (0.58–0.60). The decrease in CD risk was more pronounced in multiparas, 0.47 (0.46–0.49) than nulliparas, 0.81 (0.79–0.83). When stratified by BMI, the effect of IOL on lowering CD risk was similar across all obesity classes. Aside from an increased risk of instrumental deliveries, morbidities were comparable in both groups. Conclusions IOL at 39 weeks among obese women appears to lower the risk of CD, without compromising maternal outcomes.

The objective of this qualitative study was to understand community and health provider perspectives regarding pre-eclampsia and eclampsia in rural Tanzania. Key informant interviews and focus group discussions with health workers and community members were conducted in the Geita and Singida districts. An interview guide, focusing on individual or community-based factors affecting women's access to reproductive and maternal health services, was developed. Data was collected during December 2017 and May 2018 and analyzed using a thematic approach. Three themes emerged regarding perceptions about pre-eclampsia and eclampsia: 1) insufficient knowledge regarding signs, symptoms and risks, 2) misconceptions regarding the causes, due to beliefs and attitudes, and 3) variable patterns of health-seeking behavior among pregnant women who have signs and symptoms. While health providers had a good understanding about causes and management of pre-eclampsia and eclampsia, a much larger proportion of community members held misconceptions regarding the causes and recommended management. Community-based educational programs to improve community knowledge about the causes, risks and requirement of pre-eclampsia and eclampsia by trained health providers has the potential to improve maternal outcomesin rural Tanzania.

Dr. Godfrey Mbaruku, an obstetrician-gynecologist and one of Tanzania's most dedicated maternal health researchers, passed away in September 2018. His professional career spanned over four decades, with the last decade of his life dedicated to maternal health research, advocacy and policy in Africa. We undertook a review of the key global milestones in maternal health policy, funding and research that took place during Dr. Mbaruku's career until his untimely death in 2018. We then reflect on the progress of the maternal health agenda from 2018 to 2021 as lower middle income countries (LMICs) continue to strive to reach the sustainable development goals (SDGs) in the midst of a global pandemic. Dr. Godfrey Mbaruku's commitment to improving maternal health in Tanzania through his advocacy and research contributions over his professional life will forever serve as foundational pillars for the ongoing global effort to reduce maternal mortality.