Preterm birth among Pacific Islanders in the United States and the US-affiliated Pacific Islands: A systematic review and meta-analysis.

OBJECTIVE: To better understand the epidemiology of preterm birth among Pacific Islanders in the United States and the US-Affiliated Pacific Islands. METHODS: Systematic searches of MEDLINE, Embase, CINAHL, PsycINFO, two nonindexed regional journals, and gray literature were conducted and finalized in September 2021. Observational studies published since January 2010 that documented preterm birth outcomes among Pacific Islanders in the United States and the US-Affiliated Pacific Islands were eligible for inclusion. Outcomes of interest included preterm birth prevalence, risk compared with white women, and risk factors for preterm birth among Pacific Islanders. RESULTS: Fourteen of the 3183 screened articles were included in meta-analyses. Random-effects models were used for pooled estimates with 95% confidence intervals. The pooled prevalence of preterm birth among Pacific Islanders was 11.2%, 95% CI: 9.3%-13.6%. Marshallese women had the highest pooled prevalence (20.7%, 95% CI 18.6%-23.0%) among Pacific Islander subgroups. Compared with white women, Pacific Islander women had higher odds of experiencing preterm birth (OR = 1.40, 95% CI: 1.28-1.53). Four risk factors for preterm birth could be explored with the data available: hypertension, diabetes, smoking, and pre-pregnancy body mass index; hypertension and diabetes significantly increased the odds of preterm birth. CONCLUSIONS: Existing literature suggests that United States Pacific Islanders were more likely to experience preterm birth than white women, although the pooled prevalence varied by Pacific Islander subgroup. Data support the need for disaggregation of Pacific Islanders in future research and argue for examination of subgroup-specific outcomes to address perinatal health disparities.

Translating the Pelvic Organ Prolapse Score into Samoan using a modified back translation methodology.

BACKGROUND: Although Samoan women have a high prevalence of obesity and multiple parity which are risk factors of pelvic organ prolapse, there is no prevalence data on this condition. AIMS: Translate the Pelvic Organ Prolapse-Symptoms Score (POP-SS) from English into Samoan, MATERIALS AND METHODS: Standardised methods for translating questionnaires, individual face to face audio-recorded interviews in which women completed the POP-SS using a Think Aloud method, analysis using a Framework approach. RESULTS: The POP-SS was successfully translated in to Samoan, an additional information leaflet was developed to support women's understanding of what prolapse is, 14 Samoan women were recruited of which 13 were interviewed and completed the POP-SS, results of POP-SS (scores), results of think aloud, results in terms of research experience. CONCLUSIONS: A Samoan version of the POP-SS is now available for further evaluation of its psychometric properties prior to wider use. The team continue to collaborate on their work on establishing the prevalence of prolapse whilst building local research capacity.

How do Pacific Island countries add up on contraception, abortion and reproductive coercion? Guidance from the Guttmacher report on investing in sexual and reproductive health.

The Guttmacher-Lancet Commission report on Sexual and Reproductive Health and Rights called for the acceleration of progress to achieve SRHR that is essential for sustainable development. To integrate the essential services defined in this report into universal health coverage in the 11 sovereign nations in the Pacific, quality data is required to ensure needs are met efficiently and equitably. However, there are no comprehensive reports for Pacific Island countries that provide insight into all areas of SRHR. We collated the latest literature to identify the most up-to-date relevant data from United Nations and Guttmacher Institute reports to discern gaps in SRHR information and services relating to contraception, abortion and reproductive coercion. Investment is urgently required to strengthen health information systems for SRHR in the Pacific.

The burden of infertility in New Zealand: A baseline survey of prevalence and service use.

BACKGROUND: Studies in southern New Zealand indicate that up to a quarter of women experienced infertility, likely due to delay in childbearing. However, these findings may not be generalisable to the whole population. AIMS: To assess the lifetime prevalence of infertility and evidence for disparities for New Zealand men and women in a nationally representative sample. MATERIALS AND METHODS: In 2014/15 a general health survey with a module on sexual and reproductive health was conducted among New Zealand residents aged 16-74 years; 3792 men and 5222 women provided information on infertility. RESULT(S): There were 8.2% (95% CI 7.1-9.4%) of men and 12.5% (11.3-13.8%) of women who had experienced infertility; among fertility-tested women this was 15.4% (14.0-16.9%). Prevalence peaked in the 35-44 year age group (14.3% for men, 19.1% for women and 20.8% for fertility-tested women). Estimates for European, Maori and Asian ethnicities were similar. Pacific men and women had higher relative risks: 2.37 (95% CI 1.51-3.71) and 1.76 (1.27-2.44), respectively, compared with Europeans. Medical help was sought by 69.3% (95% CI 62.4-75.5%) of infertile men and 68.2% (63.1-72.9%) of women; this was significantly lower for Maori and Pacific. CONCLUSIONS: Infertility levels for those of European ethnicity were similar to studies in southern New Zealand, and in other high-income countries. However, infertility levels were just as high for Maori, and higher for Pacific people, despite experiencing fertility at younger ages. Focusing on reducing causes of infertility other than delayed childbearing would likely contribute to addressing this health disparity.

Barriers to seeking consultation for abnormal uterine bleeding: systematic review of qualitative research.

BACKGROUND: Although Abnormal Uterine Bleeding (AUB) can have serious medical consequences and significantly impacts daily life, the overall trend is that most women do not seek care for these symptoms. The objective of this review was to synthesise factors impeding women's access care for AUB. METHODS: Systematic literature review of qualitative studies (interview and focus group) regarding the lived in experiences of women with abnormal menstrual symptoms, followed by a thematic analysis of these studies. We screened CINAHL, SCOPUS, ProQuest, OVID and Pubmed for qualitative studies. Studies were assessed using the Clinical Appraisal Skills Programme checklist and thematic synthesis was used to develop themes from the findings of the studies. RESULTS: The review yielded 12 studies that satisfied the inclusion criteria. Three themes were developed that described barriers for women seeking care for AUB: health literacy (understanding of normal periods, role of cervical Pap smears and lack of access to appropriate information), taboo/normalisation (fear and embarrassment of symptoms, prioritising others) and health care provider (lack of accessible and trusted female GPs and poor experiences with GPs). CONCLUSIONS: For 20 years women have consistently reported poor experiences in accessing care for AUB. The findings from our review indicate that drivers to impeding access are multiple; therefore any approaches to improve access will need to be multi-level - from comprising local sociocultural considerations to improved GP training.

Dermatological conditions encountered in The Independent State of Samoa and an exploration of possible strategies to manage dermatological health-care needs in this resource-poor setting.

This report adds to the limited existing literature concerning dermatoses in Samoa. Conditions encountered during a 4-day private clinic are reported. Amongst the 75 patients reviewed, eczema was the most frequent condition diagnosed. This was followed by infective dermatoses particularly pityriasis versicolor and tinea infections. Reassuringly, in 97% of cases, suitable medications were available locally.

Cancer control in small island nations: from local challenges to global action.

Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.

Cancer management in the Pacific region: a report on innovation and good practice.

Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.

Cancer control in the Pacific: big challenges facing small island states.

This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.

Reflection on the current status of endometrial cancer in New Zealand.

Incidence of endometrial cancer is increasing rapidly in the developed world and is the most common gynaecological cancer in Australia and New Zealand. In line with obesity rates, the landscape and average age of women diagnosed with endometrial cancer are changing. There is still unmet need in early diagnosis, directed treatment, management of comorbidities and prevention strategies. This opinion piece aims to reflect on the current status of endometrial cancer in New Zealand in parallel to Australia, drawing out areas for future research and discussion.

Development and use of a research productivity assessment tool for clinicians in low-resource settings in the Pacific Islands: a Delphi study.

BACKGROUND: Research performance assessments have proliferated, but research indicators for use amongst clinicians in poorly resourced countries have been ill-defined. The aims of the present paper were to determine a set of indicators as determined by clinician participants from the Pacific Islands and a panel of research experts for use in the performance assessment of clinicians. METHODS: Two focus group discussions, one for nurses and one for doctors, were used to obtain the views of 28 Pacific Island clinicians of the BRRACAP Study about what the research indicators should be. A modified Delphi survey was used to obtain a consensus amongst 19 research experts, with Pacific Island research experience, as to what the indicators should be and then to rank these in terms of importance. A survey of the participants obtained data on the research tasks/actions performed 20 months after the initial research workshop. A resultant tool comprising of 21 indicators was used to assess the performance of 18 Pacific participants. RESULTS: The Pacific Island clinicians determined that research was important and that performance should be measured. They identified research indicators that could be used in their settings and ranked their importance using a points system. The panel of experts identified implementation of research findings, collaborations and actual change in practice as more important, with bibliometric measurements low down in the scale. Although only 64% of the 28 BRRACAP Study participants returned the questionnaire, 39% of those performed more than half of the 21 indicators used. Of the 18 Pacific clinicians assessed, 7 (39%) performed 10 or more tasks. CONCLUSIONS: A research performance assessment tool was developed using process and output indicators identified by Pacific clinicians and a panel of research experts. The tool, which placed emphasis on process and outputs that were not bibliometric based, proved useful in assessing the performance of Pacific clinicians working in a low-resource setting.

The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding.

INTRODUCTION: To evaluate the effectiveness of the levonorgestrel intrauterine system (LNG-IUS) in obese women with heavy menstrual bleeding in Counties Manukau Auckland area, New Zealand. METHODS: Prospective observational study in a tertiary teaching hospital. Twenty women with heavy menstrual bleeding (HMB) who agreed to treatment with the LNG-IUS and had a body mass index (BMI) of >30 kg/m2 were recruited between May and December 2014. The women completed two validated tools (Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart) at recruitment, 6 and 12 months follow-up. Demographic, medical and laboratory variables were obtained from the relevant CMH databases. Data on side effects and satisfaction were obtained from the women at 12 months. RESULTS: The median age (range) and BMI of the 20 women were 40.5 years (27-52 years) and 40.6 kg/m2 (30-68), respectively. Three LNG-IUS were removed due to infection and pain and these women were subsequently booked for a hysterectomy. The reduction in menstrual loss was estimated at 19.7% per month (95% CI (12.5%, 26.2%); P < 0.001), which translates to 73.2% per period of 6 months (95% CI (55.3%, 83.9%)) and 92.8% per period of 12 months (95% CI (80.0%, 97.4%)). The six items in the quality of life measure improved significantly in 14 women but only 12 women were satisfied with the treatment. CONCLUSION: The LNG-IUS was an effective treatment for 67% of obese women with heavy menstrual bleeding over a 12-month period, as assessed by the reduction in menstrual bleeding and the improvement in the quality of life measures.

Reduced primary care respiratory infection visits following pregnancy and infancy vitamin D supplementation: a randomised controlled trial.

AIM: To determine whether vitamin D supplementation reduces primary care visits for acute respiratory infection (ARI). METHODS: A randomised, double-blind, placebo-controlled trial was conducted in New Zealand and powered to determine the vitamin D dose needed to achieve normal vitamin D status during infancy. Healthy pregnant women, from 27 weeks' gestation to birth, and their infants, from birth to age 6 months, were assigned to placebo or one of the two dosages of daily oral vitamin D3 . Woman/infant pairs were randomised to placebo/placebo, 1000 IU/400 IU or 2000 IU/800 IU. For this ad hoc analysis, the primary care records of enrolled children were audited to age 18 months. RESULTS: Two hundred and sixty pregnant women were randomised to placebo (n = 87), lower-dose (n = 87) or higher-dose (n = 86) vitamin D3 . In comparison with the placebo group (99%), the proportion of children making any ARI visits was smaller in the higher-dose (87%, p = 0.004), but not the lower-dose vitamin D3 group (95%, p = 0.17). The median number of ARI visits/child was less in the higher-dose vitamin D3 group from age 6-18 months (placebo 4, lower dose 3, higher dose 2.5; p = 0.048 for higher-dose vitamin D3 vs. placebo). CONCLUSION: Vitamin D3 supplementation during pregnancy and infancy reduces primary care visits for ARI during early childhood.

Impact of using the International Association of Diabetes and Pregnancy Study Groups criteria in South Auckland: prevalence, interventions and outcomes.

INTRODUCTION: Adopting the modified International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for diagnosing gestational diabetes mellitus (GDM) will increase the prevalence of GDM resulting in increased resource utilisation and an unknown effect on clinical outcomes. AIMS: To determine the prevalence of GDM by the modified IADPSG criteria and compare characteristics and pregnancy outcomes between women with GDM by IADPSG-additional, those with GDM by the New Zealand Society for the Study of Diabetes (NZSSD) criteria and those with a normal oral glucose tolerance test (OGTT). METHODS: All women who delivered at Counties Manukau District Health Board (CMDHB) for a 12-month period from July 2012 to June 2013 had demographic, pregnancy and laboratory data obtained from hospital databases and clinical records. RESULTS: Of the 6376 (85%) of eligible women screened for GDM, 381 (6%) had GDM by NZSSD criteria and an additional 238 (4%) by the modified IADPSG-additional criteria, a relative increase of 62%. Women with GDM by NZSSD criteria had similar characteristics compared to women with GDM by IADPSG-additional. The outcomes between the two groups were also similar with the exception of a higher induction of labour (IOL) rate in women with GDM by NZSSD and a higher mean birthweight in the GDM by IADPSG-additional. CONCLUSION: Adopting the modified IADPSG criteria will result in a 62% increase in the number of GDM cases with a significant impact on workload and resources. Currently, there is insufficient evidence to support the introduction of the IADPSG criteria for our service.

Antenatal exercise in overweight and obese women and its effects on offspring and maternal health: design and rationale of the IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) randomised controlled trial.

BACKGROUND: Obesity during pregnancy is associated with adverse outcomes for the offspring and mother. Lifestyle interventions in pregnancy such as antenatal exercise, are proposed to improve both short- and long-term health of mother and child. We hypothesise that regular moderate-intensity exercise during the second half of pregnancy will result in improved maternal and offspring outcomes, including a reduction in birth weight and adiposity in the offspring, which may be protective against obesity in later life. METHODS/DESIGN: The IMPROVE (Improving Maternal and Progeny Risks of Obesity Via Exercise) study is a two-arm parallel randomised controlled clinical trial being conducted in Auckland, New Zealand. Overweight and obese women (BMI ≥25 kg/m2) aged 18-40 years, with a singleton pregnancy of <20 weeks of gestation, from the Auckland region, are eligible for the trial. Exclusion criteria are ongoing smoking or medical contra-indications to antenatal exercise.Participants are randomised with 1:1 allocation ratio to either intervention or control group, using computer-generated randomisation sequences in variable block sizes, stratified on ethnicity and parity, after completion of baseline assessments. The intervention consists of a 16-week structured home-based moderate-intensity exercise programme utilising stationary cycles and heart rate monitors, commencing at 20 weeks of gestation. The control group do not receive any exercise intervention. Both groups undergo regular fetal ultrasonography and receive standard antenatal care. Due to the nature of the intervention, participants are un-blinded to group assignment during the trial.The primary outcome is offspring birth weight. Secondary offspring outcomes include fetal and neonatal body composition and anthropometry, neonatal complications and cord blood metabolic markers. Maternal outcomes include weight gain, pregnancy and delivery complications, aerobic fitness, quality of life, metabolic markers and post-partum body composition. DISCUSSION: The results of this trial will provide valuable insights on the effects of antenatal exercise on health outcomes in overweight and obese mothers and their offspring. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000932864.

Building reproductive health research and audit capacity and activity in the Pacific Islands (BRRACAP) study: methods, rationale and baseline results.

BACKGROUND: Clinical research and audit in reproductive health is essential to improve reproductive health outcomes and to address the Millennium Development Goals 4 and 5. Research training, mentoring and a supportive participatory research environment have been shown to increase research activity and capacity in low to middle income countries (LMIC). This paper details the methods, rationale and baseline findings of a research program aimed at increasing clinical research activity and audit in the six Pacific Islands of Fiji, Samoa, Tonga, Vanuatu, Cook Islands and the Solomon Islands. METHOD: Twenty-eight clinician participants were selected by the five Ministries of Health and the Fiji National University to undergo a research capacity building program which includes a research workshop and mentoring support to perform research and audit as teams in their country. Data on the participants' characteristics, knowledge and experiences were collected from structured interviews, questionnaires, focus groups, and an online survey. The interviews and the two focus groups were audio-recorded and all replies were analysed in a thematic framework. RESULTS: The 28 participants included 9 nurses/midwives, 17 medical doctors of whom 8 were specialists in reproductive health and 2 other health workers. Most (24, 86%) were required to perform research as part of their employment and yet 17 (61%) were not confident in writing a research proposal, 13 (46%) could not use an electronic spreadsheet and the same number had not analysed quantitative data. The limited environmental enablers contributed to poor capacity with only 11 (46%) having access to a library, 10 (42%) receiving management support and 6 (25%) having access to an experienced researcher. Barriers to research that affected more than 70% of the participants were time constraints, poor coordination, no funding and a lack of skills. CONCLUSION: Building a research capacity program appropriate for the diversity of Pacific clinicians required research evidence and collaborative effort of key stakeholders in the Pacific Islands and the region. The participants had limited research knowledge, skills and experience and would require individualized training and continuous intensive mentorship to realize their potential as clinician researchers for their services in the Pacific.

Pacific Island publications in the reproductive health literature 2000-2011: with New Zealand as a reference.

BACKGROUND: There is a keen interest to develop research systems and increase research output in the 14 Pacific Island Forum Countries (PIFC) to support development of policies and practice based on locally relevant research evidence. AIMS: To assess the quantity and characteristics of reproductive health research output by each country (14 PIFC) from 2000 to 2011 using New Zealand's reproductive research outputs as the reference. METHODS: A systematic search of the literature using a broad definition of reproductive health. RESULTS: There were 174 papers published in the PIFC from 2000 to 2011 compared with 628 papers published in New Zealand (NZ). Most (57%) of the PIFC papers were from Papua New Guinea (PNG), although Samoa had the most papers by population (10/100,000). Five of the countries did not have a single publication. The majority of papers from both the PIFC and NZ were observational studies (72 vs 36%). Authors from Australia were responsible for 34% of PIFC publications followed by 25% from PNG. Sixty-three per cent of papers by PIFC sole and first authors were published in local journals, whereas 86% of non-PIFC authors published in international journals. CONCLUSION: There is a need for reproductive research in PIFC. PNG had the most publications on the back of a well-funded dedicated research institute and a significant collaboration with Australian researchers. The large number of papers in PIFC countries without PIFC authors raises the question about the need to require non-PIFC researchers to enter into genuine research partnerships in order to build research capacity in the PIFC.

Global prevalence of preterm birth among Pacific Islanders: A systematic review and meta-analysis.

The epidemiology of preterm birth among Pacific Islanders is minimally understood. The purpose of this study was to estimate pooled prevalence of preterm birth among Pacific Islanders and to estimate their risk of preterm birth compared to White/European women. We searched MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Library, CINAHL, Global Health, and two regional journals in March 2023. Observational studies were included if they reported preterm birth-related outcomes among Pacific Islanders. Random-effects models were used to estimate the pooled prevalence of preterm birth with 95% confidence interval (CI). Bayes meta-analysis was conducted to estimate pooled odds ratios (OR) with 95% highest posterior density intervals (HPDI). The Joanna Briggs Institute checklists were used for risk of bias assessment. We estimated preterm birth prevalence among Pacific Islanders in the United States (US, 11.8%, sample size [SS] = 209,930, 95% CI 10.8%-12.8%), the US-Affiliated Pacific Islands (USAPI, SS = 29,036, 6.7%, 95% CI 4.9%-9.0%), New Zealand (SS = 252,162, 7.7%, 95% CI 7.1%-8.3%), Australia (SS = 20,225, 6.1%, 95% CI 4.2%-8.7%), and Papua New Guinea (SS = 2,647, 7.0%, 95% CI 5.6%-8.8%). Pacific Islanders resident in the US were more likely to experience preterm birth compared to White women (OR = 1.45, 95% HPDI 1.32-1.58), but in New Zealand their risk was similar (OR = 1.00, 95% HPDI 0.83-1.16) to European women. Existing literature indicates that Pacific Islanders in the US had a higher prevalence of preterm birth and experienced health inequities. Learning from New Zealand's culturally-sensitive approach to health care provision may provide a starting point for addressing disparities. The limited number of studies identified may contribute to higher risk of bias and the heterogeneity in our estimates; more data is needed to understand the true burden of preterm birth in the Pacific region.

Ethnic differences in disease presentation of uterine cancer in New Zealand women.

OBJECTIVES: Little is known about the ethnic differences in disease presentation of uterine cancer in New Zealand women. The objectives of this study were two-fold: (1) to estimate the incidence and mortality of uterine cancer among women in New Zealand and (2) to examine the association of ethnicity and socioeconomic status with tumour stage and grade, at presentation of uterine cancer. METHODS: Retrospective survey of cancer cases identified from the New Zealand Cancer Registry. The authors analysed all 3203 uterine cancer cases registered with the New Zealand Cancer Registry during the period 1 January 1997 to 31 December 2006. Ethnic groups were defined based on the self-identified ethnicity recorded on the cancer registry: Ma-ori, Pacific and non-Maori non-Pacific women. Socioeconomic status was categorised as quintiles of the New Zealand Deprivation Index 2006. The mortality to incidence ratio was used as a measure of prognosis. Logistic regression was used to estimate age, ethnic and deprivation adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Pacific and Maori women have higher incidence (32.4 and 17.7 per 100 000 women, respectively) and mortality rates of uterine cancer (12.1 and 7.4 per 100 000 women, respectively). Women in the most deprived areas are more likely to present with an advanced stage of uterine cancer (OR 1.64, 95% CI 1.09-2.48). Maori and Pacific women are less likely to present with well-differentiated tumours (OR 0.69, 95% CI 0.52-0.92 and OR 0.72, 95% CI 0.52-0.99, respectively). CONCLUSIONS: Maori and Pacific women, and those from lower socioeconomic areas, are more likely to present with advanced uterine cancer.