Gender inequality and restrictive gender norms: framing the challenges to health.

Gender is not accurately captured by the traditional male and female dichotomy of sex. Instead, it is a complex social system that structures the life experience of all human beings. This paper, the first in a Series of five papers, investigates the relationships between gender inequality, restrictive gender norms, and health and wellbeing. Building upon past work, we offer a consolidated conceptual framework that shows how individuals born biologically male or female develop into gendered beings, and how sexism and patriarchy intersect with other forms of discrimination, such as racism, classism, and homophobia, to structure pathways to poor health. We discuss the ample evidence showing the far-reaching consequences of these pathways, including how gender inequality and restrictive gender norms impact health through differential exposures, health-related behaviours and access to care, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health. The cumulative consequences of structured disadvantage, mediated through discriminatory laws, policies, and institutions, as well as diet, stress, substance use, and environmental toxins, have triggered important discussions about the role of social injustice in the creation and maintenance of health inequities, especially along racial and socioeconomic lines. This Series paper raises the parallel question of whether discrimination based on gender likewise becomes embodied, with negative consequences for health. For decades, advocates have worked to eliminate gender discrimination in global health, with only modest success. A new plan and new political commitment are needed if these global health aspirations and the wider Sustainable Development Goals of the UN are to be achieved.

Patterns and Correlates of New Drug Initiation among Female Exotic Dancers: The Contribution of Occupational and Structural Risks.

Introduction: Exotic dance clubs (EDCs) can play pivotal roles in the production of drug-related risks for female exotic dancers (FED). We aimed to characterize the structural and occupational factors associated with new drug initiation post-EDC entry among new FED (N = 117) in Baltimore, Maryland. Materials and Methods: Logistic regression models tested the associations of new drug uptake, measured as initiating any illicit drug (including non-prescribed and diverted prescription narcotics) not used prior to EDC employment, with structural (e.g. debt sources, housing instability) and occupational (e.g. sex work, dancing as sole income source) vulnerabilities. Results: Most FED were younger than 24 years-old (60%), identified as Black/African American (61%), and did not complete high school (56%). Twenty-nine (25%) reported using any new drug post-EDC entry, with cocaine (34%) cited most frequently among newly initiated substances. In multivariable analysis, drug initiation was significantly associated with cumulative debt sources (Adjusted Odds Ratio [AOR] = 1.82, 95% Confidence Interval [CI]: 1.19-2.77), dancing as only income source (AOR = 4.21, CI: 1.29-13.71), and sex work (AOR = 9.26, CI: 2.74-31.32). Conclusions: Our findings implicate co-occurring structural and occupational factors in FED's initiation of illicit drugs proceeding EDC employment. Results demonstrate the coping role of drug use for FED in stressful working environments and the multiple vulnerabilities associated with illicit drug uptake. The study reinforces a need for harm reduction interventions (i.e. debt relief, employment connections, increased hourly pay) that consider the contribution of overlapping financial insecurities to the production of occupational risks motivating drug uptake.

Development of a Cost-Effective Educational Tool to Promote Acceptance of the HPV Vaccination by Hispanic Mothers.

Although vaccination against the Human Papilloma Virus (HPV) reduces the risk of related morbidities, the vaccine uptake remains low in adolescents. This has been attributed to limited parental knowledge and misconceptions. In this cross sectional study, we assessed the (1) clarity of educational material informing Hispanic mothers about HPV, cervical cancer and the HPV vaccine, (2) determined vaccination acceptability and (3) identified predictors of vaccine acceptance in an underserved health setting. 418 Hispanic mothers received the educational material and completed an anonymous survey. 91 % of participants understood most or all of the information provided. 77 % of participants reported vaccine acceptance for their children; this increased to 84 % when only those with children eligible to receive vaccination were included. Significant positive predictors of maternal acceptance of the HPV vaccine for their children were understanding most or all of the provided information, older age and acceptance of the HPV vaccine for themselves. Concerns about safety and general dislike of vaccines were negatively associated with HPV vaccine acceptance. Prior knowledge, level of education, previous relevant gynecologic history, general willingness to vaccinate and other general beliefs about vaccines were not significantly associated with HPV vaccine acceptance. The majority of participants reported understanding of the provided educational material. Vaccine acceptability was fairly high, but was even higher among those who understood the information. This study documents a cost-effective way to provide Hispanic mothers with easy-to-understand HPV-related information that could increase parental vaccine acceptability and future vaccine uptake among their children.

Clinical Risk Factors Do Not Predict Shoulder Dystocia.

Objective: To compare 2 different risk factor models for the prediction of shoulder dystocia. Study Design: We performed a retrospective study of women with vaginal deliveries at a single institution over an 8-year period. Two distinct multivariable logistic regression models were used to evaluate the occurrence of shoulder dystocia: a traditional model used information based on birthweight and macrosomia, and a clinical model used information based on esti-mated fetal weight and suspected macrosomia. Results: Of the 13,998 deliveries analyzed, there were 221 cases of shoulder dystocia (1.6%). In addition to the macrosomia or suspected macrosomia variables, the final models included prolonged second stage of labor, diabetes status, and oxytocin use. Neither model was highly sensitive or highly specific, and neither demonstrated a cutoff threshold that yielded a clinically viable PPV. Conclusion: Despite the presence of 1 or more risk factors for shoulder dystocia, its occurrence remains largely an unpredictable clinical event.

Neonatal Outcomes by Mode of Delivery in Preterm Birth.

OBJECTIVE: We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables. RESULTS: Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02). CONCLUSION: Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.

A case-control review of placentas from patients with intrahepatic cholestasis of pregnancy.

OBJECTIVE: To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP. METHODS: Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology. RESULTS: Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid. CONCLUSION: There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.

Endometrial echo complex thickness in postmenopausal endometrial cancer.

OBJECTIVE: To determine the preoperative pelvic ultrasonographic characteristics of postmenopausal women diagnosed with endometrial cancer (EC) at our institution. METHODS: Postmenopausal women with EC who underwent preoperative transvaginal pelvic ultrasound from 1999-2009 were identified from our institutional database. The histologic diagnosis was based on pathologic findings in the hysterectomy specimen. Endometrial echo complex (EEC) thickness was abstracted from ultrasound reports. In all instances, ultrasound preceded the biopsy by a maximum of 3 months. Means with standard deviations were calculated for all categorical data. Differences between type 1 and type 2 ECs were determined using Mann-Whitney U tests and Chi squared/Fisher's exact tests, as appropriate. A p-value of <0.05 was considered statistically significant. RESULTS: Among 250 patients with postmenopausal EC, 156 had type 1 EC while 94 had type 2 EC. Thirty-six percent of the cohort had an EEC ≤ 4 mm, including 37% of patients with type 1 EC and 34% of patients with type 2 EC (p=0.63). There were no significant differences between type 1 and type 2 ECs in any demographic characteristic, other than likelihood of postmenopausal bleeding. CONCLUSIONS: Current expert opinion recommends no further diagnostic procedure in a woman with postmenopausal bleeding and an EEC ≤ 4 mm. These results indicate that a sizable proportion of women with EC have EECs ≤ 4 mm during their initial evaluation. An EEC ≤ 4 mm does not completely rule out endometrial cancer and cannot supplant histologic evaluation.

Interobserver reliability of fetal heart rate pattern interpretation using NICHD definitions.

OBJECTIVE: To evaluate the interobserver reliability of fetal heart rate (FHR) pattern definition and interpretation assessed by physicians at various levels of training using standard Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) definitions and standard principles of interpretation. STUDY DESIGN: We conducted an interrater reliability study of the intrapartum FHR tracings of 32 singleton term pregnancies at Los Angeles County-University of Southern California (LAC + USC) Medical Center. Analysis included the 5 hours immediately preceding delivery, divided into 10- minute segments. A medical student, resident, and three attending physicians evaluated the same set of FHR tracings. Interobserver agreement was assessed using the free-marginal kappa coefficient. RESULTS: Reviewers demonstrated substantial to excellent agreement on baseline rate (κ = 0.97), moderate variability (κ = 0.80), accelerations (κ = 0.62), decelerations (κ = 0.63), category (κ = 0.68), and the ability to identify the presence of either moderate variability or accelerations (κ = 0.82). CONCLUSIONS: Interobserver agreement was significantly higher on all components of FHR definition and interpretation than previously expected. Standardization of FHR definitions and interpretation may improve interobserver reliability and patient safety.

Can highly sensitive antimüllerian hormone testing predict failed response to ovarian stimulation?

OBJECTIVE: To determine whether a newer commercially available antimüllerian hormone (AMH) enzyme-linked immunosorbent assay (picoAMH ELISA, AnshLabs) with a lower threshold of detection is predictive of successful ovarian stimulation in a population of women with diminished ovarian reserve (DOR). DESIGN: Retrospective case-control study. SETTING: University-based IVF program. PATIENT(S): Cases were patients whose first IVF cycle was cancelled for lack of ovarian response (<3 follicles; n = 24). Controls were patients with DOR (early follicular FSH of ≥10 IU/L), whose first cycle resulted in aspiration of at least 3 oocytes (n = 24). INTERVENTION(S): Frozen serum samples collected during routine clinical care between 2008 and 2012 before starting IVF were analyzed for AMH using the picoAMH ELISA. MAIN OUTCOME MEASURE(S): Serum AMH levels in patients who successfully reached oocyte retrieval compared with patients with a failed controlled ovarian hyperstimulation (COH) cycle. Receiver operator curve analysis was used to identify a predictive threshold AMH value. RESULT(S): No demographic differences were found between groups. The successful group had a higher antral follicle count (8.5 vs. 6) and higher AMH levels (847 vs. 406 pg/mL). The AMH level correlated with the antral follicle count (R = 0.61). The AMH level of >500 pg/mL had 83.3% sensitivity and 70.8% specificity to detect patients who proceeded to successful oocyte retrieval. Below AMH levels of 100 pg/mL, no patients achieved oocyte retrieval. CONCLUSION(S): Due to a lower threshold of detection, picoAMH may be able to predict successful ovarian stimulation among women with DOR using a threshold of 500 pg/mL, with good sensitivity and specificity.

Time interval between endometrial biopsy and surgical staging for type I endometrial cancer: association between tumor characteristics and survival outcome.

OBJECTIVE: To examine whether wait time between endometrial biopsy and surgical staging correlates with tumor characteristics and affects survival outcomes in patients with type I endometrial cancer. METHODS: A retrospective study was conducted to examine patients with grade 1 and 2 endometrioid adenocarcinoma diagnosed by preoperative endometrial biopsy who subsequently underwent hysterectomy-based surgical staging between 2000 and 2013. Patients who received neoadjuvant chemotherapy or hormonal treatment were excluded. Time interval and grade change between endometrial biopsy and hysterectomy were correlated to demographics and survival outcomes. RESULTS: Median wait time was 57 days (range 1-177 days) among 435 patients. Upgrading of the tumor to grade 3 in the hysterectomy specimen was seen in 4.7% of 321 tumors classified as grade 1 and 18.4% of 114 tumors classified as grade 2 on the endometrial biopsy, respectively. Wait time was not associated with grade change (P>.05). Controlling for age, ethnicity, body habitus, medical comorbidities, CA 125 level, and stage, multivariable analysis revealed that wait time was not associated with survival outcomes (5-year overall survival rates, wait time 1-14, 15-42, 43-84, and 85 days or more; 62.5%, 93.6%, 95.2%, and 100%, respectively, P>.05); however, grade 1 to 3 on the hysterectomy specimen remained as an independent prognosticator associated with decreased survival (5-year overall survival rates, grade 1 to 3 compared with grade change 1 to 1, 82.1% compared with 98.5%, P=.01). Among grade 1 preoperative biopsies, grade 1 to 3 was significantly associated with nonobesity (P=.039) and advanced stage (P=.019). CONCLUSION: Wait time for surgical staging was not associated with decreased survival outcome in patients with type I endometrial cancer.

A comparison of obstetrical outcomes with labor induction agents used at term.

OBJECTIVE: To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents. METHODS: This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County + University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications. RESULTS: A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher's, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p = 0.51), frequency of failed inductions (p = 0.49), the cesarean delivery frequency for "fetal distress" (p = 0.82) and five minute Apgar score <7 (p = 0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p < 0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7-8% among those in the other groups (p < 0.01). Although cases of "fetal distress" between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for "fetal distress" was higher among multipara receiving misoprostol (p = 0.004). There was no difference among the different induction agents with regards to five minute Apgar <7 (p = 0.34). CONCLUSION: Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.

The incidence of depression by fertility status in overweight and obese Latina women.

The link between depression, obesity, and fertility status is poorly understood among Latina women. The Patient Health Questionnaire 9 (PHQ-9) is routinely administered in the Diabetes and Obesity in Reproductive Age women Clinic. We describe median PHQ-9 score and PHQ-9 score ≥10 [indicative of Major Depressive Disorder (MDD)] by fertility status. Of the 76 eligible new patients seen between June 2008 and 2009, 18.4% (n = 14) had PHQ-9 scores indicative of MDD. Infertile women had marginally significantly higher PHQ-9 scores than non-infertile women (p = 0.08). 26.5% of infertile women and 12.2% of non-infertile women had a PHQ-9 score indicative of MDD (p = 0.14). Number of previous births was inversely correlated with PHQ-9 score (R = -0.34, p = 0.002), those with no previous births had higher PHQ-9 scores (p = 0.001) and were more likely to have a PHQ-9 score indicative of MDD than those with previous births (28.6 vs. 9.8%, p = 0.04). Among non-infertile women, postpartum women had significantly lower PHQ-9 scores than non-postpartum women (p = 0.002). 4.6% of postpartum women and 21.1% of non-postpartum women had a PHQ-9 indicative of MDD (p = 0.19). Further investigation is needed to determine if reproductive success is protective against MDD among overweight and obese urban Latinas. Overall, depression is common among overweight and obese reproductive-age Latinas and thus routine screening is recommended.

A low-fidelity total abdominal hysterectomy teaching model for obstetrics and gynecology residents.

INTRODUCTION: The objective is to develop a low-fidelity total abdominal hysterectomy (TAH) model for resident training with the purpose to improve residents' knowledge of anatomy, instruments, instrument handling, suture selection, and steps of a TAH. METHODS: A TAH model was created using products purchased from a crafts store. Obstetrics and gynecology residents (second-year residents and fourth-year residents) were subjected to a lecture followed by a simulated TAH. Before and after the course, subjects were given a survey to assess their confidence regarding the different surgical aspects of the TAH. Confidence was assessed regarding knowledge of anatomy, instruments, instrument handling, suture selection, incision site, steps of the TAH, and global confidence. Statistical analysis was performed using nonparametric tests. A P < 0.05 was considered significant. RESULTS: A low-fidelity TAH model was created. Eight second-year residents and seven fourth-year residents were studied. As expected, second-year residents had a lower median number of hysterectomies performed as primary surgeon when compared with fourth-year residents [0.5 (0.0-1.75) vs. 51.0 (50.0-53.0); P < 0.05]. Despite this difference, after having undergone the course, both resident classes demonstrated either statistical trends or significantly increased surgical confidence in all areas studied. CONCLUSION: Our novel, low-fidelity TAH simulation model and course improves obstetrics and gynecology residents' confidence in surgical skills and knowledge, particularly for those with less surgical experience. The total cost to make approximately 18 models was US $60.00.

Reevaluating the role of dilation and curettage in the diagnosis of pregnancy of unknown location.

OBJECTIVE: To evaluate the clinical utility of dilation and curettage (D&C) in diagnosing ectopic pregnancy (EP). DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): Clinically stable women (n = 321) who underwent a diagnostic D&C with no visible intrauterine pregnancy (IUP) on transvaginal ultrasound or those with an abnormal hCG trend. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): EP or IUP made by final pathologic review. RESULT(S): Overall, 73.2% of the patients were ultimately diagnosed with EP and 26.8% were found to have a nonviable IUP. Those with EPs had significantly lower initial hCGs than those with nonviable IUPs and were more likely to have had a history of an EP. On ultrasound, the overall impression, the presence of free fluid, and the endometrial echo complex correlated well with the final diagnoses but did not have 100% predictive value. CONCLUSION(S): D&C remains valuable to differentiate EP from nonviable IUP and to avoid misdiagnosis and unnecessary exposure to methotrexate. Low initial hCG values and ultrasound findings such as a thin endometrial echo complex and the presence of free fluid are associated with but are not diagnostic of an ectopic pregnancy.

The status of oocyte cryopreservation in the United States.

OBJECTIVE: To determine the current status of oocyte cryopreservation across the United States, and the perceived indications for its use. DESIGN: Cross-sectional survey of all IVF Centers in the United States. SETTING: Telephone and fax based survey of all IVF practice or laboratory directors, conducted March to June of 2009. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of oocyte cryopreservation, acceptable indications and age groups, number of oocyte cryopreservation cycles performed and thawed, fertilization and pregnancy rates, number of live births. RESULT(S): Of 442 centers contacted, 282 (64%) responded in 49 states. In these centers 143 (51%) programs currently offer oocyte cryopreservation, with a geographic trend toward the western-located clinics. Of all programs, 36% offer oocyte cryopreservation only for cancer patients or as an alternative to embryo cryopreservation after IVF, whereas 64% of programs offer it electively in women of advancing maternal age. For elective indications, 87% of programs accept patients aged 35-37 years, 49% consider age 38-40 years as acceptable, whereas only 26% of programs cryopreserve oocytes beyond age 40 years. Three hundred thirty-seven live births resulting from 857 thawed cycles (39.3% pregnancy rate [PR]) were reported across all centers. CONCLUSION(S): Oocyte cryopreservation is offered in more than 50% of ART clinics in the United States. Most programs that perform oocyte cryopreservation for cancer indications offer it for elective delay of childbearing as well. These data suggest a growing acceptance for this technology within our field.