Current Women's Health Reviews - Volume 5, Issue 3, 2009

In this issue of the Journal a review made some considerations about the increased use of cesarean sections (CS) in one high income country. In this report in a South-east region of Italy CS rate is about 48%, and is increasing about 4.25% in the last two years. If nothing changes it is expected that in one or two years the rate will be above 50%. If we consider “normal” as “the most frequent”, then a normal delivery in this region will be a CS. Many high-income countries and some middle-income countries are seeing a very high use of cesarean sections and many regions in these countries show figures above 50% of CS. We are facing a new obstetrician behavior. But, is this new behavior justified? Many ecological studies have shown that national figures above 10-15% are not associated with better maternal and neonatal outcomes [1, 2]. When measuring benefits and consequences of CS, the outcome could be influenced by the cause generating the CS. A systematic review of 79 studies of elective CSs versus vaginal deliveries, including observational and randomized trials, has shown that women with CS have decreased urinary incontinence at 3 months and decreased perineal pain in comparison with those having a vaginal delivery [3]. On the other hand, CS was associated with a higher risk of maternal mortality, hysterectomy, ureteral tract and vesical injury, abdominal pain, neonatal respiratory morbidity, fetal death, placenta previa, and uterine rupture in future pregnancies [4]. In summary, there are no medical justifications for the increasing trends of CS. One reason sometimes mentioned for the increase in CS is women's choice. However, at least in Latin American countries, pregnant women still favor vaginal delivery, either because recovery is faster or because it is the natural way to deliver [5, 6]. This preference is found even among women receiving a C-section and at hospitals with extremely high C-section rates. On the other hand the ecological studies already mentioned showed a low rate of CS in low income countries and an association of low rates with maternal and neonatal mortality [1, 2]. It has been estimated that the low rate of CS in low-income countries contributes to about 80, 000 maternal deaths a year [7]. This is another striking example of inequity of health provision, with some receiving more than needed and many with less than needed [8]. In this issue, Dr. R. K. Naz made a thoughtful review of contraceptive methods and how to obtain a better availability of them by every woman. Women empowerment is a needed strategy to obtain an equitable and sustainable reproductive health in every woman.

Osteoporosis is a highly-prevalent chronic disease that affects postmenopausal women who are clinically asymptomatic until complications, such as fractures, appear. Although the incidence of osteoporotic fractures is increasing in many parts of Asia, rates are still lower than those reported in Western countries. It has been postulated that soy intake, a major source of isoflavones, may have potentially-beneficial effects on bone health. In vitro and animal studies have shown that isoflavones exert their bone- supporting effects in multiple ways. Experimental data show that they act on both osteoblasts and osteoclasts through genomic and nongenomic pathways. Retrospective and prospective studies (case-control and cohort studies) have showed a conflicting effect of isoflavones on bone health. A small number of randomized controlled trials on the effects of soy isoflavones on bone mineral density and bone remodeling markers have been carried out. Only the Shanghai Women's Health Study has evaluated the association between soy consumption and the risk of fracture. The aim of this review was to evaluate the possible role of isoflavones in the prevention of osteoporotic fractures in postmenopausal women as demonstrated in high quality studies.

Chronic viral diseases impose a special responsibility for healthcare workers devoted to obstetric and human reproduction to avoid the risk of infection for the partner or the expected child. Attitudes towards carriers of viral infections are rapidly changing as a result of better medication and, consequently, a better long-term prognosis, which contribute to the progress being made in areas of cell biology and biochemistry. These infections may be transmitted from mother to child at different times not only during pregnancy, but also during intrapartum and postpartum periods. Gynaecologists should be prepared to counsel affected couples about the risks involved with natural and assisted conception and pregnancy and to recognise available testing and treatment options to optimise outcomes. We described the specificities of assisted reproductive techniques for human immunodeficiency virus (HIV)-, hepatitis C virus (HCV)- and hepatitis B virus (VHB)- infected patients, follow-up during pregnancy, recommendations about antiretroviral therapy (ARV) and delivery modes.

Triple negative breast cancer has recently been recognized as a distinct subtype of breast cancer. While TNBC and basal-type breast cancers are not identical, the terms are often used synonomously. TNBC have a poorer prognosis than other molecular subtypes of breast cancer. There are no known targeted agents, leaving chemotherapy as the primary adjuvant therapy. TNBC are associated with BRCA1 mutations, are more common in African-American women, and have a more aggressive clinical course, with high early rates of metastatic disease and early relapse. Current research is examining epidemiologic features associated with TNBC, and searching for effective targeted therapy.

Preeclampsia is a trophoblast-induced disorder of pregnancy with characteristics of a multisystem disease, resulting from an adverse maternal response to (in part) allogenic placental tissue. Preeclampsia is a heterogeneous disorder. Therefore, generalization of results from different studies is difficult and clear definitions are essential. The exact etiology of preeclampsia is still a matter of debate and many theories have been proposed. It is unlikely that a single factor underlies the development of preeclampsia. This review describes definitions of hypertensive disorders in preeclampsia and summarizes the most important pathophysiologic mechanisms.

There are several contraceptive methods available to women. These include hormonal and non-hormonal methods. Hormonal methods have various routes of delivery including oral, transdermal, and vaginal. Non-hormonal methods can be permanent such as sterilization or temporary such as barrier methods. Some couples rely on natural family planning in an attempt to avoid pregnancy. In cases of unprotected intercourse, emergency contraception is available in several different forms. Despite many contraceptive options, there continues to be a population explosion and unintended pregnancies in the United States each year. The future lies in the development of a non-steroidal, non-barrier, nonsurgical, and intercourse-independent method that can be used by both men and women without any side effects, and is acceptable in both the developed and the developing countries. Contraceptive vaccines have been proposed as a valuable alternative that can fulfill most, if not all, of the requirements for an ideal contraceptive. This article will review the various contraceptive modalities available to women and their competitive advantages and disadvantages.

Caesarean section (CS) rates are rising globally, though with considerable variation from country to country; in Italy the CS rate is about 38.2% and in Puglia, a region in the South-east (4 million inhabitants), the CS rate is about 47.7%, up 4.25% in the last two years. Currently, the high rate of CS and operative delivery in developed countries may be attributed to larger foetuses, an increase in the frequency of diabetes mellitus and pelvic adiposity, advanced maternal age at first pregnancy and a decrease in tissue elasticity. Moreover patients have a very low acceptance of any maternal-foetal risk in labour, and there is a significant increase of CS “on maternal request”. Studies of communities with low rates of caesarean delivery may help to identify factors that lower the CS rate, such as cultural attitudes toward childbirth, design of the perinatal system, and genetic and social aspects. Also needed are biopolitical projects for the rationalisation of human and technological resources, which may lead to a reduction in legal claims and a natural decrease in defensive practices or defensive obstetrics based on doubtful diagnoses. Furthermore, the number of caesarean deliveries performed “on maternal demand ” should be reduced by making sure that women are adequately informed about the safety of vaginal versus caesarean delivery. National health programs should be instituted and extended to large populations, showing the costs and benefits of vaginal versus CS delivery. This analysis reviews the current reasons for performing CS, analyzing limitations in labour management and focusing on dystocia, in order to identify possible socio-political and medical mechanisms that may reduce the CS rate in south-eastern Italy, including promising but under-used technologies.