Potential indications of cesarean myomectomy.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2965",leadTitle:null,fullTitle:"Sustainable Degradation of Lignocellulosic Biomass - Techniques, Applications and Commercialization",title:"Sustainable Degradation of Lignocellulosic Biomass",subtitle:"Techniques, Applications and Commercialization",reviewType:"peer-reviewed",abstract:"This book provides important aspects of sustainable degradation of lignocellulosic biomass which has a pivotal role for the economic production of several value-added products and biofuels with safe environment. Different pretreatment techniques and enzymatic hydrolysis process along with the characterization of cell wall components have been discussed broadly. The following features of this book attribute its distinctiveness: This book comprehensively covers the improvement in methodologies for the biomass pretreatment, hemicellulose and cellulose breakdown into fermentable sugars, the analytical methods for biomass characterization, and bioconversion of cellulosics into biofuels. In addition, mechanistic analysis of biomass pretreatment and enzymatic hydrolysis have been discussed in details, highlighting key factors influencing these processes at industrial scale.",isbn:null,printIsbn:"978-953-51-1119-1",pdfIsbn:"978-953-51-6339-8",doi:"10.5772/1490",price:119,priceEur:129,priceUsd:155,slug:"sustainable-degradation-of-lignocellulosic-biomass-techniques-applications-and-commercialization",numberOfPages:286,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"79f3af7841253f5e3e67f53245c121d6",bookSignature:"Anuj K. 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Chandel completed doctorate in 2009 from Jawaharlal Nehru Technological University, Hyderabad, India. After his masters from Indian Institute of Technology Roorkee, he joined Dalas Biotech Ltd. Bhiwadi, for the large scale production of penicillin acylase. Subsequently, he worked at University of Delhi in a research project funded by Department of Biotechnology (DBT), Govt. of India. Later he joined Celestial Labs Ltd., Hyderabad as a research associate. After this, he did post doctoral studies at University of Stellenbosch, South Africa. Currently he is working at Engineering School of Lorena, University of São Paulo in a thematic project funded by Bioen-FAPESP. He is the author of 1 book on xylitol, 45 articles in peer-reviewed journals and 12 book chapters.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Department of Biotechnology",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"138372",title:"Prof.",name:"Silvio",middleName:null,surname:"Silverio Da Silva",slug:"silvio-silverio-da-silva",fullName:"Silvio Silverio Da Silva",profilePictureURL:"https://mts.intechopen.com/storage/users/138372/images/system/138372.jpg",biography:"Professor Silvio Silvério da Silva was born on December 31st, 1959. He is a professor at Department of Biotechnology, Engineering School of Lorena, University of São Paulo (USP), Brazil. 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Among the benign uterine diseases, leiomyoma of the uterus seems to be the most common pathology. Though the endometrium is accepted as a dynamic tissue and myometrium is accepted as a silent muscular tissue, the reality is not that and it was understood from the studies that both endometrial processes and myometrial processes play a role in abnormal uterine bleeding.
\nUterine leiomyomas, also known as fibroids, are smooth muscle-derived benign masses ranging from millimeters to many centimeters. The investigation of pathological specimens of the uterus revealed that almost 80% of African Americans women and 70% of Caucasian women have detectable leiomyomas [1, 2]. The well-known risk factors for leiomyoma do not explain why racial difference is this much but genetic polymorphisms including increased aromatase activity and signal transducing genes showed that more severe phenotypic pattern may be seen in African Americans [3, 4].
\nInadequacy of medical treatment and lack of understanding of molecular physiology and pathophysiological processes make the surgical treatment as the main therapeutic option for leiomyomas [5].
\nLeiomyomas of the uterus are highly vascular benign tumors, and their volume may increase 9% in 6-month period. Growth rate of the myomas decreases after the age of 35 among Caucasian women and almost all myomas carried to menopausal period without any symptoms shrink in size together with the shrinkage of the uterus [6].
\nThere are only limited options for the treatment of leiomyomas of the uterus, and most of the time leiomyomas are asymptomatic and no treatment is necessary. For asymptomatic patients, menopause itself is a cure factor [7].
\nThere are numerous medical treatment options for the treatment of leiomyoma of the uterus like OCPs, progestins, NSAIDs, androgenic compounds, antifibrinolytics and progestin-loaded IUDs for symptom relief, and they are likely effective in at least a group of patients [8].
\nOther treatment options related to the use of GnRH agonists, GnRH antagonists and estrogen and progestin add back regimens may decrease the volume of the leiomyomas but after the cessation of medical treatment, leiomyomas resume their volume within 6 months of time [9, 10, 11].
\nSurgical therapy remains the definitive treatment option in symptomatic leiomyomas. Hysterectomy for the patients with no fertility problem increases the quality of the life of leiomyoma patients. Hysterectomy can be done by open surgery, laparoscopy or robotic-assisted surgery. Supracervical or subtotal hysterectomy is a controversial issue [12, 13, 14]. Abdominal myomectomy is the first surgical option for those who refuse to lose their uterus and who want to preserve their fertility for childbearing. Myomectomy can be done by open surgery, laparoscopic surgery and robotic-assisted surgery [15, 16]. For those who have submucous myomas, hysteroscopic resection is the gold standard treatment choice.
\nOne of the most controversial issues of obstetrics and gynecology is the presence of known or incidental leiomyomas during pregnancy and how to manage patients with myomas together with pregnancy. A total of 10–30% of the pregnancies develop some complications related to leiomyomas [17].
\nCesarean section is the most commonly performed procedure globally [18]. Due to more advanced age, pregnancies are more prevalent in developed countries, naturally encountering leiomyoma during cesarean section getting more prevalent as well. The prevalence of the leiomyomas during pregnancy varies from 0.37–12% in the current literature [19, 20, 21].
\nPerforming myomectomy during cesarean section is a controversial topic. The main concern is the potential risk of severe bleeding and increased morbidity when it is performed during cesarean section [22]. However, accumulating number of publications to support cesarean myomectomy in recent years is merging.
\nPotential indications of cesarean myomectomy are listed in Table 1.
\nContraindications of cesarean myomectomy are listed in Table 2.
\nIn contrary to common belief, Tinelli et al. presented that serosal myomectomy has a minuscule impact on blood loss in the light of no difference in blood product transfusion rates when it performed during cesarean section [23]. Ramesh et al. investigated 21 cases of cesarean myomectomy retrospectively and concluded that myomectomy during cesarean section is not associated with intraoperative and postoperative complications [24]. Leiomyomas located at the cornual region were not removed in their study. Mangala et al. compared the blood loss in single fibroid in abdominal and cesarean myomectomy cases and concluded that there is no significant difference between the groups, and it is safe to remove the single leiomyoma during cesarean section [25]. Machado et al. studied eight cases in Oman for the safety of cesarean myomectomy and concluded that in selected patients, cesarean myomectomy is safe and efficient in the hands of experienced surgeons and in the tertiary healthcare facilities [26]. Kwon et al. investigated 165 pregnant women having myomas, and they evaluated the patients whose myomas are over 5 cm in size and concluded that the size of the myoma has no greater impact on the increased rates of complications [27]. Sparic et al. assessed 350 papers on cesarean myomectomy and 38 studies found to be eligible for their evaluation for review of cesarean myomectomy in modern obstetrics. The major risk is intraoperative bleeding ranging from 0 to 35.3%. A potential late complication is the scar quality after the surgery. This may increase the risk of uterine rupture during the next pregnancy, but the literature lacks studies related to scar quality. However, Sparic et al. noted the advantages of cesarean myomectomy as smaller incision on the serosal surface, easy to perform during cesarean section, effortless suture placement and two operations in one. Another important advantage of cesarean myomectomy is the improved quality of life in affected women. However, they concluded that the risk benefit of cesarean myomectomy should be re-evaluated and further research is necessary [28]. Song et al. reviewed myomectomy during cesarean section through the database search and among 2500 studies they found nine studies eligible for their review and concluded that cesarean myomectomy may be a reasonable option in some leiomyoma patients but data driven from the meta-analysis were low quality, and definitive conclusion on this issue cannot be drawn [29].
\nSynchronous uterine contractions are mandatory for a healthy delivery. The uterus has no triggering mechanism as pacemaker in the heart, instead, uterine muscles have self- oscillators triggered by the changing membrane potentials happening in the pregnancy period and their contractility increases toward the end of the gestation [31]. Myocyte contractility also increased by the facilitation of prostaglandins and myocyte to myocyte connectivity and activated intracellular contractile mechanism, which eventually increase the intrauterine pressure that effaces and dilates the cervix for the babies to be delivered. Any leiomyoma or other uterine pathologies may have negative effect on the uterine contractility and also any surgical procedure related to the uterine musculature might have negative impact on the uterine contractility and may increase the risk of uterine rupture during delivery. Decreasing the myocyte damage during myomectomy should be taken into consideration during any myomectomy cases.
\nUterine pathologies including the leiomyoma have negative impact on the implantation and placentation [32]. Submucosal and intramural myomas deforming the endometrial surface reduce the implantation rates and increase the risk of abortion and mallocated placentation. The intramural leiomyoma not affecting the endometrial cavity is still a question. Number, size and locations of the myomas determine their impact. Small leiomyoma without endometrial impact has no adverse effects [33]. Leiomyoma classified according to new myoma classification from type 0 (submucous myoma) to type 8 (Parasitic myomas) [34]. In this study, the leiomyomas were in the range of type 2 and type 5.
\nThe human uterus may increase in volume and weight, 1000 times and 20 times respectively throughout pregnancy [35, 36]. However, myomas can only grow one in fourth size during pregnancy. Thus, myomectomy during cesarean section produces less tissue damage compared to removal of a symptomatic myoma in normal sized uterus. Serosal scarring and myocyte damage during myomectomy in nonpregnant uterus is more than that of cesarean myomectomy especially endometrial myomectomy. After all cumulated publications about the safety of cesarean myomectomies, severe bleeding and possibility of cesarean hysterectomy still remain controversial issue though these two complications are no common. Conforti et al. described techniques for reducing hemorrhagic blood loss in their study published in
Literature search for cesarean myomectomies revealed many publications supporting the cesarean myomectomy. In the retrospective study conducted by Topcu et al., 76 cesarean myomectomy cases were compared with 60 cesarean only cases for blood loss, operation time, the need for transfusion and hospital stay and concluded that size of the myoma is not important and removal of corporal and subserous myomas is safe and feasible in some patients [36]. In a large group of cases in a university hospital setting, Li et al. investigated the efficacy of cesarean myomectomy of 1242 cases by comparing three groups of cases where 200 cases without myoma (group A), 145 cases with myoma but without myomectomy (group B) and 51 cases with myoma during pregnancy resulted in cesarean hysterectomy (group C), and they concluded that myomectomy during cesarean section is a safe and effective surgical method [37]. Sparic et al. analyzed the decision 289 making in cesarean myomectomy and concluded that surgical skills, age of the patient and type of the myomas are the most important predictors of cesarean myomectomy [38].
\nCesarean myomectomy has been consistently applied in our setting for 17 years. Beginning from 2013, endometrial myomectomy has been started and selected as the cesarean myomectomy of choice instead of classical serosal approach because in serosal myomectomy, the bleeding, operative time, myometrial damage and adhesion formation possibilities are higher as compared to endometrial myomectomy [30]. The rate of suturing the endometrium during surgery is very low and uterine involution itself shrinks the surgical site to a lesser size. The surgery raises the question whether the endometrial myomectomy increases the likelihood of intrauterine adhesions or Asherman syndrome. We performed ultrasound evaluation at seventh day postoperation and evaluated the myometrial defect and found totally normal appearance in 22 cases. Also we called all patients 40 days after the surgery for saline infusion sonohysterography (SIS) and SIS outcomes revealed that no single case experienced intrauterine adhesions at any level. SIS has been neglected for long time in infertility, but actually SIS is a simple and important investigation for intrauterine pathologies. Intrauterine adhesions can be verified by simple SIS as an adjunct to other diagnostic tools [39]. CS myomectomy from endometrial approach decreases loss of blood, total operation time and adhesion formation compared to classical cesarean myomectomy.
\nHospital stay is no longer than classical myomectomies. Uterine serosa remains intact.
\nEndometrial myomectomy uses the principles of hysteroscopic myomectomy and supported by the physiological mechanism of uterine involution to decrease the blood loss and suturing during surgery. In this surgical method, unintentional opening of uterine serosa is accepted as complication because the main goal of this surgery is to remove all myomas from the endometrial layer without touching the serosal layer for preserving the uterus from dense adhesions and ease the future surgeries of the patient. All myomas located in anterior or posterior region and even the ones located close to cornual area can be safely removed by this surgical technique.
\nIn the following section, we describe the techniques of serosal myomectomy and endometrial myomectomy in detail.
\nThere are two approaches for removing the leiomyomas during cesarean section; one is the well-known serosal myomectomy and second is the novel technique recently published endometrial myomectomy. Both techniques use the same principle of intracapsular myoma removal, but the only difference is the route of myoma removal. Removing myomas by endometrial route have some advantages over the serosal myomectomy and both techniques are explained in the following section in detail.
\nSerosal myomectomy is the removal of the leiomyomas as in abdominal or laparoscopic myomectomy where incisions were made on the surface of the uterus. The only difference is the enlarged and well-vascularized uterus during cesarean section. Uterine involution squeezes the big vessels in the endometrial cavity, but the surface blood supply is not affected from the involution thus the risk of bleeding during serosal myomectomy is increased. Besides, the incision on the surface remains large which may have greater impact on the adhesion formation. In cases where multiple myoma removal is necessary, the number of incisions increases and the risk of bleeding and formation of adhesions increases. In serosal myomectomy, removal of posterior myomas and myomas close to the cornual region are not recommended. Myomas close to each other may be removed from the same incision to diminish the adhesion formation.
\nFollowing removal of baby and the placenta, the uterine cavity is swept by a gauze and incision site is controlled for any bleeding and lower uterine segment incision is closed with a running nonlocked no. 1 Vicryl suture. Uterine surface is evaluated for the locations and the sizes of the myomas present. Leiomyoma close to the low uterine segment incision site was taken out as described in endometrial myomectomy technique. Closed proximity of the leiomyomas was removed from a single incision to diminish the adhesion formation. Leiomyoma located in different locations is removed by incising each leiomyoma surface thus sutures and scarring on the surface of the uterus are prominent in classical technique. While removing the myoma, if myoma base carries a vascular pedicle, then the pedicle is clamped and sutured. The muscular layer is closed by separate no. 1 Vicryl sutures. The serosal surface is closed in either continuous locked no. 1 Vicryl sutures or a baseball suturing technique. After suturing a very hot sponge is placed on the suture line for a short time and then removed to see any bleeding foci. Any resistant bleeding not controlled by electrocautery may be controlled by no. 2 Vicryl U sutures or by figure of eight sutures around the suture line. No antiadhesion material is used for protection. After removal and suturing of all myomas, uterus is placed in the abdominal cavity and the serosal surface of the uterus and the tubes and ovaries are checked for bleeding and following hemostasis and clot removal the abdominal layers are closed according to the general principles.
\nThe long-term effect of this method is the adhesion formation, which makes the latter abdominal surgeries prone to complications. Hemostatic sutures for bleeding result in many suture nodes on the uterine surface and may prolong time of surgery.
\nIn 2013,
All myomectomy cases were performed by the same team of surgeons and cesarean section technique and myomectomy techniques used in these surgeries were the same. After removal of the baby and the placenta, the uterus is taken out from the abdominal cavity. The uterine cavity is swept by a gauze and uterine incision is controlled for any bleeding. Uterine surface and cavity are evaluated thoroughly for leiomyomas and anatomical locations and sizes are evaluated quickly. Those leiomyomas located close to the low uterine incision site (
Courtesy of Oğuz Güler M.D. & Cengiz Tokgöz M.D.
\nFollowing palpation and localization, leiomyomas (
Courtesy of Şafak Hatırnaz M.D. & Oğuz Güler M.D.
\nAny vascular structures at the root of leiomyoma were clamped and sutured (
Following bleeding control, any bleeding sites were sutured if present and if no major bleeding, myoma bed or death spaces are sutured with no. 1 Vicryl in a separated manner. Endometrium is sutured with an absorbable suture in cases where the defect site is bigger than 3 cm. Any serosal opening during subendometrial myomectomy is accepted as complication because the main goal of this surgical method is to keep the uterine serosa intact apart from cesarean lower uterine segment incision scar and by this way to minimize the adhesion formation which is a matter of fact in myomectomies. In cases where reaching myoma is difficult, the team preferred to use bivalves to open the endometrial cavity for a safe surgical procedure. Uterus itself is the major supporter of this surgery since the rapid physiological involution of the uterus diminishes the death spaces and suture sites thus endometrial scarring minimizes automatically. After inspection and hemostasis, lower uterine segment incision is closed and layers of the abdomen are closed carefully.
\nPostoperative care was not different from the cesarean section cases, and no additional treatment or follow-up was recommended for endometrial myomectomy cases.
\nNumber of the leiomyomas, leiomyoma sizes, amount of blood lost during this procedure, serosal opening during surgery and operation time are all recorded. Leiomyomas are sent for pathological evaluation in all cases.
\nAll patients are called 5 days after the hospital discharge for postoperative control and the uterus, the endometrium and the surgical sites of leiomyoma removal are evaluated carefully by transabdominal ultrasound and recorded. Every single patient is called for saline infusion sonography (SIS) 40 days after the surgery (when the uterine involution is ended and the uterus reaches the normal size) for the evaluation of endometrial damage or adhesion formation routinely and SİS findings are also recorded. Asherman syndrome at any level was not recorded in studied cases.
\nAmong the studied 22 cases, four of them were operated for next cesarean section, and no leiomyoma formation or adhesion formation was observed during their next surgeries.
\nBoth techniques carry some risks and complications during and after surgery. The complications related to cesarean myomectomy are listed in Table 3.
\n\n |
Symptomatic myomas (mild pelvic pain) | \n
Myoma >5 cm | \n
Single myoma | \n
Anteriorly located myomas | \n
Tumor previa | \n
Pedunculated myomas | \n
Avoiding extra surgical procedure | \n
Degenerative myomas | \n
Patient’s desire | \n
Potential indications of cesarean myomectomy.
\n |
Age > 40 years | \n
Multiple myomas | \n
Cornual located myomas | \n
Posteriorly located myomas | \n
Asymptomatic myomas | \n
Tendency to bleed | \n
Previous history of uterine rupture | \n
Contraindications of cesarean myomectomy.
\n |
Intraoperative bleeding | \n
Postoperative fever | \n
Blood transfusion | \n
Prolonged hospital stay | \n
Adhesion formation | \n
Asherman syndrome | \n
Abnormal placental insertions | \n
Uterine rupture | \n
Early and late complications of cesarean myomectomy.
A picture of SIS 40 days after the operation is depicted in Figure 1.
\nSaline infusion sonohysterography (SIS) 40 days after endometrial myomectomy. Courtesy of Oğuz Güler M.D.
Cesarean myomectomy still remains a controversial issue in obstetrics practice and seems to continue to be debated in the future. Because none of the studies were performed as randomized controlled trials so far, and meta-analyses derived from those studies have weak outcomes to say that cesarean myomectomy is a safe and reliable procedure. The accumulating data, however, diminished the fear of performing cesarean myomectomy.
\nThough this novel method of cesarean myomectomy, endometrial myomectomy, decreases the adhesion formation by keeping the uterine serosa intact, diminishes blood loss and reduce the operation time compared to serosal myomectomy, large-scale randomized controlled trials need to show mid-term and long-term outcomes of this novel approach. Much safer and technically easier methods may change the steady thoughts on the risks of cesarean myomectomy in future.
\nMarital rape unfortunately exists in every society. In the US, sexual coercion within marriage was banned in all 50 states by 1993 [1]. Still, marital rape charges are hard to prove, and consent to sex within marriage for each sexual encounter is a concept that remains elusive. Consensual sex between partners within the confines of a marriage is the generally accepted norm in non-abusive relationships. However, like in any other country, in abusive relationships sexual coercion continues to occur in the US and remains a difficult topic to battle. One study found that in the US 40–52% of the women in intimate relationships experiencing domestic violence, also experience sexual violence [2]. These cases can be hidden in some minority communities. The US is made up of diverse communities, and cultures. Immigrants to the US not only abide by US laws and cultural norms of the dominant culture, but also bring with them cultural values, beliefs, and practices from their own countries that are different. Many practice biculturalism, navigating two worldviews that, at times, appear to clash with each other [3]. Multiculturalism and diversity enhance the local culture and force everyone to embrace change, and look to within their customs and identify areas that need to be remedied. Domestic violence, especially marital rape, is a dark side of any culture and is unfortunately prevalent across all societies [3, 4].
Most South Asian immigrants within the US have their own values and customs regarding marriage. Like anywhere else, consent to sex is a generally accepted norm within a marriage, but how that consent is obtained varies in different cultural communities. In South Asia, marital rape is not a crime under the law, except for Nepal and Bhutan [5]. For example, the penal code of Bangladesh reads that, “sexual intercourse by a man with his own wife, the wife not being under 13 years of age, is not rape” [6]. The legal and the cultural implication of that is that by the consent to marriage, sexual consent is granted at the outset, and sexual acts are not negotiated by each encounter. This means that legally by design a husband cannot rape a wife. While these views on sexual consent within a marriage vary by age, class, education, religion, and other intersectional factors, it creates a situation in abusive relationships where sex can be demanded by the spouse at any time, regardless of their partner’s wishes. This is further complicated by patriarchal gendered norms about differences in male and female sexuality that exist within many South Asian communities. In South Asian countries, men are generally granted sole entitlement to initiation of sex and to sexual pleasure, being viewed as having biological sexual needs, and there is a common acceptance of males having multiple sexual partners or sexual encounters before and after marriage. On the flipside, women are typically viewed as the pillars of society for socialization. Hence, viewed as chaste beings, access to sex is generally accepted only through marriage. There is an expectation they will remain a virgin until married and will remain faithful to their partner after marriage. Women’s sexual pleasure is not a concept that is often accepted, written about, or talked about [7, 8]. This dichotomy between male and female sexuality creates distinctions within women, where “good women”, or those who abide by the cultural norms, have access to marriage and social status. “Bad women”, those who do not conform, have difficulty finding marriage partners and are branded within their communities. The more you deviate from those norms, the more negatively you are sanctioned. Sex workers, who are not just viewed as deviants but also as a group who takes advantage of the sexual entitlement and the biological needs of men, are granted the lowest social status, relegated to society’s margins, and are criminalized [8, 9, 10]. From this perspective, for women who abide by social norms, access to sex is seen both as a reward but also as a duty to the partner for the security and social status that marriage brings. This creates a power differential in relationships that complicates giving willing consent [7]. Misinterpretations of religious passages and cultural practices tied to religion further complicate sexual negotiations within South Asia. In the Muslim faith, many verses in the Quran and hadiths from Prophet Muhammad preach peace, love, and equality within marriage. For example, the verse, “They (your wives) are your garment and you are a garment for them” (Quran - 2:187) [11], describes equality of partners in marriage. Additionally, the hadith (hadith - teachings of Prophet Muhammad) that the Prophet said to his companions: “Not one of you should fulfill one’s (sexual) need from/fall upon his wife like an animal; but let there first be a messenger between you” And when asked “What is that messenger?”, he replied “kisses and sweet words”. In effect, the Prophet Muhammad was talking about foreplay. Several other hadiths and verses from the Quran also show that foreplay was recommended before sexual relations. This recognizes the fact that women need some time for arousal for sex to be comfortable and pleasurable. “And one of the signs is that he created for you spouses from among yourselves so that you might take comfort in them and He has placed between you, love and mercy…..” (Quran - 30:21) [11].
Yet, many Muslims believe that men can request sex from their wives anytime. In Islam, marriage is a civil contract, under this contract, both men and women are assigned specific duties. The husband is considered to have
These intersectional factors create a context where marital rape as a concept is nullified. This allows society to believe that consent is given at the time of the marriage and not with each sexual act. These values further complicate marital rape as it creates a situation where husbands can demand sex from their wives anytime, and as dutiful wives, they need to comply every time. No matter how painful it is, the concept of coercion is not accepted as rape, rather as part of wifely duty, and in some situations with the threat of a second, or third wife hanging over her head. While these concepts may create dilemmas for women even in peaceful families, these cultural norms can have especially detrimental ramifications for women undergoing domestic violence. To understand the impact of marital rape, this paper looked at immigrant Muslim South Asian female survivors of domestic violence experiences of marital rape. At the time of the interviews, all women were living in the US.
The study was conducted in the United States of America. This study is part of a larger study conducted in Texas, looking at domestic violence in the Muslim communities. While the overall study conducted qualitative interviews with 48 Muslim survivors of domestic violence coming from various backgrounds, only 20 South Asian women talked about their experiences of sexual abuse within the marriage. All 20 women were foreign-born and came from Pakistan, India, Bangladesh and Sri Lanka. Ages varied from 23 to 58. The interviews took place between 2011 and 2018. All women were fluent in English and the interviews were conducted in English. The education background of the participants varied with 10 participants having a college degree or some college experience, and 10 participants with no higher education. A content analysis approach was utilized to analyze the data. It is important to note that all participants were seeking services for domestic violence. Themes identified were based on the participants’ views only. These should not be generalized to all South Asian cultures or those who are considered Muslim.
Sexual abuse did not take place for these women in a vacuum, rather it took place in a larger context of psychological, physical, financial, spiritual, and at times even immigration related domestic violence. As the participants came from a domestic violence shelter, all the women discussed a range of abuse that took place leading them to seek help from an agency. None of the women sought help because of the sexual violence, rather it was due to other aspects of abuse. Some were there due to emotional abuse, while the majority experienced physical violence. Some stated that they were talking about their experiences related to sexual coercion and marital rape for the very first time. Women in the study appeared to have a perception that being forced to have sex with their husband was not abuse, similar to other types of abuse they had undergone. Rather it was part of marriage. The women were groomed to believe that culturally and religiously, they were expected to comply with their husband’s wishes. Sexual abuse within marriage appears to remain relatively covered up, even though every US state since the 1990s has marital rape laws. The following conversation between the researcher and the interviewee elaborates this context very well.
“Interviewer: Who do you confide about feeling forced to have sex?
Interviewee: No one.
Interviewer: You have not spoken to anyone about what you just mentioned?
Interviewee: Well, I have spoken to a counselor and the case manager about the other abuse, how he tried to choke me and kill me, how the police were involved, but not about other stuff I just told you, no.
Interviewer: May I ask your reasons for not telling anyone?
Interviewee: It is private, our culture, everyone is in the same situation, I think. You have to give in at some point. You married him. We are told that all the time growing up.”
South Asian culture in general, and Muslim culture in particular, value modesty in women very highly. Sex is not a subject that is talked about and young girls are not given much information about what to expect with regards to marital relations. They are not aware of what acceptable or “normal” behavior is and what is unacceptable or pushing the boundaries into rape. For them, anything their husband does is to be tolerated, even if they do not enjoy it or find it painful. Consent, or lack thereof, certainly never enters the equation. They are not aware they have a right to refuse certain acts if they choose to do so.
Similar to past studies on sexual behavior from South Asia, the women in the current study identified variations in the code of behavior allowed for men and women, and extending to husband and wife. While men were identified with entitlement to demand sex when desired and even allowed access to other women, the women’s role in terms of sexuality was identified by duties and an obligation to the husband. Rather the women were considered more the property of the men, with obligations to fulfill. Participants discussed that men did not consider wives as equal in sexual play, and when sexual pleasure was sought after by women, it was discouraged even within the marriage. Men are sexual beings, while women are mere receptacles. They are not viewed as active participants with sexual desires. This is derived more from South Asian culture, rather than Islamic teachings.
As mentioned above, the participants repeatedly used language of ‘belonging’ to the spouse, and discussed their role in sexual play as duties and obligations. Interestingly, while the women talked with great dissatisfaction, it was also clear through their conversations that they were also accepting of these societally assigned roles and their husband’s treatment of them. As one woman said, “This is not something we talk about in my culture, but he treated me like I was his property. It was an exchange somehow; he gave me a house that he earned money to pay for where I had to cook and be sexually available when he needed. I was denied any pleasure. There was no emotions in his sexual requests. It was nothing romantic. Just satisfy me, this is your duty”.
Other women also echoed this sentiment of being treated as property and the obligations to submit. As one said, “it is like I don’t have a say, I am like an animal to him. I just have to do what he tells, my duty and obligations, that is it.”
As mentioned above many women alluded to the concept that husbands are the only one who are normed to get sexual pleasure within the marriage and women are expected to only give pleasure to the husband. Some women discussed this concept in detail. As one woman said, “I didn’t feel I could say no. at least most times…no, he didn’t care how I felt, he didn’t think sex needs to be enjoyable for the wife. Just for the man”.
One of the women at the shelter came severely injured internally. Her husband had tried to “cleanse” her with a hose pipe. He wanted a wife who was “pure”.
In a focus group discussion two participants had this exchange. One woman was explaining that her husband cheated on her, and how she had to still accept it, but as a woman she cannot do the same:
“Female 1: Yeah. And she already say, we say jealous, okay, it’s fine, with the man, what did you do, they said okay fine, but woman, it’s no.
Female 2: Because he’s a man, he can do whatever, his family is like a property for him, it’s not like human being, no. It’s his property.”
Another woman talked about a time when she was called a slut by her own husband for initiating a sexual act. She said, “One time I watched this video involving French kissing, I was naïve and wanted to see what it was like. I asked him (referring to the husband) if we can try. He told me I was acting like a ‘slut’ and to stop demanding for sexual things. He was basically telling me I wasn’t a good woman because I asked for something sexual and made me feel ashamed. Sadly, he is not alone in this, I know all his friends would feel the same way”.
A few others elaborated this further, a few women felt that their husband’s expectation for them for sex, beyond pleasuring them is to the have children. One woman simply said, “Another said, “He only wants me to make babies”. Another elaborated further, “It was just out of the blue, he just hit me. And I wouldn’t accept that. And he wanted me to be a stay at home wife, and wanted me to have kids right away, and I had already told him before we got married, I want to go to medical school. Do you think that’s something you can handle? He said yes… I told him, I don’t want to have kids until like three, four years down the road. Is that something you’re okay with? And he said yes… right. Afterward we got married, everything changed… Right away… Within marriage, as soon as we got married… Yeah. He was like, I don’t want you to go to medical school. There’s no such thing. And he wanted kids right away, so I started hiding my birth control”.
Yet another woman said, “I have children, he just wanted me to keep making children, but, with the last child I went and got an illegal abortion in my country”.
Yet not all women bought into the belief that sex is for male pleasure. One woman stated, “I enjoy sex… despite what I went though I would like to get married again”.
The women in the study also talked about their upbringing where they were expected to me obedient and submissive to their husbands. These values were culturally and religiously emphasized in their childhood socialization process. Their upbringing of expectation that a good wife is someone who is obedient, submissive and one who does not complain about private matters of the household all created a context of future acceptance of sexual coercion by their spouse as normal sexual behavior expected of a ‘good’ wife. One woman explained, “I was told from the beginning be a good girl, men only marry good girls, I was groomed from the beginning to be a wife, a good wife, and good wife is someone who won’t fight her husband, the man is the head of the household, you have to comply to his wishes. It is in the Quran too. So, I was trying to be a good wife. I tried. I tried very hard. I did everything I was brought up to believe, but, it wasn’t enough for him, and it got worse and worse”.
This expectation to be obedient wife was something that was brought up by several other women also, another woman said, “I was brought up to be obedient to my husband”. Another talked about the more complicated dilemma it created for her, “I believe because of seeing my parents, and how I was raised everything would be easy. I didn’t expect sex to be this difficult, how do you say yes every time when it hurts every time?”
It is important to note that the majority of the women in the study did not question their culture, rather they used culture to explain their experience, and even the few that were upset with their culture or religion still understood their experience within the context of their cultural and religious backgrounds, as one of the women said, “sometimes I am upset how much I went through, it is our culture, it is my religious background, but when I really think about it, I still question myself too… was I a good wife, are there things I could have done?”
Beyond duty, women in the study talked about how threat and intimidation were used as weapons to get them to submit to sex. While emotional and physical threat is a constant fear they had to live with if they opposed the sexual demands from their husbands, the women in the study also talked about their husband’s threat about, or actual relationships with other women.
One woman talked about how an old Islamic tradition accepted in her country which allowed men to marry more than one woman was a threat for her if she did not comply. She said, “He would threaten me all the time that he can have other women, he can have four women. He told me if I don’t have sex with him, he will find someone who would and I just can’t do anything about it”. Another explained the complex play between actual acts of cheating, using that to get the wife to comply but also make her feel like his cheating is because of her inadequacies in the bedroom. She elaborated, “He found another woman, and he didn’t care how I felt. He treated me like I had to accept. It is part of culture that men have a right to sleep with whomever they please. He made me feel like I made him go out though, because I wasn’t adequate in that area. For him it was like at least it is just sex, not an emotional relationship, so I should be happy. I still had to give in to him if he wanted and if he feels like it he didn’t even look at me sometimes. He threatened to go out more if I didn’t”.
Beyond the threat of emotional and physical abuse and cheating, women also talked about how some used their religion to force compliance. In a focus group discussion two of the participants said:
“Female 1: Show it by their religion. They say in the past – The men use Quran, interpret it wrong.
Female 2: It’s different, yeah, what you – they are like it [Crosstalk].
Female 1: Like I told you, whatever you like.
Female 2: Whatever he like it, you have to obey, honestly, I’m talking about this, it’s like this, you have to obey. Because in the religion, in the Quran say that, you have to be like this. You have to respect your husband like this, what he like it. But, I don’t know if it means what men say it does. But, we have to comply”.
Yet another woman talked about how religion and threats to tell family were used against her, she said, “He would say he has the religious right to have sex with me anytime. He would threaten to tell my family if I did not give in. It would be so embarrassing and my family would have said I wasn’t being a good wife”.
In South Asian cultures, as well as in Islamic religion, the concepts of fate and patience also play a big role in the acceptance of, and submission to, domestic violence and sexual violence. In Islam it is thought that whatever happens to you has already been decided by
Given the cultural and religious understanding that in a marriage women are expected to comply many women did not identify what they went through as rape. Yet, they talked about the same symptoms of rape survivors. As one woman elaborated, “I don’t think I consider it being raped. Rape I see as someone forcibly violating you. I know I have a duty as a wife. It is part of marriage. In my case, I don’t think I have a right to say no when he demands. But, I hated it. I hated him showing any affection, because I was afraid it would lead to him wanting sex. I was afraid to go on trips with him, inevitably when the night time comes he would want to have sex. Any as the day got closer to night, I would start feeling sick, I would have a headache, I would feel sick to my stomach, I could feel my body tensing up. I hated the thought of having sex with him, as it comes closer and closer to bed time I would feel more and more stressed… yes, he knew it hurt me, he didn’t care. Sometimes, I would say I don’t want to have sex tonight, but, if I say that his mood would change and he wouldn’t talk, or he would remind me all the things he is doing for me”.
Another said, “The whole process made me feel dirty, every time we have sex. It made me want to take shower after shower. It just didn’t feel right”. Yet, another woman explained a more horrific experience in her very short marriage, “He forced on me repeatedly. He was so violent. I would bleed. Even after I got pregnant it didn’t matter. I would cry the whole time… my marriage lasted only a few months”. Yet, when asked if she would consider what she went through as marital rape, she was not sure, she said, “I am not sure, it was horrible…may be now…”.
One final woman, while also not quite acknowledging her experiences of having sex without emotional consent as rape, talked about how the cultural context of marriage does create a situation where wives at least initially are in a context ripe for rape. Yet, she accepted it as the price of marriage. She explained, “Obviously when you are kind of forced to marry at a young age, and these are arranged marriages, you don’t know him. All your life you are told keep your legs crossed, don’t let boys notice you, don’t let anyone look at you, and suddenly you are supposed to be with this stranger, even though he is your husband. Of course it is going to be difficult. How do you let all that upbringing go? You can’t relax, and our men, they are not like in the movies, they don’t talk love. They just jump to it. How are you supposed to be okay? It is not going to be okay, but, that is price of marriage”.
In many South Asian countries, arranged marriages are still the norm. Girls are brought up in strict environments with little to no contact with members of the opposite sex. Co-educational schooling is limited in conservative areas, and girls usually attend girls-only schools and thus have limited exposure and opportunities for meeting or interacting with boys/men. Marriages are arranged for them by their parents, or families, within the social group. Many of these young women meet their husbands-to-be with both families present. There is little interaction and very few chances for getting to know their prospective husbands. Their first real contact with their husbands is after the marriage ceremony has already taken place, and they have been married to a stranger.
Another woman told her story of experiencing increasingly violent sexual abuse. She said the first few months of her marriage seemed okay, but then she began noticing that her husband started forcing her even when she was not feeling well. In fact he seemed to enjoy it more when she said no. One day she accidently discovered that he watched videos of women being raped. That was when she realized he was acting those scenes out and it scared her enough to leave him. However, she did not identify what he played out as rape. Yet, she talked about the shock, the pain and the emotional trauma.
Almost all the women in the study identified that it is shameful to talk about marital sex. They acknowledged that it is the most private intimate thing in a marriage and that they were brought up not to talk about family matters, especially an area that they deem very private as sex. Some in the study acknowledged that this was the first time they were talking about their sexual abuse and that this was an area that they had not even brought up with their therapists. As one woman said, “I just couldn’t talk about such intimate issues with her (referring to the therapist), it is so shameful, it is not like physical abuse, or not giving me money, this is so private.” Yet, for another it was the fact that she felt she couldn’t comply to her husband’s wishes, “I didn’t tell even my mother, I didn’t want to be judged, I just couldn’t give every time, how am I supposed to talk about that to anyone, this was my duty as a wife?” For another woman the shame was questioning herself for husband’s extra marital affairs, “In my head, I know it is all on him for cheating like that, but he always said it was my fault that he cheated, because I didn’t know how to give him… I couldn’t satisfy him, I struggled with that, I questioned my worth with that… even now I feel this shame inside-I worry others think the same, and I know inside, but it doesn’t help”.
The women talked about how this sense of shame stopped them from reaching to anyone about how they felt. The burden of how they felt due to forcing sex upon them, or cheating on them were placed on the woman herself. The above woman continued, “I felt very alone, I didn’t know how, how do I tell anyone I hate doing anything with him, and I then I also tell he is cheating? How, everyone will say it was my fault”
While these experiences within marriage were bad enough, some younger women also identified the sexual dangers of being a divorced woman. They felt that now they don’t have the protection of a man, other men will think they are available for their pleasure. One woman felt like she has to weigh her options before considering divorce. A woman living on her own without a husband is very vulnerable and exposed to a multitude of dangers… Often she does not have the support of her family and there is no one to turn to if she is harassed. As one woman explained, “It is harder because a lot of men hit on me after my divorce. They would act like they are going to help me, but they end up wanting something else. Not a relationship, but… (referring to sex) you know what I mean… because my visa expired (because her husband didn’t apply for extension), I am illegal right, so in the end I thought, I am just going to stay in shelters (referring to DV shelters) till the Visa (VAWA petition) came. I am afraid to go out to work. It is almost a year now, I have stayed in 3 different shelters here, here (referring to current agency) more than 6 months. It is okay I don’t have money. I don’t want to be treated that way. Visa will come soon… yeah you have to consider is going through everything I went through better or am I now going to experience that from all the other men? But, I would say no. He was too extreme”. Another explained, “I am talking to guys also… you know what I am saying… they want a good woman, I am not anymore, guys just want sex and not marriage… the good woman… I am praying either get married or get through my son because he is autistic… this guy try to take advantage of me… but I don’t let any take advantage… These days they look at women who work with respect and women who don’t work they look down… in India also divorce is not okay”.
Gender roles are very strictly defined in Muslim culture. The man is the protector, the provider, and spiritual head of the family. The woman is in charge of the household and of raising the children. With the head of the family out of the picture, divorced women feel very vulnerable to any men who might try to take advantage of them. Since they are divorced, they are viewed by men in their communities as “available”. They are sexually experienced and not seen as innocent virgins - leaving them even more exposed. Traditionally, in Islamic culture, the father, or the eldest male, is the “
Women this study were all survivors of domestic violence, and findings therefore must be understood within the intersectional confines of of culture, religion, domestic violence and its impact on marital rape. This study findings reflected how South Asian girls’ upbringing steeped in patriarchal culture, and misinterpretations of religious passages led to a context ripe for sexual abuse within marriages that were already experiencing domestic violence. Yet, this same socialization prevented them from understanding marital rape as rape. Even when the women opposed what happened to them, or experienced physical and psychological symptoms related to abuse, or even when they understood the context in which they were forced to have sex by their spouses, they were reluctant to name it as rape. Within the intersectional South Asian culture and Islam, the women in the study identified that girls are taught to be submissive, obedient, silent, and patient. They identified this submissiveness as the ideal and perfect wife/daughter-in-law people are looking for. This added with the direct belief that access to women’s sex is through marriage and women’s role in sex is to cater to the husband’s needs. It means that women in the study believed that they must cater to all the demands from their husbands in the bedroom. Hence the women in the study did not complain about sexual violence and tried not go against societal and religious norms. Unfortunately, this meant that even when they understood other aspects of domestic violence and abuse, marital sexual violence was accepted. This also means that sexual abuse will be not be revealed due to the veil of silence over this subject. As participants identified it is extremely shameful to talk about this aspect of their marriage and they are taught to never bring shame on the family or their husband. Many women in the study identified that talking the researcher was the first time they talked about the sexual abuse within marriage. This contexts of uniqueness are important to understand to identify the circumstances in which marital rape happens and understood. The study findings are similar to other past studies on marital rape in South Asia [3, 7, 12, 13, 14]. These findings have implications to human rights advocates, human service workers, and legal advocates. You can’t find what you don’t know, and you can’t fight what people understand as acceptable. Hence, the study findings indicate the importance of understanding contexts in which marital sexual abuse takes places, and the importance of targeting the socialization process itself. The study highlights the importance of long-term cultural change related sexuality, promoting resect and equality that is needed to prevent domestic violence and marital rape. On an individual level, the human service sector working with this population needs to understand these contexts to effectively assist. Legal advocates also need to understand the cultural and religious backdrop that promotes a reluctance to provide evidence in court.
This publication was partially funded by Grant Number HHS-2013-ACF-ACYF-EV, Department of Health and Human Services, and the University of North Dakota grant. This affiliated agency also received partial funding from the Robert Wood Johnson Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or other funders.
“The authors declare no conflict of interest.”
We thank all current and former survivors of domestic violence for sharing their stories and insights.
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
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As the science gets more advanced and the information about these two points becomes clearer, the view of this information might modify our understanding to these processes. Then, some topics might be dropped, and others might be raised or become more obvious. However, the feeding of halophyte forages as per se has several drawbacks and therefore, they have to be fed in mixed rations, fortifying these rations with energy supplements.",book:{id:"5978",slug:"new-perspectives-in-forage-crops",title:"New Perspectives in Forage Crops",fullTitle:"New Perspectives in Forage Crops"},signatures:"Salah A. 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CW has been successfully applied as an adsorbent for removing pollutants from wastewater and gas, a precursor for obtaining activated carbon, and a feedstock for producing energy and valuable products using mono-process extraction and biorefinery.",book:{id:"8952",slug:"coffee-production-and-research",title:"Coffee",fullTitle:"Coffee - Production and Research"},signatures:"Felipe J. Cerino-Córdova, Nancy E. Dávila-Guzmán, Azucena M. García León, Jacob J. Salazar-Rabago and Eduardo Soto-Regalado",authors:null},{id:"56029",doi:"10.5772/intechopen.69614",title:"Production of Spineless Cactus in Brazilian Semiarid",slug:"production-of-spineless-cactus-in-brazilian-semiarid",totalDownloads:1875,totalCrossrefCites:4,totalDimensionsCites:8,abstract:"The term “spineless cactus” is used in Brazil to designate cultivars of Opuntia ficus indica Mill and Nopalea cochenillifera Salm Dyck. The spineless cactus was consolidated in Brazilian semiarid as a strategic fundamental food resource in several production livestock systems, constituting a plant with enormous productive potential. Thus, the spineless cactus has been widely cultivated and used for several decades, by enabling the animal feeding in critical periods of year because of its characteristics, morpho‐anatomical and physiological (CAM), which makes it tolerant to long droughts, being a crop that presents high productivity in droughts conditions, when compared to other forages. Nevertheless, the spineless cactus is a crop relatively picky about soil and climate characteristics of region, presenting greater growth in fertile soils, as well as in regions where nighttime temperatures are cool and the air humidity is relatively high. Although the crop be adapted to long droughts periods, many times it’s necessary to perform irrigation in its production system, mainly in regions of low rainfall, for to supply its water needs, thus ensuring productivity and survival of crop. Therefore, the knowledge of characteristics of plant, as well as of appropriate management techniques to crop, is essential for the good performance of spineless cactus.",book:{id:"5978",slug:"new-perspectives-in-forage-crops",title:"New Perspectives in Forage Crops",fullTitle:"New Perspectives in Forage Crops"},signatures:"Wilma Cristina Cavalcante dos Santos Sá, Edson Mauro Santos,\nJuliana Silva de Oliveira and Alexandre Fernandes Perazzo",authors:[{id:"139631",title:"Dr.",name:"Edson Mauro",middleName:null,surname:"Santos",slug:"edson-mauro-santos",fullName:"Edson Mauro Santos"},{id:"180036",title:"Dr.",name:"Juliana",middleName:null,surname:"Oliveira",slug:"juliana-oliveira",fullName:"Juliana Oliveira"},{id:"203022",title:"MSc.",name:"Wilma",middleName:null,surname:"Sá",slug:"wilma-sa",fullName:"Wilma Sá"},{id:"207265",title:"Dr.",name:"Alexandre",middleName:null,surname:"Perazzo",slug:"alexandre-perazzo",fullName:"Alexandre Perazzo"}]},{id:"69900",doi:"10.5772/intechopen.89508",title:"Coffee By-Products: Nowadays and Perspectives",slug:"coffee-by-products-nowadays-and-perspectives",totalDownloads:1126,totalCrossrefCites:3,totalDimensionsCites:6,abstract:"Coffee is one of the most consumed products around the world; 2.25 billions of coffee cup are consumed everyday in the world. For coffee crop production, different by-products are produced, such as coffee peel, coffee husk, parchment, and spent coffee grounds. These by-products have several problems associated at the final disposition. In this book chapter, we study the main coffee varieties produced in the world, the by-products produced, and its composition and finally assess the potential of supramolecular solvents (SUPRAS) and water as green solvents for high-added-value compound extractions. Bioactive compounds were extracted from fresh and dried coffee peel in an acceptable rate for industrial applications. SUPRAS offer advantages in terms of rapidity (5 min) and simplicity (stirring and centrifugation at room temperature), thus avoiding costly processes based on high pressure and temperature. Extractions carried out using water as solvent is another technique of extraction mixing temperature (above 60°C) and time (4.5 min) obtained a beverage or solution with presence a bioactive compounds how caffeine, chlorogenic acid and polyphenols.",book:{id:"8952",slug:"coffee-production-and-research",title:"Coffee",fullTitle:"Coffee - Production and Research"},signatures:"Laura Sofía Torres-Valenzuela, Johanna Andrea Serna-Jiménez and Katherine Martínez",authors:null},{id:"70151",doi:"10.5772/intechopen.89224",title:"The Harvest and Post-Harvest Management Practices’ Impact on Coffee Quality",slug:"the-harvest-and-post-harvest-management-practices-impact-on-coffee-quality",totalDownloads:1736,totalCrossrefCites:2,totalDimensionsCites:5,abstract:"Coffee is one of the most important agricultural commodities in the world. The coffee quality is associated with pre-harvest and post-harvest management activities. Each step starting from selecting the best coffee variety for plantation until the final coffee drink preparation determines the cupping quality. The overall coffee quality influenced by the factors which involve in changes the physicochemical properties and sensorial attributes, including the post-harvest operations. The post-harvest processing activities contribute about 60% of the quality of green coffee beans. The post-harvest operations include pulping, processing, drying, hulling, cleaning, sorting, grading, storage, roasting, grinding, and cupping. This chapter comprises the harvest and post-harvest operations of coffee and their impacts on coffee quality.",book:{id:"8952",slug:"coffee-production-and-research",title:"Coffee",fullTitle:"Coffee - Production and Research"},signatures:"Mesfin Haile and Won Hee Kang",authors:null}],mostDownloadedChaptersLast30Days:[{id:"71528",title:"A Detail Chemistry of Coffee and Its Analysis",slug:"a-detail-chemistry-of-coffee-and-its-analysis",totalDownloads:2264,totalCrossrefCites:5,totalDimensionsCites:0,abstract:"This review article highlights the detailed chemistry of coffee including its components; chemical constituents like carbohydrates, proteins, lipids, and caffeine; aromatic principles; oil and waxes; and minerals and acids. The high extent of caffeine can be found in the coffee plants; hence, in the second part of the study, various analytical methods are designed for the proper identification, separation, optimization, purification, and determination of caffeine present in coffee, tea, and marketed coffee. These analytical methods are appropriated for the separation and quantification of caffeine. The various analytical methods include spectroscopy methods like UV, IR, and NMR spectroscopy; chromatographic methods like paper, TLC, column, HPLC, and gas chromatography; and hyphenated techniques like LC–MS, GC–MS, and GC–MS/MS. This article compares and contrasts the amount of caffeine by various analytical methods.",book:{id:"8952",slug:"coffee-production-and-research",title:"Coffee",fullTitle:"Coffee - Production and Research"},signatures:"Hemraj Sharma",authors:null},{id:"70151",title:"The Harvest and Post-Harvest Management Practices’ Impact on Coffee Quality",slug:"the-harvest-and-post-harvest-management-practices-impact-on-coffee-quality",totalDownloads:1738,totalCrossrefCites:2,totalDimensionsCites:5,abstract:"Coffee is one of the most important agricultural commodities in the world. The coffee quality is associated with pre-harvest and post-harvest management activities. Each step starting from selecting the best coffee variety for plantation until the final coffee drink preparation determines the cupping quality. The overall coffee quality influenced by the factors which involve in changes the physicochemical properties and sensorial attributes, including the post-harvest operations. The post-harvest processing activities contribute about 60% of the quality of green coffee beans. The post-harvest operations include pulping, processing, drying, hulling, cleaning, sorting, grading, storage, roasting, grinding, and cupping. This chapter comprises the harvest and post-harvest operations of coffee and their impacts on coffee quality.",book:{id:"8952",slug:"coffee-production-and-research",title:"Coffee",fullTitle:"Coffee - Production and Research"},signatures:"Mesfin Haile and Won Hee Kang",authors:null},{id:"72400",title:"Factors Affecting Efficiency of Vegetable Production in Nigeria: A Review",slug:"factors-affecting-efficiency-of-vegetable-production-in-nigeria-a-review",totalDownloads:788,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"Vegetables are important for maintenance of good health; their production and marketing are veritable sources of employment and livelihood. To promote vegetables’ contribution to the above, there is a need for sustainable and efficient production process. The paper reviewed production, socioeconomic factors, and constraint affecting efficiency of production of three important vegetables (tomato, pepper, and onion). The review showed that socioeconomic factors found to increase technical efficiency in vegetable production were educational level, extension contact, and household size. Influence of farmer age on technical efficiency was inconclusive due to varied opinions. Increase in farm size, quantity of seed, amount of fertilizer, and agrochemical were found to have positive influence on output. Majority of the literature reviewed opined that increase in quantity of labour raises productivity; however, it must be utilized efficiently. The mean technical efficiency of the vegetables varied from the southern to the northern part of the country. The cross cutting constraints in vegetables production are pest and diseases, inadequate storage facilities, and high cost of improved inputs. The study recommends increase awareness and sensitization on optimum levels of resource use for increased productivity and appropriate intervention to constraints in the value chain.",book:{id:"10142",slug:"agricultural-economics",title:"Agricultural Economics",fullTitle:"Agricultural Economics"},signatures:"Iyabo Bosede Adeoye",authors:[{id:"317695",title:"Dr.",name:"Iyabo Bosede",middleName:null,surname:"Adeoye",slug:"iyabo-bosede-adeoye",fullName:"Iyabo Bosede Adeoye"}]},{id:"65591",title:"Insect Pest Management in Organic Farming System",slug:"insect-pest-management-in-organic-farming-system",totalDownloads:2549,totalCrossrefCites:1,totalDimensionsCites:4,abstract:"Due to the regulations of organic farming, few options remain for organic farmers to manage pests and diseases in their crops compared to conventional farming. However, major pests could still be managed through manipulation of the agroecosystem processes in advantage of the crops and disadvantage of pests. The limited number of active plant protection substances authorized for use in organic farming can provide support to natural and biological control agents in suppression of pests and diseases. This chapter highlights the principles and strategies of crop protection in organic farming, the cultural practices adopted, the active substances allowed for use to suppress pests, and the impacts on faunal and floral biodiversity. 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