{"paper_id":"7cbd6a5d-70d0-44cf-aa43-7c6d88126713","body_text":"~ 500 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2026; 10(3): 500-505 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \nIndexing: Embase \nImpact Factor (RJIF): 6.71 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2026; 10(3): 500-505 \nReceived: 11-03-2026 \nAccepted: 13-04-2026 \n \nDr. Avinashi Kujur \nProfessor & HOD, Department of \nObstetrics & Gynaecology, RSDKS \nGovernment Medical College, \nAmbikapur, Chhattisgarh, India \n \nDr. Sathi Mondal \nAssistant Professor, Department of \nObstetrics & Gynaecology, RSDKS \nGovernment Medical College, \nAmbikapur, Chhattisgarh, India \n \nDr. Sneha Singh \nSenior Resident, Obstetrics & \nGynaecology, RSDKS Government \nMedical College, Ambikapur, \nChhattisgarh, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Avinashi Kujur \nProfessor & HOD, Department of \nObstetrics & Gynaecology, RSDKS \nGovernment Medical College, \nAmbikapur, Chhattisgarh, India \n \nFactors influencing decision-making among rural \nwomen with abnormal uterine bleeding: A prospective \nobservational study from central India \n \nAvinashi Kujur, Sathi Mondal and Sneha Singh \n \nDOI: https://www.doi.org/10.33545/gynae.2026.v10.i3g.2313  \n \nAbstract \nBackground: Abnormal uterine bleeding (AUB) is a frequent reason for gynecological consultation and, in \nresource-limited rural settings, may become a pathway toward hysterectomy even when conservative \noptions remain clinically appropriate. Distance from care, limited understanding of the disease, absence of \nprior documentation, and family-level decision-making can all shape treatment preference in ways that are \nnot captured by diagnosis alone. \nObjectives: To describe the sociodemographic, clinical, access -related, and perception -based factors \ninfluencing decision -making about conservative versus operative management among rural women \npresenting with AUB. \nMethods: This prospective observational study was conducted in the  Department of Obstetrics and \nGynecology, R.S.D.K.S. Government Medical College, Ambikapur, from January 2022 to October 2023. A \ntotal of 230 consenting women with AUB were interviewed one -to-one after counselling regarding disease \nnature and available tre atment options. Demographic variables, access constraints, bleeding pattern, prior \ntreatment history, diagnostic category, and reasons favouring hysterectomy were summarized as \nfrequencies and percentages. \nResults: AUB accounted for 47% of gynecological out patient attendance during the study period. Most \nwomen were aged 36 -40 years (138/230, 60%), had parity 1 -3 (184/230, 80%), belonged to low \nsocioeconomic status (195/230, 85%), and were uneducated (184/230, 80%). Seventy percent (161/230) \ntravelled more th an 100 km to reach the hospital. Prolonged heavy menstrual bleeding was the dominant \ncomplaint (161/230, 70%), and 172 women (75%) reported bleeding for more than eight days per cycle. \nPrevious medical treatment for AUB was absent in 184 women (80%), while  207 (90%) had no records of \nearlier care. Adenomyosis (88/230, 38%) and leiomyoma (80/230, 35%) were the most frequent diagnostic \ncategories. The commonest decision -influencing reasons were lack of awareness of options other than \nsurgery (207/230, 90%), p rolonged suffering (161/230, 70%), distance -related difficulty in returning for \nfollow-up (161/230, 70%), and the husband's belief that surgery would cure the illness (138/230, 60%). \nConclusion: Decision-making for AUB among rural women in this cohort was d riven not only by \npathology but also by health literacy, travel burden, missing treatment documentation, chronicity of \nsymptoms, and household influence. Strengthening early counselling, peripheral follow -up linkages, and \ndocumentation of medical managemen t may reduce avoidable progression toward hysterectomy while \npreserving timely surgery for clinically indicated cases. \n \nKeywords: Abnormal uterine bleeding, hysterectomy, rural women, decision -making, PALM-COEIN, \nhealth access, India \n \nIntroduction  \nAbnormal uterine bleeding is not a single disease label. It is a clinical presentation covering \ndisturbances in menstrual frequency, regularity, duration, or volume, and its causes are now \nmost usefully organized through the FIGO PALM -COEIN system, which s eparates structural \ncauses such as polyp, adenomyosis, leiomyoma, and malignancy/hyperplasia from non -\nstructural causes such as coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not -\nyet-classified conditions  [1]. The diagnostic language matt ers. When AUB is described only as \n“heavy bleeding” or “menstrual problem,” the underlying cause may be missed, and the woman \nmay move directly into a surgical narrative before medical or uterine -preserving choices have \nbeen properly explored [2].  \nThe burde n is also not merely gynecological. A systematic review found that AUB among \nreproductive-age women is associated with impaired health -related quality of life, work loss, \nand considerable healthcare utilization [3]. Heavy menstrual bleeding, in particular, can quietly \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 501 ~ \nnarrow a woman's social and economic life. It affects travel, \ndaily labour, sexual life, religious participation, and the ability to \nattend family or agricultural responsibilities without anxiety \nabout bleeding through clothes. Such consequence s are often \nunder-reported in rural outpatient consultations because women \nmay normalize heavy bleeding after childbirth, sterilization, or \nthe onset of Perimenopause [4]. \nIndian good clinical practice recommendations emphasize \nstructured evaluation, classi fication according to etiology, and \nmedical or conservative management wherever clinically \nappropriate. For several AUB categories, first -line approaches \ninclude tranexamic acid, non -steroidal anti-inflammatory drugs, \ncombined oral contraceptives, oral pro gestins, or levonorgestrel \nintrauterine system, while hysterectomy is generally reserved for \nspecific indications, failure or refusal of medical management, \ncontraindications to conservative options, completed fertility \nwith appropriate pathology, or malig nant/premalignant disease  \n[5]. \nThis treatment hierarchy, however, enters a very different reality \nin rural India. National surveys show that hysterectomy is not \nevenly distributed across social and geographic groups, and \ntreatment decisions may be shaped by  age, parity, residence, \nprivate-sector exposure, and reported symptoms such as \nexcessive bleeding or fibroids  [6]. Recent Indian analyses have \nfurther shown that hysterectomy is more commonly reported \namong women above 35 years and that excessive menstrual  \nbleeding or pain remains one of the dominant self -reported \nreasons for undergoing the operation  [7]. Earlier NFHS -based \nwork also highlighted rural residence, low schooling, higher \nparity, and regional variation as relevant determinants [8].  \nThe present stu dy was therefore planned around a practical \nquestion seen every day in tertiary gynecology clinics serving \nremote catchments: why do rural women with AUB lean toward \nhysterectomy, even when conservative treatment is explained? \nThe objective was to describe  the sociodemographic, clinical, \naccess-related, and perception -based factors influencing \ndecision-making regarding conservative versus operative \nmanagement among rural women presenting with AUB at a \ntertiary care hospital in Ambikapur. \n \nMaterials and methods \nStudy Design and Setting: A prospective observational study \nwas conducted in the Department of Obstetrics and Gynecology, \nR.S.D.K.S. Government Medical College, Ambikapur , from \nJanuary 2022 to October 2023. \n \nStudy Population \nWomen presenting to the gynecology outpatient department with \ncomplaints of abnormal uterine bleeding and consenting to \nparticipate were included. The final study group consisted of 230 \nwomen. \n \nSampling Method: Eligible consenting women attending the \noutpatient service during the st udy period were enrolled \nprospectively. \n \nData Collection; Demographic details, parity, socioeconomic \nstatus, education, approximate distance from residence to \nhospital, bleeding pattern, prior treatment history, availability of \nprevious records, diagnostic category, and self -reported reasons \ninfluencing treatment choice were recorded. Each woman was \ninterviewed one -to-one after counselling regarding the disease \nprocess and available treatment options. Where reasons were \nexpressed in local language, they were  grouped into clear \noperational categories for analysis. \n \nStudy Variables: The main variables were age group, parity, \nsocioeconomic status, educational status, residence -to-hospital \ndistance, presenting bleeding complaint, duration of bleeding, \npads or cloths used per day, prior medical treatment for AUB, \navailability of previous treatment records, PALM -COEIN \ndiagnostic category, and reported reasons favouring operative \nmanagement. \n \nOperational Definitions: A decision -influencing factor was \ndefined as any reason stated by the woman or her accompanying \nfamily member that shaped preference toward hysterectomy or \ndifficulty accepting conservative management. Access difficulty \nwas defined using travel distance and inability to return for \nrepeated visits. Prior treatment documentation referred to written \nprescriptions, investigations, discharge notes, or other medical \nrecords available at the time of consultation. \n \nStatistical Analysis: Qualitative variables were summarized as \nfrequencies and percentages. As the study was descriptive and \nthe available variables did not include a comparative outcome \ngroup with complete inferential fields, no hypothesis testing was \nperformed. The outpatient proportion of AUB was reported \ndescriptively because the underlying denomina tor for total \ngynecological outpatient attendance was not available in \nanalyzable form. \n \nEthical Considerations: Informed consent was obtained from \nall participating women. Institutional Ethical Committee \nclearance was obtained. \n \nResults: During the study p eriod, 230 women with AUB \nconsented to participate. AUB accounted for 47% of \ngynecological outpatient attendance during the same period. \nThis figure is presented as an OPD -based proportion rather than \na population incidence. The age distribution was concen trated in \nthe late reproductive and perimenopausal years: 138 women \n(60%) were aged 36 -40 years, 58 (25%) were aged 41 -45 years, \nand 34 (15%) were aged 31-35 years (Table 1 and Figure 1). \nTable 1: Sociodemographic and access profile of women with AUB (n=230) \n \nCharacteristic Category n % \nAge group (years) \n31-35 34 15 \n36-40 138 60 \n41-45 58 25 \nParity \nNullipara 12 5 \n1-3 184 80 \n4-6 34 15 \nSocioeconomic status Lower middle 35 15 \nLow 195 85 \nEducational status \nUneducated 184 80 \nEducated up to primary 35 15 \nEducated up to high school 11 5 \nDistance from residence \nWithin 50 km 23 10 \n50-100 km 46 20 \n>100 km 161 70 \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 502 ~ \n \n \nFig 1: Age distribution of women presenting with abnormal uterine bleeding \n \nBar chart displays participant counts and corresponding \npercentages by age group. \nParity 1-3 was reported by 184 women (80%), while 34 (15%) \nhad parity 4 -6 and 12 (5%) were nulliparous. Low \nsocioeconomic status was recorded in 195 women (85%), and \n184 women (80%) were uneducated. Travel burden wa s a \nprominent feature of the cohort: 161 women (70%) travelled \nmore than 100 km to attend the outpatient department, while \nonly 23 (10%) lived within 50 km of the facility (Table 1). \nThe dominant presenting complaint was prolonged heavy \nmenstrual bleeding,  reported by 161 women (70%). Heavy \nmenstrual bleeding without prolonged duration was reported by \n58 (25%), and intermenstrual bleeding by 11 (5%). Bleeding for \nmore than eight days per cycle was reported by 172 women \n(75%), and the same number reported us ing more than eight \npads or cloths per day. Prior medical treatment for AUB was \nabsent in 184 women (80%), while 207 women (90%) had no \nprevious records available at consultation (Table 2 and Figure \n2). \n \nTable 2: Bleeding pattern, prior care, and documentation status (n=230) \n \nClinical/access variable Category n % \nPresenting complaint \nIntermenstrual bleeding 11 5 \nHeavy menstrual bleeding 58 25 \nProlonged heavy menstrual bleeding 161 70 \nReported bleeding days per cycle \n2-4 days 12 5 \n4-8 days 46 20 \n>8 days 172 75 \nPads/cloths used per day 4-7 58 25 \n>8 172 75 \nPrevious medical treatment for AUB Yes 46 20 \nNo 184 80 \nPrevious treatment records available Yes 23 10 \nNo 207 90 \nAUB: abnormal uterine bleeding \n \n \n \nFig 2: Previous medical treatment and availability of treatment records \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 503 ~ \nStacked bars show yes/no responses for previous AUB treatment \nand medical documentation. \nDiagnostic classification showed a predominance of structural \ncauses. Adenomyosis was diagnosed in 88 women (38%) and \nleiomyoma in 80 (35%). Malignancy or endometrial hyperplasia \naccounted for 23 cases (10%). Among non -structural causes, \novulatory dysfunction and endometrial causes were each \nrecorded in 12 women (5%). Smaller proportions were classified \nas polyp, coagulopathy, iat rogenic, or not yet classified (Table 3 \nand Figure 3). \n \nTable 3: Diagnostic profile according to PALM-COEIN categories (n=230) \n \nPALM-COEIN diagnostic category n % \nPolyp 4 2 \nAdenomyosis 88 38 \nLeiomyoma 80 35 \nMalignancy/hyperplasia 23 10 \nCoagulopathy 3 1 \nOvulatory dysfunction 12 5 \nEndometrial 12 5 \nIatrogenic 4 2 \nNot yet classified 4 2 \n \nPercentages are rounded to the nearest whole number and match the recorded study categories  \n \n \n \nFig 3: Distribution of diagnostic categories among women with AUB \n \nDonut chart shows the proportion of each recorded PALM -\nCOEIN category. \nWhen women were asked why they were inclined toward \nhysterectomy or found repeated conservative management \ndifficult, the most frequent reason was lack of awareness of any \ntreatment op tion other than surgery, stated by 207 women \n(90%). Prolonged suffering and distance -related inability to \nreturn for follow -up were each reported by 161 women (70%). \nHusband-driven belief that uterine surgery would cure the illness \nwas reported in 138 wome n (60%). Fear of cancer was reported \nby 57 women (25%). Because more than one reason could be \nreported by the same woman, these percentages are not mutually \nexclusive (Table 4 & Figure 4). \n \nTable 4: Self-reported factors influencing preference toward operative management (n=230) \n \nDecision-influencing factor n % \nUnaware of treatment options other than surgery 207 90 \nTroubled by symptoms for a long period 161 70 \nPerceived lack of benefit from medicines 69 30 \nResidence too far / difficulty returning for follow-up 161 70 \nBelief that there is a uterine lump 69 30 \nBelief that the uterus is swollen 104 45 \nHusband's belief that surgery will cure the illness 138 60 \nFear of cancer 57 25 \n \nMultiple responses were allowed; therefore, percentages exceed 100 when summed  \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 504 ~ \n \n \nFig 4: Self-reported factors influencing decision-making toward hysterectomy \n \nHorizontal bars show multiple -response frequencies; \npercentages use n=230 as denominator. \n \nDiscussion \nThis study shows that decision -making for AUB in rural women \nis shaped by a cluster of clinical, social, and access -related \npressures rather than by diagnosis alone. The most visible \nfinding is the heavy concentration of women in the 36 -40-year \nage group, with low educational status, low socioeconomic \nstatus, substantial travel distance, and prolonged symptoms. In \npractical terms, these women were not simply choosing between \ntablet and surgery in an equal clinical space. Many were \nchoosing under fatigue, uncertainty, and the fear that another \nhospital visit might not be possible. \nThe OPD -based AUB proportion of 47% reinforces how large \nthe symptomatic burden can be in a tertiary gynecology service \nreceiving rural referrals. Since the denominator was not \navailable for independent verification, the value should not be \nread as community incidence. Even so, it fits the larger \nobservation that menstrual morbidity is a frequent and under -\ntreated reason for gynecological consultation. Indian spatial \nanalyses of hysterectomy have shown clear variation by place of \nresidence and district, and rural women often carry delayed care \npathways before reaching surgical services [9]. \nAdenomyosis and leiomyoma together accounted for nearly \nthree-fourths of the diagnoses in this cohort. That pattern is \nclinically important because b oth conditions can cause heavy \nand prolonged bleeding, anaemia, pelvic discomfort, and \nrepeated health visits. National evidence has shown that \nbleeding complaints and fibroids/cysts are commonly reported \nreasons for hysterectomy in India [7]. Desai and colleagues, using \nolder women's national survey data, have also drawn attention to \nthe long life -course consequences of early hysterectomy, \nparticularly when surgery occurs before natural menopause .[10] \nThe present study does not evaluate long -term outcomes, but it \nplaces the decision point under a sharper lens. \nThe absence of prior medical treatment in 80% of women and \nthe lack of previous records in 90% are among the most \nactionable findings. When prescriptions, ultrasound reports, \nendometrial sampling resul ts, or anaemia management details \nare unavailable, the clinician at a tertiary centre has to \nreconstruct the entire history from memory. That uncertainty can \npush both patient and provider toward a definitive solution, \nespecially if the woman has travelled  more than 100 km and \ncannot promise follow -up. Khunte et al. described similar rural \nconstraints in central India, including prior irregular treatment, \npoor compliance, transport difficulty, wage loss, and refusal to \nreturn for follow -up [11]. The overlap with the present cohort is \nstriking. \nThe strongest decision -influencing factor was not pain, bleeding \nvolume, or even a diagnosis. It was lack of awareness that \ntreatment options other than surgery existed. This matters. A \nwoman who knows only hysterectomy  will interpret counselling \ndifferently from a woman who has previously received a \nstructured explanation of tranexamic acid, hormonal therapy, \nLNG-IUS, endometrial evaluation, myomectomy, or staged \nfollow-up. Desai's qualitative work from rural Gujarat de scribed \nhysterectomy as a “permanent solution” for women facing \nsevere gynecological symptoms, insecure work, poor access to \ncare, and household-level pressure [12]. The present findings echo \nthat narrative, particularly in the 60% of women where the \nhusband's belief in surgery as cure was recorded. \nDistance was not merely a geographic variable. For 70% of \nwomen, travelling more than 100 km meant cost, time, \ndependence on an escort, loss of daily wages, and sometimes \nsocial permission to leave home. A conservative plan that \nrequires repeated visits may be scientifically correct but \npractically fragile unless the woman can be linked to a nearby \nfacility. This is where counselling has to become operational: the \nwoman should leave with a written diagnosis, an explained \ntreatment plan, red -flag symptoms, anaemia management \nadvice, and a realistic follow -up location closer to home. \nWithout that chain, “conservative managemen t” can sound like \npostponement rather than care. \nGuidelines also support this measured approach. NICE \nemphasizes treatment choice based on the woman's symptoms, \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 505 ~ \nquality-of-life burden, clinical findings, and priorities, not blood \nloss alone.[13] ACOG guidance for acute AUB states that medical \nmanagement should be the initial treatment for most clinically \nappropriate patients after assessment and stabilization .[14] \nCochrane evidence similarly supports medical options such as \nLNG-IUS and antifibrinolytics for  heavy menstrual bleeding, \nwhile recognizing that invasive procedures may be needed when \nconservative treatment fails, is unsuitable, or is not acceptable to \nthe woman [15]. \nNone of this means hysterectomy should be denied where it is \nclearly indicated. Mal ignancy, atypical hyperplasia, large \nsymptomatic fibroids in women who have completed fertility, \nfailed medical treatment, and severe quality -of-life impairment \nmay all justify surgery after adequate evaluation. But the route \nto hysterectomy should be a de cision, not a default. When \nhysterectomy is required for benign disease, evidence favours \nthe least invasive safe route, with the decision individualized to \npathology, uterine size, surgical expertise, and patient factors.[16] \nThis study has limitations. I t was conducted at a single tertiary \ncare institution and therefore reflects women who reached a \nreferral hospital, not all rural women with AUB in the \ncommunity. The OPD -based AUB proportion could not be \nconverted into a true incidence measure because the  complete \ndenominator was not available for analysis. The study used \ndescriptive statistics only, and the final uptake of conservative \nversus operative treatment after counselling was not recorded in \na way that allowed comparative testing. Reasons for deci sion-\nmaking were grouped into operational categories, which may \nsimplify the emotional and household dynamics behind each \nanswer. Even with these constraints, the findings are useful \nbecause they identify modifiable points: awareness, written \ndocumentation, local follow -up, husband/family counselling, \nand earlier treatment before symptoms become chronic. \n \nConclusion \nAmong rural women presenting with AUB in this tertiary care \ncohort, preference toward hysterectomy was influenced by \nlimited knowledge of cons ervative options, prolonged heavy \nbleeding, long travel distance, lack of prior treatment \ndocumentation, low educational status, and family -level beliefs \nabout surgery. Adenomyosis and leiomyoma were the leading \ndiagnostic categories, but pathology alone d id not explain the \ndecision-making pattern. Early counselling at peripheral \nfacilities, structured written treatment plans, anaemia and \nbleeding control protocols, and practical referral -back linkages \nmay help women receive timely conservative care while s till \nallowing hysterectomy for clear and well-counselled indications. \n Source of Funding: Nil \n Conflict of Interest: Nil \n Conflict of Interest: Not available  \n Financial Support: Not available \n \nReferences \n1. Munro MG, Critchley HOD, Broder MS, et al.  FIGO \nclassification system (PALM -COEIN) for causes of \nabnormal uterine bleeding in nongravid women of \nreproductive age. Int J Gynaecol Obstet. 2011;113(1):3-13. \n2. Committee on Practice Bulletins -Gynecology. Practice  \nbulletin no. 128: diagnosis of abnormal uterine bleeding in \nreproductive-aged women. Obstet Gynecol.  \n2012;120(1):197-206. \n3. 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Prevalence, socio -demographic \ndeterminants, and self -reported reasons for hysterectomy \nand choice of hospitalization in India. BMC Womens \nHealth. 2022;22(1):514. \n8. Shekhar C, Paswan B, Singh A. Prevalence, \nsociodemographic determinants and self -reported reasons \nfor hysterectomy in India. Reprod Health. 2019;16(1):118. \n9. Singh A, Govil D. Hysterectomy in India: spatial and \nmultilevel analysis. Womens Health (Lond). \n2021;17:17455065211017068. \n10. Desai S, Singh RJ, Govil D, et al.  Hysterectomy and \nwomen's health in India: evidence from a nationally \nrepresentative, cross -sectional survey of older women. \nWomens Midlife Health. 2023;9(1):1. \n11. Khunte V, Armo M, Gahne R, et al.  Hysterectomy: still a \ntreatment of choice for pelvic pathologies in rural India. Int \nJ Reprod Contracept Obstet Gynecol. 2018;7(2):536-541. \n12. Desai S. Pragmatic prevention, permanent solution: \nwomen's experiences with hysterectomy in rural India. Soc \nSci Med. 2016;151:11-18. \n13. National Institute for Health and Care Excellence. Heavy \nmenstrual bleeding: assessment and management. NICE \nguideline NG88. London: NICE; 2018 [updated 2021 May \n24]. https://www.nice.org.uk/guidance/ng88 \n14. American College of Obstetricians and Gynecologists. \nACOG Committee Opinion No. 557: management of acute \nabnormal uterine bleeding in nonpregnant reproductive -\naged women. Obstet Gynecol. 2013;121(4):891-896. \n15. Bofill Rodriguez M, Dias S, Jordan V, et al. Interventions \nfor heavy menstrual bleeding: overview of Cochrane \nreviews and network meta -analysis. Cochrane Database \nSyst Rev. 2022;5(5):CD013180. \n16. Pickett CM, Seeratan DD, Mol BWJ, et al.  Surgical \napproach to hysterectomy for benign gynae cological \ndisease. Cochrane Database Syst Rev. \n2023;8(8):CD003677. \n \nHow to Cite This Article \nKujur A, Mondal S, Singh S.  Factors influencing decision-making among \nrural women with abnormal uterine bleeding: A prospective observational \nstudy from central India. International Journal of Clinical Obstetrics and \nGynaecology. 2026;10(3):500-505.  \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -Non-Commercial-Share Alike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to  remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}