|Year : 2016 | Volume
| Issue : 3 | Page : 169-177
The modifiable and nonmodifiable risk factors for miscarriage
Tawheda M Khalifa El-Saidy1, Tahany El-Sayed El-Sayed Amr2
1 Department of Community Health Nursing, Faculty of Nursing, Menoufia University, Egypt
2 Assistant Professor of Maternal & Newborn Health Nursing Department, Faculty of Nursing, Menoufia University, Egypt; College of Applied Medical Sciences, Shaqra University, Shaqra, Kingdom of Saudi Arabia
|Date of Submission||27-Aug-2016|
|Date of Acceptance||11-Sep-2016|
|Date of Web Publication||15-Feb-2017|
Tahany El-Sayed El-Sayed Amr
Maternal & Newborn Health Nursing Department, Faculty of Nursing, Menoufia University, Egypt
Source of Support: None, Conflict of Interest: None
Miscarriage is a failed intrauterine pregnancy that ends before 20 weeks of gestation. Many factors can lead to miscarriage, such as age, smoking, caffeine intake, infections, medications, and chronic diseases.
The aim of this study was to identify the modifiable and nonmodifiable risk factors for miscarriage.
Subjects and method
A descriptive exploratory study design was used. This study was carried out at primary healthcare centers and obstetric outpatient clinics of Shaqra and Merat general hospitals in the Kingdom of Saudi Arabia. The study included a total of 260 adult women. A structured interviewing questionnaire and modifiable risk factor assessment questionnaire were used.
The mean age of the participants was 36.8±5.2 years. The reported types of miscarriages were spontaneous (30.8%), incomplete (24.2%), and recurrent (17.7%) miscarriage. The reported modifiable risks were work that requires constant motions and hard effort (37.0%), and pregnant women working more than 40 h/week (28.4%). Lifestyle risk factors included drinking more than 200 mg caffeine/day (87.9%), eating too much spice (39.6%), eating dates daily (37.3%), drinking cola constantly (37.0%), passive smoking (35.8%), and obesity (32.3%). Moreover, there were some obstetric risk factors for miscarriage, such as no spacing between pregnancies, hormonal imbalance, ovarian cyst, and genital infections.
There was a relationship between lifestyle and risk for miscarriage. Miscarriage can be prevented by reducing the associated modifiable risk factors to low levels before and during pregnancy.
The following are recommended: regular follow-ups for pregnant women, especially those who had high parity; maintaining healthy lifestyle; encouraging preconception precautions, including intake of folic acid and treatment of health problems; immediate postnatal care; and follow-up for mothers with negative Rh to prevent complications.
Keywords: lifestyle, miscarriage, modifiable, nonmodifiable, risk factors
|How to cite this article:|
Khalifa El-Saidy TM, El-Sayed Amr TE. The modifiable and nonmodifiable risk factors for miscarriage. Egypt Nurs J 2016;13:169-77
| Introduction|| |
Having a baby is an amazing and positive experience for most of the women. However, the dream of having a baby can be shattered by the huge blow couples receive during miscarriage and introduces physical and emotional challenges (Borreli, 2014). Generally, abortion is the ending of pregnancy by removing a fetus from the uterus before it can survive on its own (Grimes and Stuart, 2010), as well as expelling of the fetus from the uterus during the first half of gestation at 20 weeks or less (Cunningham et al., 2010). An abortion that occurs spontaneously is known as a miscarriage (Grimes and Stuart, 2010). It is a common complication encountered during pregnancy (Wahabi et al., 2011).
Studies revealed that anywhere from 10 to 25% of all clinically recognized pregnancies will end in miscarriage (American Pregnancy Association, 2015). However, the actual rate of miscarriage is even higher as many women have very early miscarriages without ever realizing that they are pregnant. One study that followed women’s hormone levels every day to detect very early pregnancy found a total miscarriage rate of 31% (Danielsson, 2015). Recurrent miscarriages, the loss of three or more consecutive intrauterine pregnancies before 20 weeks of gestation with the same partner, affect 1–1.5% of the pregnant population. The inadequate secretion of progesterone in early pregnancy has been proposed as a cause of recurrent miscarriage (Hussain et al., 2012). A study conducted by Hafez et al., (2014) in Saudi Arabia reported that 44% of Saudi women with high-risk pregnancy were aged between 30 and 35 years of age. Approximately 35% of them had two or more previous abortion.
Generally, the main symptoms of miscarriage are light bleeding, brown discharge that looks like coffee grounds, spotting, bright red bleeding, passage of tissue through the vagina, abdominal pain or cramping, and gradual loss of pregnancy symptoms such as breast tenderness and nausea (UC Davis Health System, 2015). An ultrasound may be performed to look at the uterus (University of Washington Medical Center, 2010). Researchers stated different types of miscarriages that can occur at different stages of the pregnancy. It includes threatened, spontaneous, incomplete, complete, missed, and recurrent miscarriage (Miller, 2008). Threatened miscarriage is associated with increased incidence of adverse pregnancy outcome. The risk is especially increased in premature rupture of the membranes, preterm delivery, and neonatal birth weight (Ahmed et al., 2012).
The main goal of treatment during or after a miscarriage is to prevent hemorrhaging and infection. The earlier in the pregnancy, the more likely that the body will expel entire fetal tissue by itself and will not require further medical procedures. If the body does not expel entire tissue, the most common procedure performed to stop bleeding and prevent infection is dilation and curettage. Drugs may be prescribed to help control bleeding after D&C is performed (American Pregnancy Association, 2015).
Miscarriage is more common in older women. A 20-year-old woman has about a 10% risk, whereas for a 40-year-old woman the risk is about 40% (Abeysena et al., 2009; Academic Health Science Center, 2015). Miscarriage can happen due to smoking, alcohol drinking, uncontrolled diabetes (Center for Disease Control and Prevention, 2012; Costello, 2013), hypertension, obesity, genetic factor, cervical incompetence, low progesterone level, and environmental and lifestyle factor (Rodriguez, 2014, 2015; Pourmohammadi, 2015).
Although the influence of the environment on the occurrence of miscarriages is established beyond doubt, the mechanism for such an effect is not clearly understood (Frant, 2015). Researchers have also proved that exposure to air pollution due to the use of different combustion fuels, when it does not lead to miscarriage, can influence fetal development (Green et al., 2009; Wu et al., 2010). Maternal exposure to chemicals might have an effect on the gamete structure and function, which might have a significant implication in the adverse effect on pregnancy and its outcome.
Metals such as lead and mercury and industrial pollutants such as dioxin, organic solvents, and radiations had adverse effect on pregnancy outcome (Kumar, 2011). New research suggests that high levels of bisphenol A, a chemical in many plastics and canned food linings, might raise the risk for miscarriage. Therefore, to minimize bisphenol A exposures, one should not leave water bottles in the sun and limit the use of canned foods (Marchione, 2013). As regards dietary risk factors, high doses of caffeine intake during pregnancy increase the risk for miscarriage (Weng et al., 2008). With the increased number of women who continue to work during pregnancy, occupational stress has been hypothesized to be a potential contributor to adverse reproductive health outcomes. Some pieces of evidence have suggested a modest association with work-related stress but has not been conclusive (John et al., 2011). In general, working women have a higher risk for undesirable reproductive outcomes (Kumar, 2011) due to job stress (Smet et al., 2005). Moreover, prolonged mobile phone and computer use are potential novel correlates to threatened miscarriage that deserve further study (Tan et al., 2014).
Miscarriage is the most common negative outcome of pregnancy, and identification of modifiable risk factors is potentially of great importance for public health (Andersen et al., 2015). Over a quarter of miscarriages may be preventable. The potentially modifiable risk factors for miscarriage include amount of exercise, alcohol consumption (Andersen et al., 2012), smoking, coffee consumption (Klebanoff et al., 1999; Weng et al., 2008; Thorp, 2014), work schedule, lifting of more than 20 kg daily, maternal age at conception, prepregnancy weight status, and previously diagnosed genital diseases (Thorp, 2014). Borreli (2014) revealed that over a quarter of miscarriages might be preventable by reducing all of the associated risk factors to low levels and acting on the modifiable risk factors before and during pregnancy. The researchers believe that doing so could lead to a 15% reduction and 13% reduction in miscarriages, respectively. About 12% of miscarriages could be prevented if the maternal age at conception is between 25 and 29 years, and 9% could be prevented if no alcohol was consumed during pregnancy.
Although the causes of miscarriage are still not well understood, a combination of lifestyle changes can help reduce the risk (Pourmohammadi, 2015). Physical exercise, ventilation, folic acid supplements, and supervisor support were identified as protective factors for the prevention of miscarriage (Zhang et al., 2011). Any fish oil consumption was associated with reduced risk for threatened miscarriage. Establishing and distinguishing between actual and spurious risk factors are important goal of future research to provide clinicians with tools with which women can be both reassured and counseled on optimal health lifestyles to minimize the risk for threatened miscarriage (Tan et al., 2014).
As regards modification of risk factors, acting before pregnancy include fertility cleansing that helps to support the liver in cleansing the body of old toxins and excess hormones while encouraging the uterus to cleanse itself of ‘old’ contents, increasing uterine circulation and tone. The mother should nourish and build up the body to be a healthy and baby friendly. Moreover, prenatal vitamin contains B6, B12, and folic acid shown to help prevent miscarriages due to high homocysteine levels. Essential fatty acids are also extremely important for miscarriage prevention. Essential fatty acids, specifically omega-3s, are responsible for regulating inflammation response, improving cellular integrity, and maintaining hormonal balance − all key factors in helping the body prevent miscarriage (Rodriguez, 2014, 2015).
Significance of the study
Miscarriage has an adverse effect on the quality of life of many women. Thus, improvement in the diagnosis and management of early pregnancy loss is therefore of vital importance, to reduce the incidence of the associated psychological morbidity and avoid death among women (National Institute For Health And Care Excellence, 2012). Approximately 15% of all clinically recognized pregnancies result in pregnancy failure (Ford and Schust, 2009; University of Washington Medical Center, 2010). However, the actual rate of miscarriage is even higher as many women have very early miscarriages. Danielsson (2015) found a total miscarriage rate of 31%. As miscarriages are considered irreversible, prevention is probably the only way to intervene in this problem (Kong et al., 2010). Modification of risk factors by acting before and during pregnancy could lead to a prevention of 14.7 and 12.5% of the miscarriages, respectively (Nilsson et al., 2014) (Wahabi et al., 2011). Thus, this study will contribute to a better understanding of the modifiable and nonmodifiable risk factors for miscarriage and it will add to the body of knowledge related to miscarriage.
| Aim of the study|| |
The aim of the current study was to identify the modifiable and nonmodifiable risk factors for miscarriage.
Q1-What are the modifiable risk factors for miscarriage?
Q2-What are the nonmodifiable risk factors for miscarriage?
| Subjects and method|| |
A descriptive exploratory study design was used to achieve the aim of the current study. This design was mainly used to measure and understand change and to include a time dimension to the data that can be used to identify causal factors contributing to any observed change. The main purpose for collecting retrospective data is that such data provide a means of measuring change for explanatory purposes. It relies on recalling information about the past but vary in the extent to which they rely on such recall (De Vaus, 2006).
The current study was conducted at the primary healthcare centers and obstetric outpatient clinics of Shaqra and Merat general hospitals at Shaqra Governorate in the Kingdom of Saudi Arabia.
A total of 260 Saudi women were recruited for the study from women attending the selected primary healthcare centers and obstetric outpatient clinics at Shaqra Governorate in the Kingdom of Saudi Arabia.
A convenience sample was recruited, utilizing the nonprobability sampling technique. It consisted of 260 adult women for the study as participants. The researcher selected the women who met the following inclusion criteria: being in childbearing age (20–45 years), having a diagnosis of miscarriage, and consent to participate in the study.
Tools for data collection
Two tools were used for data collection.
Tool 1: Structured interview questionnaire
It included 28 questions of the data related to sociodemographic characteristics such as age, education, occupation, job stress, income, residence, reproductive characteristics, and medical history. The first five questions (from Q1 to Q5) focused on the sociodemographic characteristics of the participants, questions from Q6 to Q10 focused on the medical history, and the other 18 questions (from Q11 to Q28) focused on the obstetric history.
Tool 2: Modifiable risk factor assessment questionnaire
It was a questionnaire-based interview used to elicit details of the modifiable risk factors such as dietary risk factors (dates, spices, coffee, tea, and cola consumption), iron deficiency anemia, smoking, nature of the work, work schedule, child spacing, not taking folic acid, hormonal imbalance, previously diagnosed genital diseases, and obesity. It was classified into work-related factors, lifestyle, herbal, obstetric, and other factors. It included 30 questions. Three questions focused on work-related factors, 12 questions focused on lifestyle factors, two questions focused on herbal factors, eight questions on obstetric factors, and five questions on other factors.
- As regards working hours and its relation with miscarriage, the researcher considered working hours of 40 h/week and more is a risk factor of miscarriage for working women according to Bondeet al.(2013).
- As regards caffeine consumption, one cup of coffee is equal to 75 mg of caffeine. The current study considered consumption of less than 200 mg of caffeine/day (two cups) is safe, but more than 200 mg of caffeine/day (three cups and more) is considered as a risk for miscarriage. As regards tea, one cup of tea is equal to 50 mg of caffeine. Thus, the researcher considered consumption of less than 200 mg of caffeine/day (three cups), but more than 200 mg of caffeine/day (four cups and more) is considered as a risk for miscarriage (Wenget al., 2008).
- The researchers considered that, drinking cola sometimes, usually, and always as too much amount of cola and a risk factor. While drinking it in a rare way considered not drinking cola.
- Multipara is a woman who had two or more pregnancies resulting in viable offspring, whereas grand multipara is a woman who had six or more pregnancies that resulted in viable offspring.
- A BMI of less than 18.5 was underweight, a BMI from 18.50 to 24.99 was considered normal, BMI from 25 to 29.9 was considered overweight, and BMI more than 30 was considered obese (World Health Organization, 2006).
Content validity and reliability
The tools were developed by the researcher after review of the related literature and tested for its content validity. Tools were submitted to a panel of three experts in the field of maternity nursing and community health nursing to test the content validity. Modifications were carried out according to the panel judgment on clarity of the sentences and appropriateness of the content. Reliability test was assessed by applying the questionnaire on 10 women using test–retest.
A pilot study was conducted on 10% of the sample. This sample was excluded from the total sample. The pilot study was carried out to assess the applicability and clarity of the constructed questionnaire, to determine the time needed to answer the questions, and to detect any problems that might arise during the actual collection of data. Thereafter, the necessary modifications and clarifications of some questions were carried out according to the results of the pilot study, and a final form was developed and used in data collection.
Procedure for data collection
Before starting any step in the study, an official permission was taken from the directors of the primary healthcare centers and the hospitals where the study was intended to be conducted. Permission to conduct the study was obtained from the responsible authorities after explaining its purpose. Moreover, confidentiality of the information was assured. Data collection for this study was carried out from the first of January 2014, and completed by the end of June 2014. After obtaining approval and informed consent to conduct the study, data were collected 2 days/week through interviewing questionnaire with each participant by the researchers individually using the studied tools.
First, verbal consent of the participants of the study was obtained before the completion of the interview questionnaire sheet. Second, participants were informed of the purpose of the study, and that the participation is voluntary and that they had the right to refuse to participate. Furthermore, the participants of the study were told that they can refrain from answering any question and they can terminate the interview at any time. The researcher carried out the interview face-to-face with each patient. The cases were requested to complete the questionnaire on lifestyle, medical history, environmental risk factors, family, and job stress.
Modifiable lifestyle factors were assessed using the face-to-face interview. The modifiable lifestyle factors examined were current and past cigarette smoking, exposure to passive smoking at home, current and past caffeine consumption (coffee, tea, and cola consumption), dietary risk factors (dates and spices), iron deficiency anemia, nature of the work, work schedule, child spacing, not taking folic acid, hormonal imbalance, previously diagnosed genital diseases, and obesity. Other nonmodifiable factors were also assessed, such as maternal age, regularity of menstrual cycle, educational level, past medical history, and obstetric history. The questionnaires were obtained through face-to-face interview with each client individually by the researcher. Each client needs 25–30 min to complete the research questionnaires.
An approval was obtained from the administrative personal of primary healthcare centers and the general hospitals. The aim of the study and its implication was explained to the administrators and participants. Oral consent was obtained from the participants who were willing to participate in the study. Participants were informed that their participation will be on voluntary basis, and anonymity and confidentiality of the participants were maintained at all times.
Data were coded, entered, and analyzed using the statistical package for social science (SPSS Inc., Chicago, IL, USA), version 20. Data were presented using statistics in the form of frequencies and percentage. Interval and ratio variables were presented in the form of means and SD. The χ2-test and correlation were used to determine the relationship among the study variables. The significance level was chosen as P-value less than 0.05.
| Results|| |
The study sample included 260 women with a mean age of 36.8±5.2 years ([Table 1]). Most of the sample (95.0%) was from urban area and about three-quarters of them were highly educated (74.2). Added to that, 62.3% of them were working with moderate economic status (76.5%).
|Table 1: Distribution of sociodemographic characteristics for the participants|
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[Table 2] shows that the mean number of pregnancies for the studied women was 4.7±2.4. Moreover, it showed that the mean number of miscarriages was 1.7±0.9, with a maximum number of six miscarriages. This indicated that some of them had recurrent miscarriage. As regards gestational age of the fetus, it was 9.36±4.8 weeks. Added to that, 11.2% of them had complications after miscarriage.
As regards types of miscarriages reported in the current study, 30.8% of the participants had spontaneous miscarriage compared with 24.2% of them who had incomplete miscarriage, and 17.7% had recurrent miscarriage ([Figure 1]).
|Figure 1: Distribution for types of miscarriage for the studied sample (n=260).|
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The nonmodifiable risk factors that were reported in the current study were endogamy (41.9%), grand para (29.6%), maternal age from 30 to 35 years (29.2%), previous cesarean section (18.5%), chronic diseases (17.3%), negative Rh (11.5%), and chromosomal abnormalities (4.6%) ([Table 3]).
|Table 3: Distribution of nonmodifiable risk factors for miscarriage (n=260)|
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The modifiable risk factors that were reported in the current study were the work that requires constant motions and hard effort (37.0%), pregnant women working more than 40 h/week (28.4%), and working in shifts (34.0%). The lifestyle risk factors were drinking more than 200 mg caffeine/day (87.9%) with a mean caffeine consumption of 314.58 mg of caffeine, eating too much spice (39.6%), eating dates daily (37.3%), drinking cola constantly (37.0%), passive smoking (35.8%), and obesity (32.3%). Moreover, there were some obstetric risk factors for miscarriage, such as no spacing between pregnancies (29.6%), hormonal imbalance (26.9%), ovarian cyst (23.8%), and genital infections (16.2%). The other factors included were iron deficiency anemia (36.5%), not taking folic acid during pregnancy (33.1%), and exposure to radiography (11.9%) ([Table 4]).
|Table 4: Distribution of modifiable risk factors for miscarriage (n=260)|
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[Table 5] shows the correlation between maternal age, working hours, caffeine consumption, and numbers of miscarriage. There was a significant correlation between working hours, caffeine consumption, and numbers of miscarriage (P<0.05). Moreover, 17.7% of the participants had recurrent miscarriage, with a mean number of miscarriage of 3.2±0.5. The most reported risk factors for recurrent miscarriage were Rh negative (36.7%), increased maternal age (30.0%), obesity (23.5%), work shifts such as night shifts (21.8%), hormonal imbalance (17.1%), and endogamy (15.5%) ([Figure 2]).
|Table 5: Correlation between maternal age, working hours, caffeine consumption, and numbers of miscarriage [n=46 (17.7%)]|
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| Discussion|| |
Miscarriage is the most common type of pregnancy loss, affecting around one in four pregnancies. It can be a very difficult and distressing experience, affecting many women and their partners (Miscarriage Association, 2015). It can cause significant psychological distress besides the feeling of loss (Andersen et al., 2015). Miscarriage risk increased with multiple potentially modifiable risk factors and a considerable proportion of miscarriages may be preventable (Nilsson et al., 2014). Identifying modifiable risk factors for miscarriage are potentially important for public health (Andersen et al., 2015).
The aim of the current study was to identify the modifiable and nonmodifiable risk factors for miscarriage. The mean age of the studied sample was 36.8±5.2 years. Women who had miscarriage and were aged 35–40 years constituted 29% of the sample. Added to that, 11% of them had complications after miscarriage. This result is in agreement with that of Tarkan (2015), who mentioned that risk for miscarriage for women younger than 35 is 10–12%; for women between 35 and 39 years of age it is about 18%, and it increased to 34% for women between 40 and 44 years old. Moreover, another study stated that women in their 30s are at an increased risk for miscarriage, birth defects, and pregnancy complications. Age 35 is considered advanced maternal age, but the risks increase as a woman ages (University of Rochester Medical Center, 2015). Therefore, there is an increased chance of having a successful pregnancy at a relatively young age and is an important perspective (Borreli, 2014).
As regards types of miscarriages reported in the current study, 30% of the participants had spontaneous miscarriage compared with 24% of them who had incomplete miscarriage. In agreement with the current results, Jeffries (2015) stated that there are several different types of miscarriage, such as threatened, inevitable, incomplete, complete, missed, recurrent, and septic miscarriage.
Fetal chromosomal anomalies and maternal systemic disease are known to predispose to threatened and actual miscarriage (Farioli et al., 2010). Moreover, El-Dahtory (2011) reported that most spontaneous abortions happen in the first and second trimesters and are caused by chromosomal abnormalities. This is in contrast to the present study. It illustrated that only about 5% of the studied participants had miscarriage due to chromosomal abnormalities, whereas the major nonmodifiable risk factors that were reported include endogamy, grand para, maternal age between 30 and 35 years, previous cesarean section, chronic diseases, and negative Rh.
The modifiable risk factors reported in the current study are work-related factors, lifestyle, obstetrical, and other factors. Work-related factors include work that requires constant motions and hard effort and pregnant women working more than 40 h/week and working in shifts. In general, working women have a higher risk for undesirable reproductive outcomes. There is a need to educate childbearing women, to avoid exposure to the known or suspected risk factors, and their employers, to take measures to reduce the toxicant levels in workplace (Kumar, 2011). Job stress causes negative physical and emotional responses that occur when the requirements of the job were higher than the women capabilities. It has been well-accepted that women are more sensitive compared with men to the stresses of their job (Smet et al., 2005). It has an effect on the health of women, especially pregnant women. This is in agreement with another study that mentioned that working fixed nights was associated with a moderately increased risk for miscarriage, and that working for more than 40 h weekly, standing for more than 6 h/day, and physical workload were associated with small risk increments. Women should be advised regarding the risks of work, especially who had high risk pregnancy. They should received tailored individual counseling (Bonde et al., 2013).
As regards the studied lifestyle risk factors, it included drinking more than 200 mg caffeine/day, eating too much spice, eating dates daily, drinking cola constantly, passive smoking, and obesity. A study performed by Weng et al. (2008) stated that an increasing dose of daily caffeine intake during pregnancy was associated with an increased risk for miscarriage, compared with no caffeine intake, with an adjusted hazard ratio of 1.42 for caffeine intake of less than 200 mg/day, and a hazard ratio of 2.23 for intake of 200 mg/day or more. Another researcher found a positive association of threatened miscarriage with second hand smoke exposure, computer usage (>4 h/day), mobile phone usage (>1 h/day), and caffeine consumption. This study identified some modifiable lifestyle factors as correlates for threatened miscarriage. Novel factors include DHA supplementation and computer and mobile phone usage (Tan et al., 2014). Added to that, a recent study found that smoking, alcohol consumption, prepregnancy obesity, heavy lifting, and nightshift work were important preventable risk factors for miscarriage (Andersen et al., 2015). As regards smoking and obesity, several studies confirmed that women smokers and women exposed to passive smoking present a high risk for spontaneous abortion, still birth, tubal ectopic pregnancies, and congenital abnormalities (Hyland et al., 2015).Maternal obesity is associated with menstrual disorders, infertility, and miscarriages. Recurrent miscarriage affects at least 1% of couples trying to conceive (Winnie et al., 2012). Generally, the mother’s general health should be a priority to help prevent miscarriage. Pregnant women should avoid (Alcohol, drugs, smoking) and limit the amount of caffeine intake. Prenatal vitamins can help support even the healthiest of diets to ensure that the woman and her baby get all of the nutrients needed. Light regular exercise can also improve fetal health (Moore, 2012). In addition, the current study stated that there were some obstetric risk factors for miscarriage, such as no child spacing, hormonal imbalance, ovarian cyst, and genital infections. The other factors included were iron deficiency anemia, not taking folic acid during pregnancy, and exposure to radiography.
Recurrent fetal loss (RFL) is a prevalent problem affecting 1% of all women of childbearing age. Many factors can lead to RFL; however, recent studies have indicated the important role of the maternal immune system in this process. The human leukocyte antigens (HLAs), HLA-linked genes, and regulatory factors play an important role in fetal loss and in fetal development. No relationship was seen between sharing of HLA alleles and the number of RFL experienced by the couples (Moghraby et al., 2010). The most reported risk factors for recurrent miscarriage in the current study were Rh negative, increased maternal age, obesity, work shifts such as night shifts, hormonal imbalance, and endogamy.
Finally, miscarriage can be prevented by reducing all of the associated modifiable risk factors to low levels before and during pregnancy. There are some precautions that can be taken before conception to decrease the chance of miscarrying, such as treatment of health problems such as anemia, hormonal imbalance, ovarian cyst, and genital infections, in addition to consuming organic vegetables and fruits daily and intake of folic acid daily for 1 or 2 months before conception. Although the cause of miscarriage is usually out of a woman’s control, she can increase her chances of having a successful pregnancy by eating healthy diet, avoiding obesity, controlling chronic diseases, avoiding smoking, avoiding exposure to radiography, limiting intake of caffeine to less than 200 mg/day, and taking folic acid daily.
| Conclusion|| |
On the basis of the findings of the present study, it was concluded that there is a relationship between lifestyle and risks for miscarriage. Miscarriage can be prevented by reducing all of the associated modifiable risk factors such as work, which requires constant motions and hard effort, working more than 40 h/week and work shifts, drinking caffeine, eating dates daily, passive smoking, being obese, not have spacing between pregnancies, with hormonal imbalance, ovarian cyst, genital infections, and iron deficiency anemia. 
Regular follow-up for pregnant women, especially those with high parity.
- Pregnant mothers should avoid sitting with smokers and maintain healthy lifestyle.
- Encourage preconception precautions, including intake of folic acid daily for 1 or 2 months before conception and treatment of health problems such as anemia, hormonal imbalance, ovarian cyst, and genital infections.
- Immediate postnatal care and follow-up for mothers with negative Rh.
- Follow-up after miscarriage to prevent complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]