Women who experience miscarriage are likely to die young - Study

A new study warns that spontaneous abortion was associated with an increased risk of premature mortality, particularly death from cardiovascular disease.

The study adds that spontaneous abortion [medically known as miscarriage] is linked to risk of dying younger, and could be an early warning sign of potential health issues.

The authors found that the association between miscarriage and premature death was particularly strong for women who had a miscarriage before age 24 or who had three or more miscarriages.

They state that women who miscarried were 19 percent more likely to die prematurely than women who did not miscarry, with the strongest associations for women with recurrent miscarriages and for miscarriages occurring early in a woman’s reproductive life.

This is even as Professor of Obstetrics and Gynaecology, Adetokunbo Fabamwo, who is also the Chief Medical Director at the Lagos State University Teaching Hospital, said that, taking certain health indices into consideration, one could say that miscarriage reflects a woman’s overall health.

Also, Senior Obstetrician and Gynaecologist at the Federal Medical Centre, Ebute-Metta, Dr. James Taiwo Odofin, said that when talking about health, “you are talking about the complete wellbeing — physical, psychological, mental, and social.

“So, there is no how miscarriage will not affect a woman psychologically and it can affect the health of the woman.”

The study, published in the peer-reviewed journal BMJ edition of March 24, states that the overall goal is to investigate the association of spontaneous abortion [medical term for a miscarriage] with the risk of all cause and cause-specific premature mortality (death before the age of 70).

The study is titled, ‘Association of spontaneous abortion with all cause and cause specific premature mortality: prospective cohort study.’

SDG 3 and health

Reducing a third of premature deaths from non-communicable diseases by 2030 is a United Nation’s sustainable development goal [SDG 3: Good Health and Well-being]. The study authors are of the opinion that identifying risk factors for death from non-communicable disease to highlight priorities for intervention is needed urgently.

Although traditional risk factors that affect both men and women (eg, tobacco use, overweight and obesity, and physical inactivity) explain most of the deaths from non-communicable diseases globally, increasing evidence suggests that reproductive factors unique to women are associated with a greater risk of death from non-communicable diseases, the study notes.

Even if reproductive events do not increase the risk of death from non-communicable diseases, they could be useful as an early stress test of underlying risk factors that cause adverse reproductive outcomes and death from non-communicable diseases, they added.

Miscarriage: Taboo subject — WHO

According to the World Health Organisation, losing a baby in pregnancy through miscarriage or stillbirth is still a taboo subject worldwide, linked to stigma and shame.

The global agency notes that many women still do not receive appropriate and respectful care when their baby dies during pregnancy or childbirth.

The WHO notes that miscarriage is the most common reason for losing a baby during pregnancy.

“Estimates vary, although March of Dimes, an organisation that works on maternal and child health, indicates a miscarriage rate of 10-15 percent in women who knew they were pregnant,” WHO says.

While noting that pregnancy loss is defined differently around the world, WHO states that, in general a baby who dies before 28 weeks of pregnancy is referred to as a miscarriage, and babies who die at or after 28 weeks are stillbirths.

The study authors are spread variously across the Harvard T H Chan School of Public Health; Rollins School of Public Health, Emory University; College of Human Medicine, Michigan State University; Brigham and Women’s Hospital and Harvard Medical School; and the School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.

According to lead author, Jorge E Chavarro, an associate professor at the Department of Epidemiology, Harvard T H Chan School of Public Health, substantial evidence indicates that women with a history of spontaneous abortion [miscarriage] have a greater risk of non-communicable diseases, including hypertension, cardiovascular diseases, and type 2 diabetes.

Says Chavarro, “There is increasing evidence that different reproductive events throughout a woman’s life, including miscarriages, are associated with later risk of heart disease and premature mortality;” adding, “Events such as a miscarriage could serve as an early warning sign to women and their doctors that they may have an elevated susceptibility to these conditions.”

The authors used data from The Nurses’ Health Study II (1993-2017), United States.

The authors note that while existing studies have shown that women with a history of miscarriage have a greater risk of high blood pressure, cardiovascular diseases, and type 2 diabetes, there isn’t much evidence relating miscarriage to risk of early death and that what exists is inconsistent.

To explore this link further, the researchers used data from 101,681 female nurses who took part in the Nurses’ Health Study II, an ongoing study of U.S. women of reproductive age at the beginning of the study (age 25–42) whose pregnancies and health were followed over a 24-year period between 1993 and 2017.

The women completed questionnaires every second year during the follow-up period and were asked about pregnancies and their outcomes, as well as lifestyle factors and health-related conditions.

The researchers found that 25.6 percent of the women (26,102) had at least one pregnancy end in miscarriage. During the 24 years follow-up period, there had been 2,936 premature deaths among the women, including 1,346 cancer deaths and 269 cardiovascular disease deaths.

Death rates from all causes were comparable for women with and without a history of miscarriage (1.24 per 1,000 person years in both groups), but were higher for women experiencing three or more miscarriages (1.47 per 1,000 person years) and for women reporting their first miscarriage before the age of 24 (1.69 per 1,000 person years).

Investigators then controlled for other potentially influential factors that included body mass index (BMI), ethnicity, marriage status, gestational diabetes, hypertension during pregnancy, smoking, eating habits, physical activity, and parental history of heart attack or stroke.

After accounting for those factors and using updated dietary and lifestyle characteristics, the researchers found that women who miscarried were 19 percent more likely to die prematurely than women who did not miscarry, with the strongest associations for women with recurrent miscarriages and for miscarriages occurring early in a woman’s reproductive life.

The study notes that “evidence relating to spontaneous abortion to mortality, however, is scant and inconsistent,” recommending more insight into the findings.

WHO on miscarriage

In terms of support that a woman who has a miscarriage should receive, WHO notes that some women who lose their babies are made to feel that they should stay silent about their grief.

The WHO states that there are many reasons why a miscarriage may happen, including foetal abnormalities, age of the mother, and infections, many of which are preventable such as malaria and syphilis, noting, though, that pinpointing the exact reason is often challenging.

The United Nations agency laments that general advice on preventing miscarriage focuses on eating healthily, exercising, avoiding smoking, drugs and alcohol, limiting caffeine, controlling stress, and being of a healthy weight.

“This places the emphasis on lifestyle factors, which, in the absence of specific answers, can lead to women feeling guilty that they have caused their miscarriage,” it said.

Stages of miscarriages

Speaking with our correspondent, Professor of Obstetrics and Gynaecology/Chief Medical Director at the Lagos State University Teaching Hospital, Adetokunbo Fabamwo, said that in a way, one could say that miscarriage reflects a woman’s overall health.

“But the issue about miscarriage is that you need to know what kind of miscarriage we are talking about — there are early miscarriage and late miscarriage.

“Early miscarriage happens in the first three months of pregnancy; late miscarriage would occur at about the fourth and fifth month and after that, if pregnancy is terminated prematurely, it will be regarded as a late miscarriage,” Fabamwo explained.

He said that the timeline for deciding pregnancy loss varies from country to country. “In the United States, it is 20 weeks; in the UK, it’s about 22-24 weeks; but in Nigeria, it is 28 weeks.

“So, any pregnancy that is terminated below 28 weeks in Nigeria is regarded as abortion. Between 28 weeks and 37 weeks, any pregnancy that is delivered is regarded as premature,” he added.

The CMD said that early miscarriage is usually in the first three months and it may determine the woman’s overall health because certain medical conditions predispose to early miscarriage.

Such conditions include diabetes mellitus and high blood pressure, “but majorly, the reasons for early miscarriage are foetuses that have abnormal component, so you have genetic abnormalities — foetuses that are abnormally formed are the ones that are usually rejected from the body in the first three months,” Fabamwo enthused.

Continuing, he said, “Between three to five months, miscarriages are usually due to a defective cervix which is the neck of the womb. The cervix is supposed to be firm and be able to sustain the pregnancy until the baby is ready to be delivered.

“However, in some cases, due to congenital abnormalities due to injury to the cervix, due to previous deliveries, due to repeated abortions, the cervix may be incompetent. So, it’s unable to carry the load of a pregnancy and it just gives way and there is a miscarriage.

“So, a miscarriage can be a reflection of the overall health of the woman.”

He advised that women who have had a miscarriage should be screened for many things, noting, however, that heart disease is not a major factor in causing miscarriages. “So, it may not be time well-spent screening a woman for heart diseases.

“Rather, women should be screened for certain viral diseases, genetic studies can be done, you can screen for diabetes mellitus, you can determine the genotype, the blood group because certain incompatibility in genotype and blood group can cause miscarriages,” Fabamwo said.

Reasons for repeated miscarriages

In terms of reasons for repeated miscarriages, the physician said, “Some women have certain genetic incompatibilities between themselves and their husbands and, for as long as they continue to make babies, these abnormalities will be reflected in the formation of the foetus, and there will be a miscarriage.

“Some women have diabetes mellitus who do not treat it and for as long as the disease persists and they keep getting pregnant, they will have miscarriages.

“For those women who have incompetent cervix, unless they see specialists who, at a certain period during the pregnancy will tie the neck of the womb such that it doesn’t open up when pregnancy advances, they will keep on having recurrent miscarriages.

“For women who have fibroids in their wombs and don’t have them removed, when the pregnancy reaches a certain stage, the fibroid will push the baby out and until the fibroids are removed, the pregnancy experience will continue to be the same.”

Also speaking on the study findings, Senior Obstetrician and Gynaecologist at the Federal Medical Centre, Ebute-Metta, Dr. James Taiwo Odofin, said that when talking about health, “you are talking about the complete wellbeing — physical, psychological, mental, and social.

“So, there is no how miscarriage will not affect a woman psychologically and it can affect the health of the woman.”

He said that most early miscarriages are due to genetic abnormalities — it is the genetic makeup of the couple.

“Other causes of miscarriage are trauma, drugs, infection in pregnancy, and cervical incompetence.

“If the cervix is not competent to hold the pregnancy, at a particular gestational age, from 40 weeks and above, the pregnancy can come down and antiphospholipid syndrome (an autoimmune disorder that is associated with pregnancy complications) can set in,” Odofin said.

He also stated that heart disease does not cause miscarriage, “so you don’t need to screen women who have had a miscarriage for heart disease.

“However, some medical conditions can lead to miscarriage. These are uncontrolled diabetes mellitus, uncontrolled hypertension and it does not mean that someone with diabetes or hypertension will have a miscarriage but the conditions have to be controlled.”

He stressed that cervical incompetence, congenital uterine anomalies, and antiphospholipid syndrome are the likely reasons for multiple miscarriages among some women.

“Meanwhile, if the miscarriage is due to congenital uterine anomalies, the person needs to be investigated; and for cervical incompetence, the mouth of the womb can be tied at a particular time of the pregnancy.

“For antiphospholipid syndrome, some treatment can be given to the woman and the woman needs to see a gynaecologist for appropriate treatment,” Odofin counselled.