An exploration of miscarriage in the Republic of Ireland: incidence, management, risk factors, interventions, and populations’ knowledge

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San Lázaro Campillo, Indra
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University College Cork
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Background: Miscarriage is one of the most common complications in early pregnancy. It is estimated that approximately one out of five women will have a miscarriage throughout their reproductive lives. Despite the high prevalence of miscarriage and the biopsychological burden associated with experiencing miscarriage, there are several gaps in the literature. For example, there is a lack of standardisation of definitions and types of miscarriage worldwide. This high heterogeneity in cut-offs for defining miscarriage is limiting international comparisons of the evidence available. This is distorting the recording of data related to miscarriage in national and international health databases. Furthermore, little is known about the trends of hospital admissions for miscarriage and the non-fatal complications associated with it. In fact, there is no sufficient evidence of the validity of diagnosis of miscarriage in routinely collected health databases. In addition, although approximately 50% of miscarriages are linked to chromosomal abnormalities, the underlying causes of miscarriage are still unclear for the remainer. Therefore, it is imperative to understand and identify causes and risk factors of unexplained miscarriage in order to develop effective treatments and promote healthy behaviours among the population. The most well-established risk factors for miscarriage are advanced maternal age, previous pregnancy loss and parity. However, there is a need to identify risk factors in order to be able to prevent the likelihood of experiencing miscarriage. It is accepted that women who experience miscarriage suffer from psychological morbidity after the loss and in subsequent pregnancies. Nevertheless, further research is needed in order to obtain robust evidence on what specific group of women are more susceptible to develop psychological morbidity after miscarriage, what are the psychological and emotional changes during pregnancy after a miscarriage, and what are the effective non-pharmacological interventions to improve psychological wellbeing as well as future pregnancy outcome. Outline and aims: In this thesis, I explored several dimensions surrounding the event of miscarriage. To do that, I firstly reviewed the published evidence to date about miscarriage in order to find gaps in the literature. This thesis encompassed a total of six research studies to contribute to the existing body of knowledge about miscarriage. The main objective of the first study was to determine national trends in incidence and management of inpatient admissions for early miscarriage in the Republic of Ireland. After this study, it was essential to validate the diagnosis of miscarriage in the national health system used to obtain these trends. Consequently, the aim of the second study was to compare agreement for the diagnosis of miscarriage between three types of routinely collected hospital-based health records. This thesis includes three research studies that explored several gaps in the literature about pregnant women with a history of miscarriage. The first study explored the risk factors associated with miscarriage among women attending an early pregnancy assessment unit (EPAU). The second study aimed to determine barriers and facilitators when designing large-scale longitudinal studies; and the third study was a systematic review, which aimed to identify randomised controlled trials that assessed the effect of interventions to reduce stress, anxiety and depression in pregnant women with a history of miscarriage. Finally, this thesis includes a cross-sectional study that was designed to assess university student’s knowledge of basic reproductive health information about miscarriage. Findings and clinical implications: This thesis provides additional evidence to the growing body of work focusing on miscarriage. This thesis highlights the need for unifying inpatient and outpatient data in order to estimate the total burden of miscarriage at a national level. Furthermore, it is crucial to standardise the diagnosis of the type of miscarriage at a national level. The results presented in this thesis also emphasise the misunderstanding of causes, signs and symptoms of miscarriage, which shows it is essential to inform the public about miscarriage in general, as well as its treatments and the scientific evidence available to date. In addition, reproductive health information about miscarriage should be disseminated to a younger stratum of the population, who are at early stages in their reproductive life. Indeed, this would enable better informed decision-making about their reproductive behaviour and lifestyle by helping them to be aware of risk factors for miscarriage, identifying signs and symptoms of miscarriage and learning what to expect when experiencing a miscarriage. Moreover, providing reproductive health information about miscarriage will help the population to be aware of when and where seek for help. In this thesis, I suggest University settings as the ideal scenario to reach and promote reproductive health information about miscarriage in this targeted group. Efforts to satisfy the population’s needs on reproductive health and pregnancy loss should be made by healthcare professionals and researchers, and should also include public health advocates and policymakers. As a result of the findings from this thesis, I suggest further research in the area of miscarriage, and I outline a number of recommendations in relation to clinical practice and public policy. It is essential to obtain robust evidence on the association of poor mental health and adverse pregnancy outcomes that may lead to targeted interventions for women who are at higher risk of developing stress or mental disorder before, during and after pregnancy. The need for targeted interventions to reduce stress and increase mental wellbeing among pregnant women with a history of miscarriage is also warranted. An effort should be made to design and implement high quality, appropriately powered, RCTs that can provide reliable and non-biased evidence on preventable risk factors and effective psychological and behavioural interventions that may improve outcomes in future pregnancies. To achieve this goal, research funders need to acknowledge the burden of miscarriage at national and international level and support well-designed and large-scale RCTs. Funding RCTs in this area will lead to increase the understanding of potential interventions that might improve women´s psychological wellbeing after pregnancy loss.
Miscarriage , Incidence , Management , Risk factors , Interventions , Populations' knowledge
San Lázaro Campillo, I. J. 2019. An exploration of miscarriage in the Republic of Ireland: incidence, management, risk factors, interventions, and populations’ knowledge. PhD Thesis, University College Cork.