Environmental Effects On Women's With Spontaneous Abortion

Background: spontaneous abortion constitutes one of the most important adverse pregnancy outcomes affecting human reproduction, and its risk factors are not only affected by biological, demographic factors such as age, gravidity, and previous history of miscarriage, but also by individual women’s personal social characteristics, and by the larger social environment. Objective : To identify Environmental effects on Women's with Spontaneous Abortion.

Spontaneous abortion and miscarriage are synonymous terms.In the medical literature, spontaneous abortion is most often used, while in clinical practice and among the general population, it occur in approximately 15-20% of all known (1) .One factor that does increase likelihood of miscarriage is regular exposure to environmental factors classified as teratogens, or agents that have been found to cause disruption in fetal development.Teratogens can be toxic chemicals and radiation, certain viral and bacterial infections, or even cigarette smoke and alcohol (2) .The effects may emerge at key life transitions: for example, when attempting conception, during pregnancy, during development of the embryo or fetus, in the newborn, and during the offspring's childhood, puberty, and eventual fertility as an adult.For this reason, it is important to be aware of the potential effects over a long period of time, rather than only during the period immediately after exposure.These effects include early pregnancy loss, fetal death, impaired fetal growth, low birth weight, premature birth, and structural (e.g., cardiac defect) or functional (e.g., learning disability) birth defects (3) .

OBJECTIVES:
-To identify Environmental effects on Women's with Spontaneous Abortion.

METHODOLOGY:
A descriptive Analytical study was carried out upon women who suffering from spontaneous abortion in maternity unit.Study implemented for the period of February 3 rd 2013 to April 26 th 2013.Data collection will be gathered by questionnaire format and interview with women.The period of data collection for all hospitals was three months.The research study was conducted in four hospitals at Baghdad City which include Al-Elwiya Maternity Teaching Hospital, and Baghdad Teaching Hospital at Al-Russafa sector.Al -karekh Maternity Hospital, and Al-Yarmook Teaching Hospital at Al-karekh sector.Number of the sample who suffering from spontaneous abortion in maternity unit in their hospitals were selected as study sample.A questionnaire was used as a tool of data collection to fulfill with objective of the study and consisted of four parts, including demographic, reproductive characteristics, causes of spontaneous abortion, and environment domains of quality of life.A pilot study was carried out between the January 25 th to January 31 st of 2013, on (10) women who suffering from spontaneous abortion in maternity unit to determine the reliability of the questionnaire and content validity was carried out through the 20 experts.Descriptive and inferential statistical analyses were used to analyze the data.Table (2) shows that the women's Gravida the majority of the sample is reported at the first and second groups with range interval (1 -4) states, and they are accounted 132(66.0%).Relative to women's parity the highest percentage 50(25%) second delivery, 49(24.5%)multipara, and 41(20.5%)primipara.Relative to women's "Number of Abortion", the majority of the sample was reported at "previous one abortion", and they are accounted 105(52.5%) of the study sample.Regarding to " Blood Group -wife and husband", the vast majority types of Blood group were recorded at group " O ", and they are accounted 120(60.0%)and 140(70.0%)respectively.In addition to that, "Rhesus -wife and husband", the vast majority were reported at "Positive" type and they are accounted 178(89.0%)and 196(98.0%)respectively.Finally, "Type of Current Abortion", contains several types, the vast majority types were recorded at "Missed", and they are accounted 67(33.5%).The results have indicated that there are a highly significant differences at P<0.01 among the different of the studied parameter levels.Regarding Part 1 of "Environment Main Domain" in light of "Home Environment", table 3 shows " Pass -(P)" assessment at the two items, since their relative sufficiency were under cutoff point (66.67%) for negative scale scoring for and they are accounted 2(100.0%).Regarding subdomain two "Health Care and Social Care ", it presents " Pass -(P)" assessment at the items "2,3,and 4", since their relative sufficiency were under cutoff point (66.67%) for negative scale scoring and they are accounted 3(75.0%), while the leftover item were reported "Failure -(F)" assessment, since their relative sufficiency were upper cutoff point (66.67%) and accounted 1(25.0%).Regarding women's responses of Part 3 of "Financial Resources ", it presents " Pass -(P)" assessment at all items, since their relative sufficiency were under cutoff point (66.67%) for negative scale scoring for items 1&2 and upper than the cutoff point for positive scale scoring for the item my family helped me to meet my health needs and they are accounted 3(100).
Vol. ( 4 The table demonstrates statistical significant differences between husband occupation and environment domain (p=0.010),nature of work and environmental domain (p=0.041),and finally no significant difference with leftover characters.The table demonstrates the association between women's gravid and environmental domain (p=0.029).

DISCUSSION OF THE RESULTS:
Socio Demographic Characteristic:(Table 1) 1.Age:-The highest percentage (26.5%) of the study sample are at age group ranged (25 -29) years;and the mean age with SD of age old (30.025± 7.00).This finding is in agreement with, Wyatt et.al (4) study in which they considered that fetal loss rates increased in both younger and older women.In this study spontaneous fetal loss rates in each group were evaluated after adjusting fetal losses associated with amniocentesis and identifiable ethnic groups.

2.Education level for both (wife and husband):
The greater number of them illustrated low levels of education, such as illiterate, read and write, primary, and intermediate schools and they are accounted for 127(63.3%) of the total sample in wife, and the greater number of husband illustrated high levels of education(Institute, College or above) are accounted for 50 (25%) of the total sample This finding is consistent with Norsker et.al., (5) study in Denmark in which the women of lower educational status have an elevated risk of spontaneous abortion, the large cohort study is based upon a large population and a considerable number of spontaneous abortions.to that Women with <10 years of education had an elevated risk of spontaneous abortion when compared with women with >12 years of education.

3.Occupational level for both (wife and husband)
A height significant in occupational status of wife, are "Housewife", and they are accounted for160 (80.0%) of the total sample, and with respects level of occupational status of husband, the majority of the sample are "Employee", and they are accounted for109 (54.5%) of the total sample.This finding is constant with study reported by Banerjee, (6) who revealed that the significant work factors directly correlated with adverse pregnancy outcomes included: fewer household helpers, standing at work for more than 17 hours per day, working in hot environments, commuting, walking, and carrying and lifting heavy weight.

4.Residential Environment
The vast majority of the women were living at urban areas accounted 184(92%).Such finding had emerged due to the fact that urban areas were having crowded and transportation was available and made easier for them to seek health care.But in rural area they were considered women who had spontaneous abortion as stigma, therefore ,large number of them prefer to go at a midwife to reach their facility care.This is in agreement with study reported by Carlson and Mourgova (7); Yong and Wang, (8) they presented that place of residence, affect the risk of miscarriage, it concluded that women in cities reported a level of miscarriage clearly higher than those in towns and in the countryside: 3.7 versus 3.2 and 3 percent respectively.

5.Consanguinity:
Although that the majority of the sample were reported non consanguinity , and they are accounted 111(55.5%),whereas whose had consanguinity are accounted 89(44.5%), it can be interpreted that the vast majority of women were living at the urban areas.So that the life style can create an impact on the social relations to become with partners who have non consanguinity to start with a social life, but result of this study represent no significant different at p<0.05 between consanguinity and spontaneous abortion occurrence.Socioeconomic Status :-(Figure 1) The vast majority of the study sample is within low category and accounted for 96(48.0%),then followed within moderate category of assessment and they accounted for 89(44.5%)and the remaining within high score and accounted for 15(7.5%).This result is constant with studies of Sundari, (9) and Family Health International (fhi) (10) they reported that the social and economic circumstances under which women live influence their reproductive behavior.Poor families tend to marry off their daughters at a young age, which usually means these young wives start having children right away.This often perpetuates a vicious cycle of poverty, low education, and high rates of unintended pregnancy and fertility, and have poorer health status because their limited access to resource inhibits access to good food and health care.Women from the poorer segments of society are more likely to have an unintended pregnancy than wealthier women for a variety of reasons.More important, poor women are less likely to decide independently about using contraception, and they may have less access to family planning information and services.In Egypt, pregnant women in the poorest fifth of the population are twice as likely to report their pregnancy as unintended as those in the wealthiest fifth.Body Mass Index (Figure 2) The vast majority of the study sample is within normal weight group, and they are accounted for 96(48.0%),but the overweight, and obesity are highest association together they are accounted 104(52%)of the study sample, these result are in agreement with the study reported by Turner et.al., (11) who concluded that the miscarriage rate was 2.3% in the obese category (n=217), compared with 3.3% in the overweight category (n=329), and 2.3% in the normal BMI group (n=621).Its means that the rate of spontaneous miscarriage is low and is not increased in women with BMI>29.9 kg/m(2) compared to women in the normal BMI category.Other study reported by Fedorcsak et.al.; Glueck et.al.; Bellver et.al.showed significant differences in spontaneous abortion rates between obese women (38.1%,BMI=30 kg/m 2 ) and normal weight (13.3%, BMI 20-24.9 Vol. (4)  No.( 1) 2014 ٩ kg/m 2 ) or overweight (15.5%, BMI 25-29.9kg/m 2 ) women, supporting the concept that obesity is an independent risk factor for spontaneous abortion.

Reproductive Parameters (Table2) 1.Gravida (Number of Pregnancy)
The investigation of women who suffer from spontaneous abortion are primigravida and multigravida.Some of the women who are multigravida had previous stillbirth, preterm birth, multiple birth, and previous miscarriage.This finding is constant with Yong& Wang, (8) study who reported that gravidity, length of pregnancy interval, and pregnancy history are highly correlated, they also pose a challenge to assessing the independent effect of each on the occurrence of miscarriage.
2.Para:-The majority of the sample reported at second delivery and they are accounted 50(25%), nullipara 49(24.5%),and primipara 41(20.5%) of the study sample, this result is in agreement with Sundari, (9) study who reported that women of parity two and three had a slightly higher rate of neonatal deaths than primiparae women.However, this does not alter the finding that negative pregnancy outcome is associated more with lower order pregnancies contrary to the findings reported by other studies which find a relationship between parity and negative pregnancy outcome: high for primiparae, low for parities two to four or five, and increasing steeply thereafter.

3.Number of Abortion:-
The majority of the sample was reported at "previous one abortion", and they are accounted 105(52.5%),previoustwo 41(20.5%)and previous three are accounted 34(17%) of the study sample.This result is in agreement with Hassan and Killick, (12) study.They reported after a previous miscarriage, the risk of miscarriage in the subsequent pregnancy is increased to 16-20%.

4.Blood group and Rh:
The wife and husband who have type (O)of blood group hasn't any problem or any risk for their fetus, but this study reported Rh negative at some of wife who accounted 22 (11%) and at some of husband who accounted 4(2%), which can cause risk for miscarriage.These results are in agreement with study of Ghasemi et.al., (13) who reported that the blood group incompatibility can affect adversely the outcome of pregnancy.Couples with blood group incompatibility are more involved in spontaneous miscarriage.

5.Type of Current Abortion:-
This study present that the vast majority of abortion types were recorded at "Missed, Threatened, and Habitual ", and they are accounted 67(33.5%),53(26.5%),and 47(23.5%)respectively, while the others types were reported with the leftover "Incomplete, Inevitable, and Complete", and they are accounted 23(11.5%),8(4.0%), and 2(1.0%) respectively.This study present that majority of abortion types are missed abortion related to that, missed abortion may be no symptoms at all, or just little amount of a brownish vaginal discharge or brown vaginal bleeding may occasionally be seen, pain is unlikely and os will be closed (Neville et.al) (14) .Relative to Environment Domains:-(Table 3) 1.Home Environment This result can be interpreted in a way that investigated women suffering from nervous and distress from the home live due to discomfort from family work burden responsibility, uncomfortable house because un available of simplest things for rest and comfortable, and finally due to the behavior of some person live with them.This result is in agreement with study of Evans and Kantrowitz, (15) ;Kruize and Bouwman, (16) ; Walker et.al. (17), they reported that the risk of miscarriage has also been linked to a woman's behavior and to the social and environmental context a woman lives in, which is referred to as "residential location" which leads to different levels risk when exposure to conditions such as e.g.lack of comfort, home safety, space accessibility and other factors all impact on health and the respective exposure varies between social groups and within the population.

Figure ( 2 )
Figure (2): BMI Groups of the Studied Sample between Socio-Demographical Characteristics Variables with an Overall Assessments due to Compact all Main Domains according to "Under/Upper" Cutoff Point (*) NS : Non Sig. at P>0.05 ; S : Sig. at P<0.05 ; HS : Highly Sig. at P<0.01 (*) Sig:-Significant

χ 2 = 34.420 P=0.000 HS Reads and writes 20 10 Primary 55 27.5 Intermediate 28 14 Preparatory 23 11.5 Institute , college or above 50 25 Educational Level Husband Illiterate 17 8.5 χ 2 = 26.200 P=0.000 HS Reads and writes 29 14.5 Primary 38 19 Intermediate 45 22.5 Preparatory 21 10.5 Institute , College or above 50 25 Occupational Status of Wife Housewife 160 80 χ 2 = 338.120 P=0.000 HS Student 1 0.5 Employee 36 18 Free Jobs 3 1.5 Occupational Status of the Husband Official 75 37.5 χ 2 = 154.640 P=0.000 HS Employee 109 54.5 Retired 1 0.5 Without Work 15 7.5 Place of Work for wife Very Close 8 20.5 χ 2 =9.103 P=0.028 S
Table(1)shows a highly significant differences at P<0.01 among the different of the studied levels at all Socio-Demographical Characteristics variables.Relative to age groups, the majority of the sample were reported (26.5%) at the age ranged (25 -29) yrs.Regarding to the women's level of education, the greater number of them illustrated low levels of education (illiterate, read& write, primary, and intermediate schools) and they are accounted for 127(63.3%) of the total sample, and with respects to husband level of education, the greater number of them illustrated high level of education(Institute , college or above) and they are accounted for (25%) of the total sample.With respect to the women's occupational status, the majority of the sample are "Housewife", and they accounted for 160 (80.0%) of the total sample, and with respects to the husband occupational status, the majority of the sample are "Employee", and they accounted 109(54.5%) of the total sample.Relative to ''Place of Work for wife'' the highest percentage are accounted 17(43.6%)at close place of work.Relative to ''Specialization in which they operates'' the highest percentage are accounted 21(53.8%)at work that requires women's focus on mind.Relative to women's "Residential Environment", results indicated that a highest percentage of the study sample are "Urban", and they are accounted 184 (92.0%).High Moderate Low Figure (1): Socioeconomic Status of the Studied Sample