https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Physical Factors of Spontaneous Abortion in Maternity Teaching Hospital in Erbil City ABSTRACT Background and objectives: Abortion is considered a major reproductive health issue that acts as a health risk factor for mothers' well-being and threatens their lives and comfort. This study will contribute to recognize and be a better understanding of the physical risk factors for spontaneous abortion. The aim of the study was to find out the physical factors, which include previous and current medical factors of different types of spontaneous abortion by comparing the case and control groups among women in the Maternity Teaching Hospital in Erbil City. Methods: A quantitative case-control study was conducted on 850 women with sponta- neous abortions and pregnant women (each group was 425) pregnant women. However, the sample size of the study was 770 for both groups (each group was 385), however, 850 women were chosen who were admitted to Maternity Teaching Hospital and were selected through non-probability purposive sampling. A questionnaire was developed for the purpose of data collection, which included socio-demographic characteristics of the study sample and questions about physical characteristics. Frequency, percentage, the inferential statistical analysis of the Chi-square test (fissure exact test), and binary logistic regression were used for data analysis. Results: There was a significant difference between spontaneous abortion and physical factors which included medical conditions such as cardiovascular, urinary tract, neuro- logical, and immune diseases. Additionally, medical history such as obstetrical and gyne- cology surgery, gynecology disease, family history of chronic disease, and family history of spontaneous abortion. Cardiovascular diseases (OR:2.710; CI:1.636-4.483), immune diseases (OR:0.230; CI:0.113-0.466), history of obstetrics and gynecology surgeries (OR:0.599; CI:0.436-0.824), family history of chronic diseases (OR:1.834; CI:1.336-2.518), family history of spontaneous abortion (OR:0.098; CI:0.050-0.193) were predictors of the spontaneous abortion. Conclusion: Some physical factors are risk factors for spontaneous abortion. Keywords: Spontaneous abortion; Physical factors; Pregnant women. Jwan Kareem Salh; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: jwan.salh@hmu.edu.krd). Hamdia Mirkhan Ahmed; College of Health Sciences , Hawler Medical University, Erbil, Iraq. 01 Received: 19/07/2022 Accepted: 29/09/2022 Published: 30/05/2024 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:jwan.salh@hmu.edu.krd?subject=jwan.salh@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Abortion is considered a major reproduc- tive health issue and acts as a health risk factor for mothers' well-being and threat- ens their lives and comfort [1]. Abortion is defined as the induced termination of a spontaneous pregnancy before fetal viabil- ity [2]. Spontaneous abortion is another term for miscarriage, which refers to a pregnancy loss that happens before the 20th week of gestation or the expulsion of a fetus weighing 500 grams or less [3]. Ac- cording to the clinical features and differ- ent stages of development, spontaneous abortion can be divided into threatened abortion, inevitable abortion, incomplete abortion, complete abortion, missed abor- tion, recurrent abortion, and infection abortion [4]. A study was done in Kurdistan by Azo and Akbay reported that the total prevalence of abortion among Kurdish married women was 27.7% [5]. Another study was done in Kermanshah provenance in Iran by Moradinazar et al, which found that about 25.7% of women had a history of spontaneous abortion [6]. It is the most common complication during pregnancy, affecting thousands of couples in the Unit- ed Kingdom every year. The average risk of spontaneous abortion has been calculated to be 15.3% of all recognized pregnancies [7].Risk factors for spontaneous abortion include maternal age of more than 35 years, less education, women who had up to eight years of study, lower family in- come, and health conditions such as hyper- tension, heart disease, overweight, and obesity. Additionally, there were infectious factors, which include infection by cyto- megalovirus, rubella, toxoplasmosis, and bacterial vaginosis. Hormonal changes in- clude progesterone, hyperinsulinemia, and hyperandrogenism [8]. The research on the effects of viral respiratory infections on pregnancy, particularly during the first half of pregnancy, has been inconsistent. At the beginning of the COVID-19 pandemic, there were risks that SARS-CoV- 2 infection could increase the risk of spontaneous abortion [9]. Prevention of spontaneous abortion can occasionally be accomplished by reducing risk factors. This may include good antenatal care, avoiding medications and alcohol, preventing infectious diseases, and avoiding X-rays. Detecting the reason for the spontaneous abortion may help prevent future pregnancy losses, specifically in cases of recurrent abortion [10]. This study will contribute to recognize and be better understanding of the physical risk factors for spontaneous abortion. The study aimed to find out the physical factors which include previous and current medical factors of different types of spontaneous abortion by comparing the case and control groups among women in the Maternity Teaching Hospital in Erbil City. A quantitative case-control study of a non- probability purposive sample was conducted on 850 women with spontaneous abortion and pregnant women (each group 425) who were admitted to Maternity Teaching Hospital and were available during data collection. However, the sample size of the study was 770 for both groups (each group 385), but I took 850 women with spontaneous abortions and pregnant women. By using calculator.net (Sample size calculator) following values were entered confidence interval was 95 %, the margin of error was 5 % and the population proportion was 50%. The inclusion criteria for the case group included women who agreed to participate in the study, women with spontaneous abortions, and the control group included pregnant women at the end of the second and third trimesters of pregnancy and women who progressed 02 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article utilizing descriptive and inferential statis- tics. Descriptive statistical analyses include frequency and percentage, the inferential statistical analysis of the Chi-square test (fissure exact test), and logistic regression analysis. Table 1 shows the differences between women with spontaneous abortions and pregnant women regarding socio- demographic characteristics. There were significant to highly significant differences between the scores of the items of the woman with spontaneous abortion and the pregnant woman with regards to socio -demographic characteristics except for the items ;( level of education, possession of a car, and socioeconomic status) which represented no significant difference at P≥0.05. Table 2-1 illustrates the differences be- tween women with spontaneous abortions and pregnant women regarding physical factors. There were significant to highly significant differences between the scores of the items of the women with spontane- ous abortions and pregnant women with regards to physical factors, which including medical conditions, except for the items ; ( Respiratory diseases, gastrointestinal dis- eases, endocrine diseases, hematological diseases, reproductive diseases, and mus- culoskeletal diseases) which represented no significant difference at P≥0.05. to labor . The exclusion criteria for the case group included those who refused to be interviewed, women with induced abor- tions and women who were not talking in the Kurdish language. Also, the control group was the pregnant women in the first, and beginning of the second tri- mester of pregnancy, and not talk in the Kurdish language. Data was collected in the period from October 25th 2021to May 25th, 2022. The sample was selected from the emergency department, delivery room, postpartum unit, high-risk department, and outpatient unit. A questionnaire was developed for the data collection for the study. In the first part socio-demographic characteristics included women’s age, level of education, occupation, residential sta- tus, type of family, possession of a car, and possession of a house. The socioeconomic status index was constructed using the in- dex, it was depending on the patient's age, level of education, patient occupation and also the husband’s occupation, car, and house. The socioeconomic status index is divided into three levels: low, middle, and high economic level. Physical characteris- tics included medical conditions and medi- cal history.23 experts in the field reviewed the questionnaire and checklist and sug- gested some modifications to improve the internal validity of the tool. This study was approved by the scientific and ethical com- mittee at Hawler Medical University / College of Nursing. The code number was 102 and the date was 7 / 10/ 2021. Formal permission was given by the administra- tion of the hospital. Before data collection, all study participants were informed about the aims and characteristics of the study. Informed consent was obtained after con- firmation of confidentiality and was col- lected through a face-to-face interview technique, and analyses were assessed us- ing the statistical package for social science (version 26).Variables were analyzed 03 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article 04 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Difference between case and control groups regarding socio-demographic char- acteristics. Socio-demographic characteristics Case F (%) Control F (%) Age group ≤ 19 years old 34 (44.2) 43 (55.8) 20-29 years old 169 (45.1) 206 (54.9) 30-39 years old 181 (53.7) 156 (46.3) 40-49 years old 41 (67.2) 20 (32.8) Level of education Illiterate 100 (51.5) 94 (48.5) Primary (or read and write) 149 (52.3) 136 (47.7) Intermediate 78 (54.2) 66 (45.8) High school or vocational 45 (45.5) 54 (54.5) Institute (2 years) 28 (39.4) 43 (60.6) College (Bachelor degree) 23 (41.8) 32 (58.2) College (Master degree) 2 (100) 0 (0) Occupation status Unskilled Manual 23 (60.5) 15 (39.5) Semi-Skilled Manual 322 (47.6) 354 (52.4) Skilled manual and non-manual 40 (62.5) 24 (37.5) associate professional 30 (51.7) 28 (48.3) Skilled professional or senior manage- rial 10 (71.4) 4 (28.6) Residential area Urban 210 (55) 172 (45) Rural 46 (48.4) 49 (51.6) Sub-urban 169 (45.3) 204 (54.7) Type of family Nuclear 327 (55.1) 266 (44.9) Extended 98 (38.1) 159 (61.9) Possession of car No 162 (46.4) 187 (53.6) Yes 263 (52.5) 238 (47.5) Possession of house No 218 (46.8) 248 (53.2) Yes 207 (53.9) 177 (46.1) Economic status Low economic level 310 (51.1) 297 (48.9) Middle economic level 113 (46.9) 128 (53.1) High economic level 2 (100) 0 (0) Total 425 (50) 425 (50) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article 05 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2-1: Difference between case and control groups regarding physical factors (medical condition) Medical conditions Case F (%) Control F (%) Cardiovascular diseases No 394 (53.1) 348 (46.9) Yes 31 (28.7) 77 (71.3) Respiratory diseases No 422 (49.9) 423 (50.1) Yes 3 (60) 2 (40) Gastrointestinal disease No 414 (50.2) 411 (49.8) Yes 11 (44) 14 (56) Endocrine diseases No 384 (50.1) 383(49.9) Yes 41 (49.4) 42 (50.6) Hematological diseases No 343 (50.3) 339 (49.7) Yes 82 (48.8) 86 (51.2) Urinary tract disease No 386 (51.3) 366 (48.7) Yes 39 (39.8) 59 (60.2) Neurological disease No 411 (49.3) 422 (50.7) Yes 14 (82.4) 3 (17.6) Reproductive disease No 363 (50.1) 361 (49.9) Yes 62 (49.2) 64 (50.8) Immune disease No 375 (47.5) 414 (52.5) Yes 50 (82) 11 (18) Musculoskeletal disease No 419 (49.7) 424 (50.3) Yes 6 (85.7) 1 (14.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article regards to physical factors, which including medical history, except for the items ; ( coronavirus disease, receiving corona- virus vaccine, history of surgical operation, drug history and drug allergy) which repre- sented no significant difference at P≥0.05. 06 Table 2-2 2 illustrates the differences be- tween women with spontaneous abor- tions and pregnant women regarding medical history. There were significant to highly significant differences between the scores of the items of the woman with abortion and the pregnant woman with Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2-2: Difference between case and control groups regarding physical factors (medical history) Medical history Case F (%) Control F (%) Coronavirus No 340 (51.8) 316 (48.2) Yes 85 (43.8) 109 (56.2) Receive corona virus vaccine No 414 (49.6) 421 (50.4) Yes 11 (73.3) 4 (26.7) History of surgical operation No 360 (50.6) 352 (49.4) Yes 65 (47.1) 73 (52.9) History obstetrical and gynecological surgeries No 235 (45.2) 285 (54.8) Yes 190 (57.6) 140 (42.4) History of past gynecological diseases No 360 (48.5) 382 (51.5) Yes 65 (60.2) 43 (39.8) Drug history No 400 (49.7) 405(50.3) Yes 25 (55.6) 20 (44.4) Drug allergies No 414 (49.8) 418 (50.2) Yes 11 (61.1) 7 (38.9) Family history of chronic diseases No 268 (54.7) 222 (45.3) Yes 157 (43.6) 203 (56.4) Family history of spontaneous abortion (mother, sister) No 342 (45.3) 413 (54.7) Yes 83 (87.4) 12 (12.6) *Fissures exact test was used https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article women who had not disease, history of obstetrics and gynecology surgeries (P= 0.002 ;OR:0.599; CI:0.436-0.824) times more likely expose to be spontaneous abortion, compare with women who had not history, family history of chronic dis- eases (P= <0.001 ;OR:1.834;CI:1.336-2.518) times more likely expose to be spontane- ous abortion, compare with women who had not history, family history of spontane- ous abortion (P= <0.001 ;OR:0.098; CI:0.050-0.193) times more likely expose to be spontaneous abortion, compare with women who had not history the predic- tors for spontaneous abortion. Table 3 indicates that woman from sub- urban (P= 0.015 ;OR:1.465; CI:1.077-1.992) times more likely expose to be spontane- ous abortion, compare with women who had from urban, woman having extended family (P= 0.003 ;OR:1.766; CI:1.217- 2.564) times more likely expose to be spontaneous abortion, compare with women who having nuclear family, cardio- vascular diseases (P= <0.001 ;OR:2.710; CI:1.636-4.483) times more likely expose to be spontaneous abortion, compare with women who had not disease, immune dis- eases (P= <0.001;OR:0.230; CI:0.113- 0.466) times more likely expose to be spontaneous abortion, compare with 07 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3: Logistic regression analysis of spontaneous abortion with some variables Variables Odds Ratio 95% CI P-value Residential area Urban Reference category Sub-urban 1.465 1.077-1.992 0.015 Type of family Nuclear Reference category Extended 1.766 1.217-2.564 0.003 Cardiovascular diseases No Reference category Yes 2.710 1.636-4.483 <0.001 Immune disease No Reference category Yes 0.230 0.113-0.466 <0.001 History obstetrical and gynecological surgeries No Reference category Yes 0.599 0.436-0.824 0.002 Family history of chronic diseases No Reference category Yes 1.834 1.336-2.518 <0.001 Family history of spon- taneous abortion (mother, sister) No Reference category Yes 0.098 0.050-0.193 <0.001 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article Medical conditions such as cardiovascular, urinary tract, neurological, and immune diseases. Medical history such as obstetri- cal and gynecology surgery, gynecology disease, family history with chronic dis- ease, and family history of spontaneous abortion are risk factors for spontaneous abortion. [1] Umar NJ, Olubiyi SK, Aliyu U, Aminat GU, Imam AA, Ibraheem MA et al.Spontaneous abortion among women admitted into gy- naecology wards of three selected hospitals in Maiduguri, Nigeria. International journal of Nursing and Midwifery. 2014 Apr 30;6 (2):24-31. [2] Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS. Williams obstetrics, 24e. New York, NY, USA: Mcgraw-hill.2014:pp 350. [3] Buzad P, McCoy TW, Mularz A, Dalati S, Pedi- go R. Spontaneous abortion and recurrent pregnancy loss. Ob/Gyn Secrets,4e. USA: Elsevier.2016:pp 113. Available from:https:// books.google.iq/books? hl=en&lr=&id=J8VDAAAQBAJ&oi=fnd&pg=P A113&dq=Buzad+P,+McCoy+TW.+Spontane ous+abortion+and+recurrent+pregnancy+los s.&ots=5VGvsXP8W3&sig=mXtTzEVg2Q0UUJ Vl8GhQ6dWmimc&redir_esc=y#v=onepage &q&f=false [4] Hu X, Miao M, Bai Y, Cheng N, Ren X. Repro- ductive factors and risk of spontaneous abortion in the jinchang cohort. Internation- al Journal of Environmental Research and Public Health. 2018 Nov;15(11):2444. [5] Azo FM, AKBAY CA. Prevalence and risk fac- tors of abortion among a sample of married women in Kurdistan Region of Iraq. Zanco Journal of Medical Sciences. 2016 Dec 15;20 (3):1424_1432-. [6] Moradinazar M, Najafi F, Nazar ZM, Hamzeh B, Pasdar Y, Shakiba E. Lifetime prevalence of abortion and risk factors in women: evi- dence from a cohort study. Journal of Preg- nancy. 2020;2020 (4871494). [7] Quenby S, Gallos ID, Dhillon-Smith RK, Po- desek M, Stephenson MD, Fisher J, et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. The Lancet. 2021 May 1;397(10285):1658-67. The present study shows that there is a significant difference between case and control regarding medical conditions such as cardiovascular, urinary, neurological, and immune diseases and medical histo- ries such as obstetrics diseases, gynecolog- ical surgery, gynecological diseases, family history with chronic diseases, and family history with spontaneous abortion. Re- garding another study, the results of the study were done by Makharadze et al. (2019) disagree with our study, their study concluded that there was no difference between spontaneous abortion and medi- cal conditions [11].Regarding logistic re- gression in the present study sub-urban (OR:1.465; CI:1.077-1.992) is the predictor for spontaneous abortion and, also having an extended family (OR:1.766; CI:1.217- 2.564) .The study was done by Zheng et al. (2017) their results disagree with our study. In their study, increased risk of spontaneous abortion in rural areas was 1.68 times greater than in urban areas (OR = 1.68 ;CI: 1.54–1.84) [12].Cardiovascular diseases(OR:2.710;CI:1.636-4.483), immune diseases (OR:0.230; CI:0.113- 0.466),history of obstetrics and gynecolo- gy surgeries (OR:0.599; CI:0.436- 0.824),family history of chronic diseases (OR:1.834;CI:1.336-2.518), family history of spontaneous abortion (OR:0.098; CI:0.050-0.193) are the predictors for spontaneous abortion. Also, a study was done by Magnus et al. (2021) their results agree with our study. In their study, ob- served an increased risk of spontaneous abortion among women with cardiometa- bolic diseases (OR 1.25, CI 1.20 to 1.31) [13]. The study was conducted by Sunil and Valsan (2020) Their results disagree with our study, in their study in the family history of abortion (OR:0. 79; CI 0.31-2.03) had risks for spontaneous abortion [14]. 08 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. REFERENCES CONCLUSION DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 Erbil j. nurs. midwifery, Vol. 7, No. (1), May, 2024 Original Article [8] Bellieni CV, Buonocore G. Abortion and sub- sequent mental health: Review of the litera- ture. Psychiatry and Clinical Neurosciences Journal. 2013 Jul;67(5):301-10. [9] Favre G, Pomar L, Musso D, Baud D. 2019- nCoV epidemic: what about pregnancies? 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International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2020 Oct 1;9(10):4118-23. 09 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/