Tavoli et al.

Health and Quality of Life Outcomes (2018) 16:150

https://doi.org/10.1186/s12955-018-0982-z

RESEARCH Open Access

Quality of life and psychological distress in

women with recurrent miscarriage: a
comparative study
Zahra Tavoli1, Mahsa Mohammadi2, Azadeh Tavoli3, Ashraf Moini1, Mohammad Effatpanah4, Leila Khedmat5
and Ali Montazeri6*

Abstract
Background: This study aimed to evaluate quality of life and psychological distress in Iranian women with recurrent
miscarriage and to compare it in women without miscarriage.
Methods: This was a comparative study of quality of life among women with and without recurrent miscarriage. Cases
were selected from patients with complain of recurrent miscarriage and comparison group were selected from women
attending to two teaching hospitals for annual screening. Quality of life (QOL) was measured using the 36-Item Short
Form Survey (SF-36). In addition the Hospital Anxiety and Depression Scale (HADS) were used to measure anxiety and
depression. Comparison was made between two groups using the independent samples t-test and chi-square.
Results: In all 105 women with recurrent miscarriage and 105 healthy women were studied. The socio-demographic
status for both groups was similar. Women with recurrent miscarriage showed a significant higher degree of
psychological distress [mean (SD) anxiety score was: 10.6 (2.3) vs. 9.1 (2.2), P < 0.0001; and mean (SD) depression score
was: 11.0 (2.3) vs. 9.5 (1.9), P < 0.0001]. In addition women with recurrent miscarriage reported significantly lower level
of quality of life in all domains (role physical, general health, vitality, social functioning, role emotional, and mental
health, all P values < 0.0001), except for physical functioning (P = 0.06) and bodily pain (P = 0.17).
Conclusion: The findings demonstrated that women with recurrent miscarriage reported extensive functional
disability, and lower level of well-being compared to women without recurrent miscarriage. The findings have some
implications for prenatal care and suggest that appropriate treatment of recurrent miscarriage is essential.
Keywords: Recurrent miscarriage, Quality of life, Anxiety and depression

Background of recurrent pregnancy loss remain unexplained in 60%

Recurrent pregnancy loss or recurrent miscarriage is of cases [2]. Qualitative studies indicated that a history
characterized as three or more consecutive pregnancy of miscarriage could harm women and be associated
loss prior to 20 weeks from the last menstrual period. with feeling anxious, development of psychological dis-
Spontaneous pregnancy loss has been estimated to be orders, and affecting quality of life in this population [3].
prevalent in approximately 15% of clinically diagnosed Most studies on quality of life and psychological disor-
pregnancies [1]. There are a number of etiological causes ders come from more developed countires. Women with
for recurrent miscarriage such as immunologic, genetic, a history of recurrent miscarriage experience an increase
and anatomic abnormalities, endocrine disorders, infec- in depressive symptoms and may be at increased risk of
tious, heritable and/or acquired thrombophilias and en- negative psychological effects such as pregnancy-related
vironmental factors. However, after the actual evaluation anxiety, depression, irritability, excessive fatigue, fear,
sleep disorders and lack of concentration [4, 5] The in-
* Correspondence: [email protected]
crease in psychological morbidity immidetly following
6
Population Health Research Group, Health Metrics Research Centre, Iranian miscarriage among women are well documented [6].
Institute for Health Sciences Research, ACECR, Tehran, Iran
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tavoli et al. Health and Quality of Life Outcomes (2018) 16:150 Page 2 of 5

The importance of psychological factors and socioeco- 1. A demographic questionnaire containing 19

nomic status instantly affecting pregnancy or mediating questions was admistered to collect data on age,
the effects leading to pregnant loss continues to be occupational status, smoking, education, number
underestimated in clinical grounds especially recurrent of children, number of abortions, gestational age at
miscarriage, despite research extrapolating their import- the time of abortion and time of abortion.
ance. In parallel, health behaviors of women with history 2. The SF-36 questionnaires: this is a general measure
of recurrent miscarriage are of great concern. Under- of health-related quality of life and contains 8
standing of women’s health behaviors subsequent to subscales namely physical functioning, role physical,
miscarriages is very important for the promotion of opti- bodily pain, general health, vitality, social functioning,
mal health for women with history of recurrent miscar- and role emotional and mental health. Score on each
riage. Therefore, the purpose of this study was to subscale range from 0 (the worse) to 100 (the best).
evaluate the effects of recurrent miscarriage on quality Psychometric properties of the Iranian version of the
of life and psychological distress of women with recur- questionnaire are well documented [7].
rent miscarriage. 3. The Hospital Anxiety and Depression Scale (HADS)
was used to evaluate the levels of anxiety and
Methods depression. The HADS is a fourteen-item scale with
Study population and data collection two subscales including anxiety and depression and
This was a cross sectional study and participants were score on each subscale range from 0 to 21 with
selected from 15 to 50-years-old women attending the higher scores indicating higher level of anxiety and
gynecology outpatient clinics at two teaching hospitals depression. Score of 11 or more is considered as a
affiliated to Tehran University of Medical Sciences case suffering from disorder that usually requires
between 2014 and 2015. A sample of women who had a treatment, scores 8–10 represent the boarderline
history of three or more recurrent miscarriage (as condition that individuals who have these scores are
defined: any pregnancy involuntarily ending before usually referred for psychiatric assessments, and
20 weeks), and a comparison group consisting of a sam- scores between 0 to 7 show normal statuses [8].
ple of women who did not have recurrent miscarriage, The Iranian version of the HADS exists and its
and did not face infertility problems were entered into psychometric properties are reported elsewhere [9].
the study. Exclusion criteria included women with a
history of psychiatric disorders, having a history of ad- Statistical analysis
diction, treated with anti-anxiety and depression drugs, Descrptive statistics were used to explore the data. We
pregnant at the time of study, and suffering from performed independent samples t-test and chi-square for
chronic diseases. All women in both groups were appor- group comparison where necessary. P value less than 0.05
ached during the study period and they were asked to was considered as significant level.
respond to the study questionnaires. They were assured
that their information would remain confidential. In- Ethics
formed consent was obtained from all participants. The ethics committee of Tehran University of Medical;
Sciences approved the study. All participants gave informed
Sample size calculation consent prior to the study commence.
The sample size was calculated using the following formula
Results
 2 In all 210 women were entered into the study. The mean


z1− a = þ z1−β s21 þ s22 age of women with and without miscarriage was 32.1
2
n¼ (SD =4.7) and 32.2 (5.6) years, respectively (P = 0.86).
ðμ2 −μ1 Þ2 Furthermore, 72.4% of participants were housewife and
27.6% were employed. In terms of educational, the ma-
As such to have a study with a 80.0% power and able jority of women had higher education (53.3%). Overall
to detect a 20% difference in quality of life score be- 52.9% of the participants had a history of childbirth and
tween women with and without miscarriage a sample of 47.1% had no successful childbirth history. There were
100 women in each group was thought. no significant differences between the study groups.
However, there was a significant difference in terms of
Questionnaires having a child as expected (P < 0.0001). The results are
Data were collected using a demographic questionnaire, shown in Table 1.
the Short form Health survey (SF-36), and the Hosptial The quality of life data are summarized in Table 2.
Anxiety and Depression Scale (HADS). There were significant differences between women with
Tavoli et al. Health and Quality of Life Outcomes (2018) 16:150 Page 3 of 5

Table 1 Descriptive information regarding education, Table 3 Comparison of anxiety and depression in women with
occupation and childbirth in women under the study and without recurrent miscarriage
With recurrent Without recurrent With recurrent Without recurrent
miscarriage miscarriage (n = 105) miscarriage (n = 105) miscarriage (n = 105)
(n = 105)
Mean (SD) Mean (SD) P*
No. (%) No. (%) P*
Anxiety 9.1 (2.2) 10.6 (2.3) 0.0001
Age
Depression 11.0 (2.3) 9.5 (1.9) < 0.0001
Mean (SD) 32.2 (4.7) 32.1 (5.6) 0.86
*Derived from independent two samples t-test
Education 0.076
Primary 7 (6.7) 2 (1.9) have a child were suffering more comapred to those who
Secondary 47 (44.8) 42 (40)
had at least one child (P value for anxiety = 0.005, P value
for depression = 0.02). The findings are shown in Table 4.
Higher Education 51 (48.6) 61 (58.1)
Occupation 0.80 Discussion
Housewife 76 (72.4) 64 (61) The purpose of this study was to determine the impact of
Employed 29 (27.6) 41 (39) recurrent miscarriage on the quality of life and psycho-
Having a child 0.0001 logical distress in women with recurrent miscarriage com-
Yes 26 (24.8) 85 (81)
pared to other women without history of miscarriage. The
results showed that women with a history of recurrent
No 79 (75.2) 19 (20)
pregnancy loss differed from women without a history of
*All P values derived from chi-square test except for age that derived from
two independent samples t-test
recurrent pregnancy loss on most health-related quality of
life measures. The quality of life scores based on the SF-36
and without miscarriage in all quality of life subscales as indicated that general health perceptions, vitality, role
measured by the SF-36 (P < 0.0001) except for physical physical, role emotional, social functioning and mental
functioning (P = 0.06) and bodily pain (P = 0.17). health in women with recurrent miscarriage were lower
Table 3 presents data for anxiety and depression. than those without a history of multiple miscarriages.
There were significant differences between women with However, no significant difference was found in terms of
and without miscarriage indicating that women with re- physical functioning and bodily pain between women with
current miscarriage experienced higher levels of anxiety and without history of recurrent miscarriage,
and depression. The finding suggests that, in order to prevent the loss
Furthermore, the data demonstrated that there were no of quality of life in women subsequent to a miscarriage,
significant differences in quality of life score between supportive measures should be initiated by the treatment
women with and without child in recurrent miscarriage
group except for general health (P = 0.001) and mental Table 4 Comparison of anxiety, depression and quality of life
health (P = 0.03). In addition, when anxiety and depression among women with a history of recurrent miscarriage with or
was compared between these women the findings showed without child
that those women with recurrent micarriage who did not Women with recurrent Women with recurrent
miscarriage with child miscarriage without
Table 2 Comparison of quality of life between women with (n = 26) child (n = 79)
and without miscarriage Mean(SD) Mean(SD) P*
With recurrent Without recurrent Anxiety 9.57 (2.3) 11.0 (2.2) 0.005
miscarriage miscarriage (n = 105) Depression 10.1 (1.5) 11.3 (2.4) 0.02
(n = 105)
Physical 74.2 (22.3) 73.5 (17.3) 0.87
Mean (SD) Mean (SD) P*
functioning
Physical functioning 73.7 (18.5) 79.1 (23.1) 0.06
Role physical 46.1 (42.8) 44.3 (39.4) 0.83
Role physical 44.7 (40) 66.1 (37.4) < 0.0001
Bodily pain 48.7 (13.7) 49.9 (11.9) 0.66
Bodily pain 49.6 (12.3) 47.5 (10.1) 0.17
General health 63.6 (16.7) 50.3 (17.2) 0.001
General health 53.6 (17.9) 66.3 (19.2) < 0.0001
Vitality 47.1 (20.3) 51.2 (13.3) 0.20
Vitality 50.2 (15.3) 59.7 (15.7) < 0.0001
Social 63.4 (14.9) 57.2 (20.8) 0.16
Social functioning 58.8 (19.6) 76.6 (22.3) < 0.0001 functioning
Role emotional 40.6 (38.6) 64.7 (39.7) < 0.0001 Role emotional 46.1 (49) 38.8 (34.7) 0.40
Mental health 54.2 (16.2) 66.7 (17.6) < 0.0001 Mental health 57.0 (20.2) 53.2 (14.7) 0.03
*Derived from two independent samples t-test *Derived from independent two samples t-test
Tavoli et al. Health and Quality of Life Outcomes (2018) 16:150 Page 4 of 5

groups to promote mental health, in addition to physical Our findings suggested that the level of anxiety and
illness. depression of the women without children suffering
Couto et al., [10] reported that women with recurrent from recurrent miscarriage increased more markedly, as
miscarriage had poorer results in all items including compared to that of women with at least one child. This
physical functioning, social functioning and role emo- is probably due to their fear that they may never have
tional, bodily pain, general health, mental health and vi- children, indicating the effect of anxiety and depression
tality. However, in the present study, there were no on the mental health and quality of life.
significant differences between two groups in physical If a woman has a recurrent abortion, the quality of life
function and bodily pain. This difference could be due of the affected woman decreases, while having a child may
to the different status of the participants in the study be- increase mental health and general health perceptions
cause both groups of participants in mentioned study than other women with recurrent miscarriage. It has been
had been pregnant that due to the fear of the occurrence reported that the children-to-pregnancies ratio showed
of abortion, their physical function has been limited and a significant associate with the mental health and sleep
physical bodies have been created physical pain such as quality [11].
headaches that can be signs of anxiety. Another study
showed that women with recurrent abortions had a low Limitations
score in mental health and physical health [11]. The descriptive nature of the study could be regarded
In the present study, the findings indicated that indi- as a limitation. In addition we did not collect data on
viduals with recurrent miscarriage experienced more many confounding factors that might influence the results.
anxiety than those without a history of recurrent miscar- For instance we did not collect data on socioeconomic back-
riage. Similarly, Couto et al. [9] using the HADS found grounds of women or data on some important reproductive
that anxiety level in women with a history of unsuccess- information including gestational age at miscarriage, and
ful pregnancy was higher than that of control group. history of infertility. For future studies a better study design
Other studies showed that two or more miscarriages and a thorough collection of data are recommended.
were correlated with higher levels of state anxiety during
pregnancy [12]. Conclusion
It has been reported that women with a history of mis- The findings from this study indicated that women with re-
carriage showed higher levels pregnancy-related anxiety, current miscarriage suffer from sub-optimal health-related
but studies cannot consistently suggested whether these quality of life and experience higher level of anxiety and
psychological disorders remain via the subsequent preg- depression as compared to women without history of mis-
nancy [2, 5, 13]. carriage. The findings have some implications for prenatal
Mevorach-Zussman et al. [11] found that all women care delivery.
with recurrent miscarriage showed mild to moderate anx-
iety levels and these results indicate that women after ex- Abbreviations
HADS: Hospital Anxiety and Depression Scale; QOL: Quality of life; SD: Standard
periencing recurrent miscarriage, if they do not undergo a Deviation; SF-36: Short Form Health Survey
new pregnancy or women who were pregnant subsequent
to a miscarriage, may suffer higher rate of anxiety in com- Acknowledgements
parison with those without such experiences. High levels The authors are grateful to participant who made this study possible.

of anxiety can lead to a decreased quality of life and per- Funding

haps can be a factor for spontaneous abortion in subse- Tehran University of Medical Sciences financially supported the project.
quent pregnancies or premature birth.
Availability of data and materials
In the present study, the rate of depression increased
A minimal set of data is available from the corresponding author on request.
more markedly in recurrent miscarriage group, as com-
pared to that of the control group. Couto et al., reported Authors’ contributions
that the rate of depression in pregnant women with pre- ZT performed the research, designed the study and wrote the first draft; MM,
AT, AM, ME and LKH, collected clinical data and clinical interpretation,
vious adverse pregnancy was more than that of control participated in literature search, and drafted the manuscript, analyzed the
group women which is consistent with our study results data and read and revised the paper. AM: was involved in drafting, reviewing
[10]. Blackmore et al., [14] found that previous recurrent the manuscript and gave the final approval for publication. All authors read
and approved the final manuscript.
pregnancy loss might be a predictor of perinatal depres-
sion. Depression not only can harden patients’ living con- Ethics approval and consent to participate
ditions but also affects the quality of life by reducing The study was approved by the Tehran University of Medical Science. All research
activities were performed in accordance with the Declaration of Helsinki.
vitality, mental health, general health perceptions and so-
cial role functioning. Therefore, the quality of life of these Consent for publication
patients may be improved by eliminating depression. Not applicable.
Tavoli et al. Health and Quality of Life Outcomes (2018) 16:150 Page 5 of 5

Competing interests
The authors declare that they have no competing interests.

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Author details
1
Department of Obstetrics and Gynecology, School of Medicine, Tehran
University of Medical Science, Tehran, Iran. 2School of Medicine, Tehran
University of Medical Sciences, Tehran, Iran. 3Department of Psychology,
Faculty of Educational Sciences and Psychology, Alzahra University, Tehran,
Iran. 4Department of Psychiatry, School of Medicine, Tehran University of
Medical Science, Tehran, Iran. 5Department of Community Medicine, School
of Medicine, Tehran University of Medical Science, Tehran, Iran. 6Population
Health Research Group, Health Metrics Research Centre, Iranian Institute for
Health Sciences Research, ACECR, Tehran, Iran.

Received: 15 April 2018 Accepted: 23 July 2018

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