Abstract
Objectives:
To investigate whether adverse childhood experiences are associated with miscarriage.
Methods:
The Gulf Resilience on Women’s Health Consortium recruited from clinics and community organizations in Southern Louisiana, 2011-2016. Data from 1511 reproductive-aged women with at least one pregnancy were analyzed. Adverse childhood experiences including abuse, neglect, and family dysfunction, as a child (< age 12), and as an adolescent (12-17), were assessed. Outcome measures were self-reported miscarriage at first pregnancy and at any pregnancy, analyzed with logistic regression with adjustment for maternal age at pregnancy, race, BMI, education, marital and smoking status.
Results:
Women reporting four or more adversities as a child and as a teen had higher odds of experiencing miscarriage at first pregnancy (AORchild = 1.71, 95% CI: 1.00 – 2.90; AORteen = 1.73, 95% CI: 1.05 – 2.87) and miscarriage at any pregnancy (AORchild = 1.74, 95% CI: 1.16 - 2.62; ORteen = 1.65, 95% CI: 1.10 - 2.45) compared to those with no adverse childhood experiences. Similar patterns of association were seen for other ACE sub-categories.
Conclusions:
Childhood adversities were associated with miscarriage. Further research is needed on the pathways which created this association, including psychological, behavioral, and physiological mechanisms and factors which can mitigate the effects of these outcomes.
Keywords: Abortion, spontaneous, adverse childhood experiences, adolescent, child
Introduction
Miscarriage is both a common and distressing pregnancy outcome that is influenced by a multifactorial set of complex, interrelated physiological and biological mechanisms . Approximately 10 – 15% of clinically confirmed pregnancies end in recognized miscarriage, defined as a pregnancy loss prior to completion of 20 weeks’ gestation (1,2). Environmental factors such as social adversities, economic insecurities, lifestyle stressors, and behavioral choices have beenshown to have a considerable impact (3), in addition to well-established biological factors such as uterine malformations and parental balanced chromosomal translocations (4, 5).
Studies have demonstrated associations between psychosocial stressors during pregnancy (6) and poor pregnancy outcomes in women exposed to stressful life events in childhood (3, 7). Previous research in the life course perspective acknowledges the influence of the socially patterned exposures during childhood and adolescence on health outcomes in adulthood.(8) Studies of Adverse Childhood Experiences (ACE) integrate this life-course perspective to assess the effects of childhood exposure to adverse events on numerous detrimental adulthood outcomes, including adolescent pregnancy, fetal death (9), unintended pregnancy(10), neurodevelopment deficits (11) and depressive disorders (12). Adults who are exposed to ACE are more likely to adopt behaviors such as smoking(13), illicit drug use(14), and alcohol abuse (15, 16).
ACE studies have found a graded relationship between number of ACE and poorer health outcomes following exposure to adverse childhood events in 10 ACE areas: physical abuse, verbal abuse, sexual abuse, physical neglect, emotional neglect, parental substance use, parental domestic violence, household criminal activity, household mental illness, and familial separation (16–18). ACE in the form of physical and sexual abuse has also been identified as a risk factor for repeat induced abortions (19, 20). Moreover, history of early childhood adversities has also been associated with increased risk of acquiring subsequent sexually transmitted diseases due to adoption of risky sexual behavior (21). Psychosocial stress arising from multiple sources across women’s course of life could contribute to unfavorable pregnancy outcomes. Adversities earlier in life might also alter adult health outcomes through persistent activation of the inflammatory pathways in response to stress signals, disrupting the neuroendocrine pathways. In addition to psychosocial stressors, lifestyle and health behaviors that are associated with ACE, such as alcohol consumption and smoking during pregnancy(22–24), may contribute to a cumulative increase in risk of miscarriage or other complications.
Capitalizing on this perspective, the present study hypothesizes that women who are exposed to higher adverse experiences in childhood (prior to age 18 years) would have higher risk of miscarriage than those who are not exposed to ACE. Thus, the primary aim of this study is to explore the contribution and influence of adverse experiences such as abuse, neglect and parental substance use as a child (<12 years) and/or as an adolescent (12-17 years) on miscarriage at first pregnancy (MFP) and miscarriage at any pregnancy (MAP).
Methods
Data for the present study were derived from “The Deepwater Horizon Disaster, Lifetime Adversity and Reproductive Aged Women” study conducted as part of the Gulf Resilience on Women’s Health (GROWH) Consortium at Tulane University, New Orleans, Louisiana. Women were recruited between December 2011 and December 2016 from prenatal, health, and WIC clinics; day care centers; and community events and gathering places in southeastern Louisiana (targeting Lafourche, Plaquemines, St. Bernard, Terrebonne, and the West Bank of Jefferson and Orleans Parishes). Eligibility criteria include: aged 18-45, living in the Gulf area during the oil spill, and, if pregnant, carrying a singleton gestation. Women were interviewed, completed a questionnaire (usually on the spot, although taking it home and returning it by mail was allowed), and provided saliva and blood samples. The purpose of this study was expressed as “to determine how social and environmental hardship affect the mental and physical health of reproductive-aged women.” From the total sample of 1511 women who reported at least one pregnancy, a sample of 1225 and 1374 women were analyzed for MFP and MAP respectively. The study was approved by the Institutional Review Board of Tulane University.
Outcome Measures
Cohort members were asked if they had ever been pregnant, and, if so, the outcome of each pregnancy (miscarriage, abortion, stillbirth, livebirth, molar/ectopic) in order. In addition, the gestational age when pregnancy losses occurred or the pregnancy ended was recorded (25). Two primary outcomes of interest in this analysis - MFP and MAP were defined based on these self-reports of pregnancy history.
Both the outcomes were dichotomized as using women who had a livebirth at first pregnancy as the reference group for MFP and other women who reported at least one pregnancy, regardless of outcome, as the reference group for MAP. Women included in the MFP group were also included in the MAP group.
Exposure Measures
Multiple forms of adverse experiences prior to age 18 years were ascertained by administering the ACE Survey during an in-person interview. The ACE survey was adapted from the Family Health History Questionnaire developed by Kaiser Permanente, in conjugation with the Centers for Disease Control and Prevention (CDC), in the original CDC-Kaiser ACE Study (17)(20). For the present study the questionnaire was modified to assess variety of childhood adverse experiences including abuse (physical, sexual, emotional), neglect (physical, emotional), family dysfunction (exposure to domestic violence, parental substance abuse, household mental illness, parental separation/divorce, and incarceration of family members) at different life stages: as a child prior to age 12 and as an adolescent, 12-17 years of age. Since adverse experiences are highly interrelated, ACE score domains were used as a measure of cumulative exposure and affirmative responses from all items in the ACE sub-categories were summed to calculate overall adversity score as child (<12 years) and as an adolescent (12-17 years). The maximum adversity score possible for the ACE survey questions was 32 (16 each for sum of ACE as child and as a teen). domain f scores included sum of: sexual abuse, physical abuse (excluding a question on spanking, which was normative in the population), emotional abuse, parental substance abuse and neglect. Scales were categorized for analysis, separating those who reported 0 experiences and creating roughly equal numbers for higher categories: overall adversity score was the overall score was categorized as high adversity (4 or more ACE domains), low adversity (1-3 ACE domains) and none (0 ACE domain), while other domains were categorized into 3+, 1-2, and 0, except for sexual abuse and parental neglect, which were dichotomized as none/any.
Covariates
Potential covariates such as maternal age at pregnancy, race, BMI, education, marital status, and smoking were examined for confounding effects based on existing literature and prior knowledge of factors associated with adverse experiences in childhood (9, 18, 19). Age at first pregnancy was used as a variable for outcome 1 - MFP and age at most recent pregnancy was used for outcome 2 - MAP. Because miscarriage is strongly associated with older age at pregnancy, the MAP analysis was adjusted for age at oldest pregnancy rather than age at first pregnancy. Age at pregnancy was assessed using self-reported age in years for question – “When was the first time you got pregnant?”, or from the reported date of first pregnancy, from the pregnancy history module of the questionnaire. Self-reported race/ethnicity was categorized as black non-Hispanic vs. other. Likewise, self-reported values for current (for non-pregnant) and pre-pregnant BMI were collected from study participants. Highest level of education completed was classified as high school or less, some college or associate degree and college or more. Marital status was classified into 2 categories: married or living with partner vs. separated, widowed and/or never married at the time of the interview. Smoking status was classified as smoker if any cigarette use was reported in past 2 years.
Statistical Analysis
Socio-demographic characteristics of the study participants were compared using t-tests for continuous variables and chi-square tests for categorical variables for both outcomes.
Logistic regression analysis was used to examine the relationship between ACE and the two outcomes, MFP and MAP. For both outcomes, 2 models were run: model 1 (unadjusted for any covariates) and multivariable model 2 (adjusted for age at first pregnancy, race, BMI, education, marital status, and smoking status for – MFP, and age at last pregnancy, race, BMI, education, marital status, and smoking status adjusted for – MAP). For outcome 1 – MFP, 286 cohort members (18.9 %) and for outcome 2 – MAP, 137 cohort members (9.1 %) were missing data for at least 1 confounding variable or adverse experiences category. For the purpose of this analysis, these missing records were excluded and only complete records were analyzed for both the outcomes among women who reported at least 1 pregnancy. From the total sample of 1511 women who reported at least one pregnancy, a sample of 1225 and 1374 women were analyzed for MFP and MAP respectively. The analysis includes all pregnancies, regardless of timing; an analysis limited to pregnancies occurring at age 18 or later did not change results (Table S1).
All analyses were completed using SAS version 9.4. A two-sided p-value <0.05 was considered statistically significant for all analyses.
Results
The mean age of the women in our sample was 20.3 ± 4.4 years at their first pregnancy and 26.2 ± 5.3 years at their last pregnancy. Among the cohort of women analyzed for MFP, 63.3 % women identified themselves as black, non-Hispanic and about half (53.8%) reported being a high school education.
Comparative analysis of the socio-demographic characteristics of participant women comparing those who had experienced MFP or MAP to those who had not (Table 1) showed women who identified as black non-Hispanic had significantly lower number of MFP or MAP. Similarly, women with a history of MFP or MAP were more likely to be married rather than living with partner, separated, widowed or never married. Differences in smoking status in the past 2 years were significant, with 37% of women who had MFP smoked in comparison to 28% of those who did not (p=0.04). No significant differences were seen between the two groups for education.
Table 1.
Socio-demographic characteristics and self-reported pregnancy outcome: miscarriage in reproductive aged participating woman of southern Louisiana
| Miscarriage at first pregnancy | Miscarriage at any pregnancy | |||||
|---|---|---|---|---|---|---|
| Variable | Yes (128) | No (1097) | p value | Yes (254) | No (1120) | p value |
| Age at first pregnancy, Mean (SD), yrs | 21.1 (6.2) | 20.2 (4.2) | 0.02 | - | - | |
| Age at last pregnancy, Mean (SD), yrs | - | - | 28.04 (5.9) | 25.9 (5.08) | <.0001 | |
| BMI, kg/m2, Mean (SD) | 32.2 (9.1) | 30.7 (8.6) | 0.06 | 31.8 (10.1) | 30.4 (8.20) | 0.02 |
| Marital status, N (%) | 0.03 | <0.01 | ||||
| Married | 44 (34.4) | 279 (25.4) | 82 (32.3) | 260 (23.2) | ||
| Living With Partner, Separated, Widowed, Never Married | 84 (65.6) | 818 (74.6) | 172 (67.7) | 860 (76.8) | ||
| Race Categories, N (%) | <0.01 | <0.01 | ||||
| Black, non-Hispanic | 66 (51.6) | 710 (64.7) | 139 (54.7) | 735 (65.6) | ||
| Other | 62 (48.4) | 387 (35.3) | 115 (45.3) | 385 (34.4) | ||
| Education, N (%) | 0.32 | 0.90 | ||||
| High School or less | 62 (48.4) | 597 (54.4) | 132 (52.0) | 597 (53.3) | ||
| Some college/associates | 54 (42.2) | 427 (38.9) | 102 (40.2) | 442 (39.5) | ||
| College or more | 12 (9.4) | 73 (6.7) | 20 (7.9) | 81 (7.2) | ||
| Smoked in last 2 years, N (%) | 0.04 | 0.02 | ||||
| Yes | 47 (36.7) | 308 (28.1) | 88 (34.65) | 305 (27.2) | ||
| No | 81 (63.3) | 789 (71.9) | 166 (65.35) | 815 (72.8) | ||
| ACE (all), Mean (SD) | 5.91 (5.5) | 4.77 (5.5) | 0.03 | 5.58 (5.33) | 4.83 (5.6) | 0.05 |
| ACE as a child, categories, N (%) | 0.05 | <0.01 | ||||
| High (4+) | 42 (32.8) | 283 (25.8) | 78 (30.71) | 293 (26.2) | ||
| Low (1-3) | 60 (46.9) | 483 (44.0) | 126 (49.61) | 488 (43.6) | ||
| None (0) | 26 (20.3) | 331 (30.2) | 50 (19.69) | 339 (30.3) | ||
| ACE as teen, categories, N (%) | 0.01 | 0.02 | ||||
| High (4+) | 46 (35.9) | 265 (24.2) | 77 (30.31) | 278 (24.8) | ||
| Low (1-3) | 52 (40.6) | 505 (46.0) | 123 (48.43) | 511 (45.6) | ||
| None (0) | 30 (23.4) | 327 (29.8) | 54 (21.26) | 331 (29.6) | ||
Maximum ACE score = 32, range for sum of ACE as child and as teen = 0-16
Reference for Outcome 1 - Miscarriage at first pregnancy: Women who had a live birth at first pregnancy
Reference for Outcome 2 - Miscarriage at any pregnancy: Women who reported at least one pregnancy with another outcome
ACE, Adverse Childhood Experiences Scale
SD - Standard Deviation
Median adverse childhood events experienced by women with MFP (4.0 vs 2.0) and MAP (4.0 vs 3.0) were higher compared to women who did not have miscarriage. Women with MFP were significantly more likely to report at least 1-3 (low) or more than 4 (high) adverse experiences as child (46.9% for low versus 32.8% for high versus 20.3% for none, p = 0.05) and as teen (40.6% for low versus 35.9% for high versus 23.4% for none, p=0.01) compared to those who did not have MFP. A similar pattern was observed among women who reported MAP.
All ACE measures examined were associated with increased odds of MFP, with odds ratio (OR) ranging from 1.04 to 2.17 (Table 2). Overall, for each additional adverse event experienced, the odds of MFP increased by 4% (OR=1.04, 95% CI: 1.00 - 1.07) and odds of MAP by 2% (OR=1.02, 95% CI: 1.00 - 1.05). Women who experienced high (4+) adversities as a child (ORchild = 1.89, 95% CI: 1.13 – 3.16) and as a teen (ORteen = 1.89, 95% CI: 1.16 – 3.08) were more likely to experience MFP. A similar association (ORchild = 1.58, 95% CI: 0.98 – 2.56) was observed among women who experienced low (1-3) adversities during childhood (<12 years) and as a teen (ORteen = 1.12, 95% CI: 0.70 - 1.80) and MFP as compared to those with none adversities experiences. These estimates were attenuated in multivariable analysis; however, the pattern of association still existed. The association remained significant for high (4+) levels of adversities experienced both as child (AORchild = 1.71, 95% CI: 1.00 – 2.90) and as teen (AORteen = 1.73, 95% CI: 1.05 – 2.87).
Table 2.
Association between Adverse Childhood Experiences: Miscarriage at first pregnancy and Miscarriage at any pregnancy - Results of Logistic Regression
| Miscarriage at first pregnancy (N=1225) | Miscarriage at any pregnancy (N=1374) | |||
|---|---|---|---|---|
| ACE Score Categories | Unadjusted OR | Adjusted OR a | Unadjusted OR | Adjusted OR b |
| ACE (all) | 1.04 (1.00 - 1.07) | 1.03 (1.00 - 1.06) | 1.02 (1.00 - 1.05) | 1.02 (0.99 - 1.04) |
| ACE as child (all) | 1.06 (1.00 - 1.13) | 1.05 (1.00 - 1.12) | 1.04 (1.00 - 1.09) | 1.03 (0.99 - 1.08) |
| ACE as teen (all) | 1.07 (1.01 - 1.14) | 1.06 (1.00 - 1.13) | 1.05 (1.00 - 1.10) | 1.04 (0.99 - 1.09) |
| ACE as a child domains | ||||
| High (4+) | 1.89 (1.13 - 3.16) | 1.71 (1.00 - 2.90) | 1.81 (1.23 - 2.66) | 1.74 (1.16 - 2.62) |
| Low (1-3) | 1.58 (0.98 - 2.56) | 1.49 (0.91 - 2.42) | 1.75 (1.23 - 2.50) | 1.79 (1.24 - 2.60) |
| None (0) | Ref | Ref | Ref | Ref |
| ACE as a teen domains | ||||
| High (4+) | 1.89 (1.16 - 3.08) | 1.73 (1.05 - 2.87) | 1.70 (1.16 - 2.49) | 1.65 (1.10 - 2.45) |
| Low (1-3) | 1.12 (0.70 - 1.80) | 1.07 (0.66 - 1.73) | 1.48 (1.04 - 2.09) | 1.48 (1.04 - 2.12) |
| None (0) | Ref | Ref | Ref | Ref |
| Abuse | ||||
| Sexual | 1.64 (1.04 - 2.58) | 1.49 (0.94 - 2.37) | 1.36 (0.96 - 1.94) | 1.17 (0.81 - 1.68) |
| Physical (Spanking not included) | ||||
| High (3+) | 1.95 (1.23 - 3.08) | 1.88 (1.17 - 3.00) | 1.40 (0.99 - 1.98) | 1.37 (0.96 - 1.96) |
| Low (1-2) | 2.17 (1.41 - 3.34) | 2.06 (1.33 - 3.20) | 1.77 (1.29 - 2.45) | 1.75 (1.26 - 2.43) |
| None (0) | Ref | Ref | Ref | Ref |
| Emotional | Ref | |||
| High (3+) | 1.97 (1.31 - 2.95) | 1.78 (1.18 - 2.70) | 1.60 (1.17 - 2.16) | 1.44 (1.05 - 1.98) |
| Low (1-2) | 1.33 (0.80 - 2.23) | 1.22 (0.73 - 2.07) | 1.16 (0.80 1.70) | 1.04 (0.71 - 1.54) |
| None (0) | Ref | Ref | Ref | Ref |
| Parental Neglect | 1.22 (0.80 - 1.86) | 1.12 (0.73 - 1.74) | 1.17 (0.85 - 1.61) | 1.10 (0.79 - 1.52) |
| Parental Substance Use | ||||
| High (3+) | 1.45 (0.83 - 2.53) | 1.33 (0.75 - 2.35) | 1.17 (0.75 - 1.83) | 1.11 (0.70 - 1.75) |
| Low (1-2) | 1.33 (0.84 - 2.11) | 1.22 (0.76 - 1.96) | 1.48 (1.06 - 2.07) | 1.46 (1.03 - 2.08) |
| None (0) | Ref | Ref | Ref | Ref |
Maximum ACE score = 32, range for sum of ACE as child and as teen = 0-16
- adjusted for Age at 1st Pregnancy, BMI, Education, Race, marital status and Smoking status
- adjusted for Age at last Pregnancy, BMI, Education, Race, marital status and Smoking status
Reference for Outcome 1 - Miscarriage at first pregnancy: Women who had a live birth at first pregnancy
Reference for Outcome 2 - Miscarriage at any pregnancy: Women who reported at least one pregnancy with another outcome
All values in bold are significant at p<0.05
Adversities experienced in the form of physical abuse (both high and low) and higher levels of emotional abuse were most strongly associated with both the outcome measures.
Discussion
Our analysis shows strong evidence of graded association between increasing number of adversities endured as a child or teen assessed in the form of adversity scores and miscarriage among women of reproductive age. Women reporting four or more ACEs as a child and as a teen were found to be at 1.9-fold higher odds of experiencing MFP and over 1.7-fold higher odds of experiencing MAP, without adjusting for covariates. Our findings extend the work of previous studies documenting a relation between adverse experiences prior to age 18 and reproductive health, by exploring the impact on miscarriage. Adjustment of potential confounders weakened but did not eliminate associations. While these results are consistent with previous work showing associations between childhood adversities and other birth outcomes such as gestational age, birthweight (7, 26), and spontaneous preterm birth (27), some studies of stillbirth have yielded mixed findings, documenting an association between childhood maltreatment and stillbirth only for the emotional neglect subscale (28).
Findings from the present study also suggest that certain types of adverse experiences may have greater impact on pregnancy outcomes than others. Adverse experiences of abuse in physical and emotional form as a child or as teen were found to be significantly associated with miscarriage. For other ACE domains such as sexual abuse, parental neglect, or substance use, the associations were not statistically significant; however, the pattern of association was similar. These results are consistent with a previous study of Michigan women which found increased odds of miscarriage with adversities exposure across life course, particularly legal stressors occurring during both childhood and adulthood(29). However, this study found no strong associations between childhood abuse, loss, economic problems, or substance use; and miscarriage. The effect sizes were similar for overall number of adversities and miscarriage in this and our study. Whether specific ACE are particularly problematic for pregnancy health remains to be determined, and may vary by population.
While childhood adversities can be related to miscarriage via a complex matrix of interrelated pathways, psycho-neuro-immunological pathways and stress have been suggested to be involved in triggering miscarriages (30). The latest research in this area integrated this biosocial approach to further explain a mechanism through which adverse experiences over the life course could possibly influence critical regulatory neurological and immune dynamics (31). Cytokines secreted in response to stress signals provide biological plausibility to the idea that the cumulative stress could increase risk of miscarriage via disrupting the neuroendocrine pathway. Additionally, exposure to childhood stress may be responsible for long-term physiological alterations in the form of neuroendocrine (30) or immunological disruptions (32, 33) resulting from hyperactivity of the hypothalamic-pituitary-adrenal and sympatho-adrenal-medullary axes, and persistent activation of these inflammatory pathways could be one of the mechanisms through which adverse experiences in early life may alter adult health outcomes(22, 34). The psychological stressors created by the adversities earlier in childhood may also be responsible for altered sexual behavior, contributing to subsequent increased risk of acquiring sexually transmitted infections (21, 35), thereby increasing odds of negative pregnancy outcomes.
Although our study employed robust methods including a standardized protocol and structured questionnaire for data collection, some limitations should be noted. First, a potential weakness with retrospective reporting of childhood experiences is recall bias, due to difficulty in recalling certain events; reporting is largely influenced by the age (36) at which the event occurred and its perceived severity and impact on the study participant. Nevertheless, in spite of this, research using retrospective study designs is still considered to be a valuable tool and a validated measure of collecting data related to early childhood experiences was used(37, 38). A second limitation is that the outcome measures were self-reported by the study participants. However, since not all miscarriages, especially the early ones, necessarily require medical treatment, even medical records data is largely self-reported. Validation studies of self-report have also found reasonable if not excellent agreement with medical records and prospective data (39) with late miscarriages being particularly well-reported (40). Third is the increased propensity of some women to recall and report negative experiences, possibly creating a spurious association between ACE and miscarriage.
Although we adjusted for potential confounders, we were not able to exhaustively include some possible confounders. We adjusted for recent smoking (past 2 years) but did not necessarily have information on smoking at the time of the miscarriage; a similar concern can be expressed about BMI and marital status. Median time since first pregnancy in the cohort was 7 years and since last pregnancy was 1 year, so the potential for bias is stronger for the analysis of first pregnancy. Our experience is that women often do not admit to alcohol or other substance abuse during pregnancy, so the questionnaire did not include details about these two behavioral factors. To the extent that these are risk factors for the outcome, adjustment would reduce the association. While mild-moderate use of alcohol is probably not a strong risk factor for spontaneous abortion (23), ACE causing substance use, including early-pregnancy smoking, leading to miscarriage would be a true association, albeit one mediated by a behavioral factor. In this case, mediation analysis would be required to thoroughly assess the indirect and direct effects. Similarly, women who experience ACE may be at higher risk for adverse or traumatic experiences as adults (41), which may be preconception causes or even short-term triggers of miscarriage. We did not have detailed enough information about timing of traumatic events to assess this possibility.
The study is a convenience sample, originally intended to examine exposure to the Gulf oil spill and reproductive outcomes, and women who agreed to participate may have had a particular concern about the oil spill. However, our analyses of this sample do not indicate extensive exposure to the oil spill, or associations between oil spill exposure and miscarriage (25). The study population primarily included women with a relatively young age at first pregnancy, low-income women, and non-Hispanic African-American women, who may have particular childhood experiences and reproductive history that is not be completely generalizable to other populations. However, as studies with preconception information on miscarriage often focus on older and white women (42), this study provides valuable information about a different population.
Collectively, our findings indicate that adversities experienced prior to age 18 have an enduring impact on pre-conception health of women. Implications of these findings for practice and policy include the possibility that the associations between ACE and other reproductive outcomes, such as adolescent pregnancy, induced abortion (19), and pregnancy complications (9), may be underestimated, if miscarriage acts as a competing risk.
While this association may be governed by multiple webs of socio-economic and individual behavioral factors, recent research in this area has helped in further clarifying various mechanisms underlying this association between childhood adversities and pregnancy outcomes. Future studies and interventions should also look at potential mitigating or resilience factors, such as family support, that can be encouraged by practitioners or policy (43). These new insights offer prospects for developing novel and tailored clinical and public health interventions to promote women’s psychological and reproductive wellbeing.
Supplementary Material
Acknowledgments
Funding: This research was supported by NIH grant U19 ES020677 and the Baton Rouge Area Foundation.
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
None of the authors have a conflict of interest.
Data availability: Data is available to qualified researchers by request of the authors and signing of appropriate data use agreements.
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