Self-Protective Behaviors among Pregnant Women regarding Spontaneous Abortion

Background: Spontaneous abortion is considered a main reproductive health issue acts as a risk factor for pregnant women's welfare and a prominent component of maternal mortality statistics. Knowledge and self-protective behaviors among pregnant women regarding spontaneous abortion are very important. The aim of this study: was to identify knowledge and self-protective behaviors among pregnant women regarding spontaneous abortion. Subjects and Method: A descriptive study design was used. The study was conducted in Egypt at the out-patients' clinics of obstetrics departments of Tanta University Hospitals affiliated to Ministry of High Education and Scientific Research and El-Menshawy General Hospital affiliated to Ministry of Health and Population. A purposive sample of 200 pregnant women who had past history of spontaneous abortion was selected from the previously mentioned settings. Two tools were used for data collection; Tool 1: Pregnant women's knowledge regarding spontaneous abortion, Tool 2: Women self-protective behaviors regarding spontaneous abortion. Results: The finding of the present study revealed that the majority of the studied pregnant women had low level of knowledge and three quarters of them had negative self-protective behaviors regarding spontaneous abortion. Conclusion: There are highly statistical significant relationships between women's age at marriage, educational level, occupation and their knowledge regarding spontaneous abortion. Additionally, no significant relationship exists between knowledge and self-protective behaviors regarding spontaneous abortion among the studied pregnant women. Recommendations: Implementation of continuous educational programs for pregnant women and newly appointed health care providers regarding self-protective behaviors of spontaneous abortion, and encouragement of early and regular antenatal care.


Introduction
Spontaneous abortion is defined as the loss of pregnancy naturally before the 20 th week of gestation, or if the fetus is less than 500 grams, or his/her length is less than 25 cm (Dugas & Slane, 2022;Eldabae, 2019;Mansour, Alabiad, & Hamed, 2021).According to National Health Service, spontaneous abortion occurs in at least 15-20% of pregnancies (Zakira & Hardianto, 2021).The reasons of spontaneous abortion are varied and can be caused by many factors.The most common cause for firsttrimester abortions is chromosomal abnormalities and placental abnormalities.(Abdelghani, Mahdi, Abohashim, & Alqaed, 2023;Zakira & Hardianto, 2021).The reasons of the second trimester pregnancy loss are more likely due to maternal conditions, for example incompetent cervix, congenital or acquired anomaly of the uterine cavity, hypothyroidism, diabetes mellitus, and chronic nephritis.In addition to consumption of crack cocaine, inherited and acquired thrombophilias, lupus, and acute infection (Abdelghani et al., 2023;Franjic, 2021;Pun, Silwal, Poudel, & Panthee, 2021;Zakira & Hardianto, 2021).The main types of abortion identified by Royal College of Obstetrics and Gynecology (RCOG) are threatened miscarriage, inevitable miscarriage, incomplete miscarriage, full miscarriage, missed and recurrent miscarriage (AI-Eidan, Alghaneem, AlMosfer, & AlZahrani, 2017; Nanko & Mari, 2022).Although the reason of the most of pregnancy loss is usually out of a woman's control, the pregnant woman is having a chance for successful pregnancy by improving their knowledge and following a healthy lifestyle during pregnancy regarding spontaneous abortion.Changing unhealthy lifestyle to a healthy one is crucial during pregnancy.Pregnant women can follow a healthy lifestyle through eating healthy diet and avoiding eating preserved foods, avoiding obesity, smoking, caffeine, lifting heavy stuff, several climbing stairs and exposure to radiography.In addition, they can take folic acid daily, and monitor chronic diseases (Eldabae, 2019;Nguyen et al., 2022).The nurses must integrate their multidisciplinary professional roles for dealing with women suffering from spontaneous abortion.As nurses as a direct care provider must provide evidence based practice for caring of such women, and must keep in mind psychological status of these women (Bailey & Nevill, 2020).
Miscarriage is the biggest reproductive health crisis in the history of our species (Miller, 2023).Spontaneous abortion is one of the most common causes of maternal morbidity and mortality during reproductive period, especially in developing countries (Pun et al., 2021).Empowerment of the women is also a crucial strategy for decreasing maternal mortality through enhancement of their self-protective behaviors' education and early intervention because it allows them to make crucial decisions about their own health and take timely steps to access health care (Mwilike et al., 2018;Zaki, Fouad, & khedr, 2021).The aim of this study is to identify selfprotective behaviors among pregnant women regarding spontaneous abortion.Research Question: What are the selfprotective behaviors among pregnant women regarding spontaneous abortion?

Subjects and method
Study Design: A descriptive research design was used to conduct this study.Setting: The study was conducted in Egypt at the out-patients' clinics of obstetrics departments of: Tanta University Hospitals affiliated to Ministry of High Education and Scientific Research and El-Menshawy General Hospital affiliated to Ministry of Health and Population.Subjects: A purposive sample of 200 pregnant women was selected from the previously mentioned settings and fulfilling the following inclusion criteria; age ranged between 18-45 years old, past history of spontaneous abortion, at the first trimester of pregnancy, and with normal current pregnancy course (free from any medical or obstetrical complications).

Tools of data collection
To achieve the aim of this study the following two tools were used.-After collecting the required data, an instructional brochure regarding spontaneous abortion was given to women up on their request to improve their knowledge regarding spontaneous abortion.
-Data collection was carried out over a period of six months started from the start of May 2023 until the end of October 2023

Statistical analysis
The collected data were coded, entered, tabulated and analyzed using SPSS (Statistical Package for Social Science) version 25 (IBM Corporation, Armonk, NY, USA).For quantitative data, the range, mean and standard deviation were calculated.For qualitative data, which describe a categorical set of data frequency, percentage or proportion of each category was calculated.For comparison between means of two groups of non-parametric data of independent samples, Z value of Mann-whitney test was used.For comparison between more than two means of non-parametric data, Kruskal-Wallis ( 2 ) was calculated.Correlation between variables was evaluated using Pearson's correlation coefficient (r).Significance was adopted at p<0.05 for interpretation of results of tests of significance (Dawson & Trapp, 2001)

Table (1):
Shows bio-socio-demographic characteristics of the studied pregnant women with past history of spontaneous abortion.It reveals that the age of slightly less than three quarters (71.0%) of the studied pregnant women ranged from 19 to 39 years with a mean age 27.37±4.20.Concerning their residence, it was noticed that the majority (93.0%) of the studied pregnant women were from rural areas, the entire sample (100.0 %) were married, and slightly more than one-half (55.5%) of them were married at the age of 15-20 years.As regards to the educational level, it was reported that slightly less than onehalf (45.5 %) of the studied pregnant women had secondary school education.It was also observed that slightly more than three quarters (77.5%) of the studied pregnant women were housewives.

Figure (1):
Illustrates frequency distribution of past spontaneous abortions among the studied pregnant women with abortion.It demonstrates that slightly less than four fifths (79.5 %) of the studied pregnant women had one previous abortion, and slightly less than one fifth (16%) of them had two abortions.Table (2): Reports the mean score of the studied pregnant women's knowledge regarding spontaneous abortion.It reveals that the total mean score of the studied pregnant women's knowledge was (2.61±1.68).

Table (3):
Displays the mean score of the studied pregnant women's self-protective behaviors during pregnancy regarding spontaneous abortion.It presents that eating more vegetables had the first rank of self-protective behaviors during pregnancy with a mean 1.63±1.46,and the total mean score was 23.99±8.83.

Figure (2):
Exemplifies the total score level of the studied pregnant women's knowledge regarding spontaneous abortion.It proves that the majority (93.5%) of the studied pregnant women had low level of knowledge regarding spontaneous abortion, compared to only (6.0% and 0.5% respectively) of them who exhibited moderate and high level of knowledge regarding spontaneous abortion.

Figure (3):
Elucidates the total score level of the studied pregnant women's self-protective behaviors during pregnancy regarding spontaneous abortion.It clarifies that exactly three quarters (75.0%) of the studied pregnant women had negative self-protective behaviors during pregnancy regarding spontaneous abortion, and only one quarter (25.0%) of them had positive selfprotective behaviors during pregnancy regarding spontaneous abortion.

Table (4):
Elucidates the relationship between total score level of the studied pregnant women's knowledge regarding spontaneous abortion and their bio-sociodemographic characteristics.It portrays that there was a highly statistically significant relationship between women's age at marriage, women's educational level, husband's educational level, women's occupation, husband's occupation family income from women's point of view and their total score level of knowledge regarding spontaneous abortion (p= 0.0001*, 0.0001*, 0.0001*, 0.003*, 0.0001* and 0.001* respectively).Conversely, there was no significant relationship between women's age, women's residence, the consanguinity between women and their husbands, type of family, number of family members and their total score level of knowledge regarding spontaneous abortion (p= 0.096, 0.103, 0.152, 0.068 and 0.067 respectively).
Table (5): Establishes the relationship between total score level of selfprotective behaviors of the studied pregnant women regarding spontaneous abortion and their bio-socio-demographic characteristics.It that there was a statistical significant relationship between women's educational level and their total score level of self-protective behaviors during pregnancy regarding spontaneous abortion (p=0.010*).It was also noticed that there was no statistical significant relationship between women's age, women's residence, age at marriage, husband's educational level, women's occupation and their total score level of self-protective behaviors during pregnancy regarding spontaneous abortion (p=0.713,0.321, 0.980, 0.282 and 0.641 respectively).Table ( 6): Shows the relationship between total score level of knowledge of the studied pregnant women regarding spontaneous abortion and their obstetric history.It exposes that there was a statistical significant relationship between women's parity, history of previous stillbirth, start of the first antenatal visit, place of current antenatal care and their total score level of knowledge regarding spontaneous abortion (P= 0.006*, 0.009*, 0.001* and 0.015* respectively).On the other hand, there was no statistical significant relationship between gravidity, history of previous preterm labor, history of previous low birth weight baby, number of antenatal visits during current pregnancy, number of previous abortions and their total score level of knowledge regarding spontaneous abortion (p=0.614,0.817, 0.515, 0.208 and 0.774 respectively).8): Explicates the relationship between the studied pregnant women's total score level of knowledge and their total score level of self-protective behaviors.It explains 93.5% had low level of knowledge, 6% had moderate level of knowledge, and 0.5% had high level of knowledge.The table also shows that 75.4% of the studied pregnant women who had low level of knowledge and 75 % of the studied pregnant women who had moderate level of knowledge had negative self-protective behaviors during pregnancy regarding spontaneous abortion, compared to only one pregnant woman (0.5%) who had high level of knowledge exhibited had positive selfprotective behaviors during pregnancy regarding spontaneous abortion.

Dscussion
Spontaneous abortion is one of the most common adverse pregnancy events that can cause great physical and psychological distress to couples.Approximately 10-20% of pregnancies result in a spontaneous abortion by the 13 th gestational week.It might be due to lack of knowledge, awareness and ignorance of some preventive steps (Singh, Gautam, & Jeyaseelan, 2023;Tyagi, Hamouda, Ateya, & Ali, 2021).Selfprotective behaviors during pregnancy can have significant impact on reducing pregnancy-related complications such as spontaneous abortion.So, healthy practices can positively affect the health condition of pregnant women and the development of their fetuses (Nguyen et al., 2022;Nurhasanah et al., 2020).
Clinical attention has mainly focused on the precautions and prevention of early pregnancy loss (Singh et al., 2023;Tyagi et al., 2021).However, inadequate studies were done to address self-protective behaviors of pregnant women regarding spontaneous abortion.Therefore, the present study was conducted to assess the knowledge and self-protective behaviors of pregnant women regarding spontaneous abortion.Concerning bio-socio-demographic characteristics of the studied pregnant women with previous history of spontaneous abortion, the findings of the present study revealed that the age of slightly less than three quarters of the studied pregnant women ranged from 19 to 39 years with a mean age 27.37±4.20.This finding comes in accordance with Pun et al., (2021) who reported that the mean age of the respondents was (28.36±6.07).Additionally, Chanomethaporn et al., (2018) mentioned that the mean age of the study participants was (28.5 ± 4.7).On the other hand, this finding is in disagreement with Klu (2022) who indicated that approximately less than Vol.33.No. 2 (Suppl 1) ,May 2024 two fifths of their respondents aged 30-39 years old.Additionally, Giotta, Bartolomeo, and Trerotoli, (2023) found that slightly less than one third of the study sample.Regarding place of residence, the current study revealed that the majority of the studied pregnant women were from rural areas.This result is strongly in agreement with Eldabae (2019) who found that the majority of the studied women were from rural areas, while it is contradicted with Ahmad & Kareem (2020) who revealed that less than three quarters of the respondents were from urban areas.Pertaining to the age at marriage, the current study indicated that slightly more than one-half of the studied pregnant women were married at the age 15-20 years.Similarly, Moradinazar et al., (2020) found that first marriage age is 16-20 years old in less than one-half of the participants in their study.In addition, Alam (2021) who assessed miscarriage and associated factors mentioned that less than one-half of their participants married at age 17 years and under.Conversely, Mekonnen and Awoke (2020) pointed out that slightly more than two fifths of the women had their first marriage at 20-24 years old in their study.Concerning the studied pregnant women's educational level, it was reported that slightly less than one-half of the studied pregnant women had secondary education.Similarly, is a study conducted by Omer, Elsheikh, Saeid, & Ali, (2022) to assess knowledge and attitude of recently aborted women in relation to family planning methods.They found that slightly more than one third of the studied women had secondary school education.On the other hand, this finding is dissimilar to Salama, Abou-Shabana, Attiat Allah, and Mohammed, (2020) who revealed that slightly more than one third of the women had high level of education in their study.Wassie, Lemlem, Boka, and Gelaw, (2019) also reported that slightly less than one-half of the study participants had illiterate mother in their study.Pertaining to the women's occupation, slightly more than three quarters of the studied pregnant women were housewives.This finding is consistent with Abd Elsalam, Wassif, Eltaieb, & Abou Talib, (2019) who reported that the majority of the women were not working.In contradiction with the current study are Dickson, Adde, & Ahinkorah, (2018) who revealed that slightly less than one third of the respondents were employed in their study of socioeconomic determinants of abortion among women in Mozambique and Ghana.As regard to number of previous spontaneous abortion, the current study revealed that slightly less than four fifths of the studied pregnant women mentioned that they had one previous abortion.Likewise, Abd Elsalam et al., (2019) reported that three quarters of the study subjects had one previous spontaneous abortion in their study.On contrast, Ticconi et al., (2020) revealed that slightly more than one-half of the women had ≥3 pregnancy losses in their study of Chinese traditional herbs enhanced the clinical efficacy of low-molecularweight heparin in the treatment of recurrent spontaneous abortion complicated with thrombophilia.
Regarding the total score level of knowledge among the studied pregnant women regarding spontaneous abortion, the current study noticed that the majority of the studied pregnant women had low level of knowledge regarding spontaneous abortion.From the researcher's point of view, the result of the present study may be attributed to the fact that the majority of the women in the current study were housewives, from rural areas and didn't attend any health education sessions/programs during antenatal visits regarding spontaneous abortion.Concerning to the total mean score of the studied pregnant women's knowledge regarding spontaneous abortion, the current study revealed that the total mean score of the studied pregnant women's knowledge was (2.61±1.68).This finding is in agreement with Nurhasanah et al., (2020) who conducted a study of a structure equation model examining self-care behavior toward pregnancy-related complication and their associated factors among women in Indonesia.They found that the average score of knowledge on self-care of pregnancy-related complications was 11.85 (SD = 1.98), with a range of 8 to 21 which shows that the knowledge of pregnant women about pregnancy-related complications was still low.Regarding the mean score of selfprotective behaviors during pregnancy of the studied pregnant women regarding spontaneous abortion, it was found that the total mean score was 23.99±8.83.This finding is dissimilar to Nurhasanah et al. (2020) who found that the pregnant women had moderate self-care behaviors with a mean ±SD of 156.5±16.91.Concerning the relationship between the studied pregnant women's total score level of knowledge and total score level of selfprotective behaviors.The current study revealed that there was no significant relationship between the total score level of knowledge and the total score level of selfprotective behaviors regarding spontaneous abortion among the studied pregnant women (p= 0.221).This finding is in line with Mu, He, Wang, and Wang, (2024) who revealed that there was no significant relationship between the total knowledge score level about pregnancy loss and practice toward pregnancy loss (p=0.310).Additionally, Nurhasanah et al., (2020) revealed that selfcare behaviors toward pregnancy-related complication was negatively associated with knowledge of pregnancy-related complications (p=0.26).Regarding the relationship between total score level of knowledge of the studied pregnant women regarding spontaneous abortion and their bio-socio-demographic characteristics, the finding of the present study revealed that there was no significant relationship between women's age and total score level of knowledge (p=0.096).This finding is similar to Chanomethaporn et al., (2018) who said that there is no significant relationship between miscarriage and age (p=0.61).The current study stated that there was a highly statistical significant relationship between women's knowledge regarding spontaneous abortion and their educational level, occupation, and family income (p= 0.0001*, 0.003* and 0.001* respectively).This finding is in agreement with Mu et al. (2024) who revealed that there was a significant relationship between women's knowledge about pregnancy loss and their educational level, occupation, and family income (p= p < 0.001*, 0.002* and < 0.001* respectively).Regarding the relationship between the total score level of self-protective behaviors of the studied pregnant women regarding spontaneous abortion and their bio-socio-demographic characteristics, the present study revealed that there was a significant relationship between self-protective behaviors during pregnancy regarding spontaneous abortion and their educational level (p=0.010*).However, there was no significant Vol.33.No. 2 (Suppl 1) ,May 2024 relationship between self-protective behaviors during pregnancy regarding spontaneous abortion and women's age and occupation, and husband's educational level (p=0.713,0.980, and 0.282 respectively).This result is in line with Gebremariam, Tesfai, Tewelde, Kiflemariam, and Kibreab, (2023) who reported that there was no significant relationship between total score level of self-protective behaviors during pregnancy and the respondents' age in (years), husband's education, level of education, and women's occupation (0.083, 0.469, and 0.872 respectively).As regard to relationship between the total score level of knowledge of the studied pregnant women regarding spontaneous abortion and their obstetric history, the current study showed that there was a significant relationship between women's parity and their total score level of knowledge regarding spontaneous abortion (P= 0.006*).This finding is dissimilar to Mu et al. (2024) who revealed that there was no significant relationship between women's times of previous live births and their knowledge score about pregnancy loss (P= 0.146).On the other hand, the current study showed that there was no significant relationship between number of previous abortions and their total score level of knowledge regarding spontaneous abortion (p= 0.774).This finding is in line with Mu et al. (2024) who showed that there was no significant relationship between women's times of previous abortion and their knowledge score about pregnancy loss (p= 0.193).As regard to the relationship between total score level of self-protective behaviors of the studied pregnant women regarding spontaneous abortion and their obstetric history.It is observed that there was no significant relationship between total score level of self-protective behaviors and gravidity and parity (p= 0.487 and 0.600 respectively).This finding is in disagreement with Gebremariam et al., (2023) who found that the level of gravidity and parity of the mothers showed statistical significant associations to their level of practice (p < 0.003 and <0.001 respectively).

Conclusion
Based on the findings of the present study, it can be concluded that the research question has been answered.This was very evident as the majority of the studied pregnant women with past history of spontaneous abortion had low level of knowledge regarding spontaneous abortion, three quarters had negative self-protective behaviors, no significant relationship exists between the total knowledge score level and the total score level of self-protective behaviors regarding spontaneous abortion among the studied pregnant women with past history of spontaneous abortion.Additionally, there was a highly statistically significant relationship between women's total score level of knowledge regarding spontaneous abortion and their age at marriage, educational level, and occupation, and husband's educational level, and occupation, and family income from the women's point of view.

Recommendations
Based on the findings of the current study, the following recommendations are derived and suggested: --Provision of appropriate and accessible posters and booklets in Arabic language containing basic needed information about self-protective behaviors regarding spontaneous abortion at all women's healthcare settings.

Figure ( 1
Figure (1): Frequency distribution of past spontaneous abortions among the studied pregnant women with abortion (n=200).

Figure
Figure (3): Total score level of the studied pregnant women's self-protective behaviors during pregnancy regarding spontaneous abortion (n=200 )