Non-developing pregnancy: a medical or social issue?

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Non-developing pregnancy (NDP), that is often referred to as the "plague of the 21st century", is a special variety of miscarriage [3, 5]. Despite availability of many highly efficient diagnostics and treatment methods developed over the last few years, the frequency of this pathology is persistently high and shows no signs of lowering. Different aspects of this issue in working with women with a history of NDP were discussed in a focus group (December 16, 2015) established by the Journal of Bioethics on the basis of the Laboratory of Ethical, Legal, and Social Expert Evaluation at the Volgograd Medical Research Center. The following handouts were distributed between the participants: results of surveys among obstetricians and gynecologists of outpatient and inpatient divisions, patients with a history of NDP, statistical data on prevalence of missed miscarriage not only in Volgograd, but all over the world. Ten people participated in the study, while the monitor completed special training. Below you will find the most important extracts from the focus group minutes. Monitor. I'm glad to welcome the participants of this round table. We haven't talked with obstetricians and gynecologists in a while, but there are so many pressing issues that demand attention of medical staff, patients, and experts from other subject areas. So, what is exactly the issue we are discussing today? Expert 1 (professor, obstetrician-gynecologist). Today, we will talk about non-developing pregnancy, and it is not mere chance. Any obstetrician-gynecologist knows that the number of missed miscarriages has been increasing dramatically over the last 10 to 15 years. The numbers more than doubled over the last 7 years. These are data for Volgograd, but the situation in Russia doesn't differ much. Global data prove this tendency. The world of medicine paid much attention to this issue over the last 10 years, including development of diagnostic methods, methods to terminate missed miscarriage, i. e. the medical part of this pathology is resolved, so to say. However, we still have no idea about ethiology of the issue, we do not know why a pregnancy goes that way» [5]. This issue is not within the scope of professional abilities of obstetricians and gynecologists. That is one of the reasons why we believe it cannot be solved without taking the social aspects into account. And we don't know much about it yet, we are just at the beginning of the road, but we are definite about the following: if we do not explain the impact of this social aspect to the public, the situation will worsen progressively. Monitor. Do you mean to say that missed miscarriage may be caused not only by medical, but by social factors as well? Expert 1. They are using quite an interesting definition of missed miscarriage, saying that nondeveloping pregnancy is a variety of miscarriage. What is miscarriage, though? This is one and the same response to any ill-being of the body, the environment, and the living conditions. This creates a negative environment where pregnancy cannot progress and stops at a certain stage. It's not a matter of a single factor. The obstetrics and gynecology community has been studying this issue for many years, but cannot ascertain anything unambiguously. Even geneticists fail! Expert 2 (obstetrician-gynecologist, a member of a healthcare organization, Sochi). We take into account biomedical factors, family composition, living conditions, whether the marriage is official or not, occupational health hazards and risks, stressful moments, and the husband's age, as all these are risk factors. Expert 3 (obstetrician-gynecologist of a maternity hospital). Of course, all obstetricians and gynecologists know about these aspects, but currently there exists no single algorithm to forecast this pathology. Just be brave to take it. Pregnancy risk factors that we get to know of do not include many of what you've just said, including family conflicts, etc. We work with a log of medical data (number of abortions, somatopathy, gynecopathy, etc.), but social data is very scarce. Monitor. So, how does the woman reacts to missed miscarriage? Expert 4 (obstetrician-gynecologist, head of a maternity clinic). Most women nowadays are very savvy. When they come to a doctor, s/he tells them it is necessary to have ultrasonic tests done on time, to exclude suspected missed miscarriage. Women say that they know what it is, 43 and I think that every third patient understands that this issue may arise. Monitor. Well, that's very good. Aren't all pregnant women warned of the necessity to take a special medical examination to make sure everything is all right? Expert 5 (obstetrician-gynecologist, staff member of inpatient gynecology hospital). As a staff member of a gynecology hospital, I would like to mention the cyclic nature of this phenomenon: a temporary lull is followed by a huge number of women with non-developing pregnancy, and it's hard to identify the reason for that. At dismissal, we strongly recommend that they plan their next pregnancy and prepare well during the preconception period. What do you think we see in their following admission? Half of our recommendations are not complied with, recommended periods for rehabilitation, medical examination, and psychological preparation in the family are not followed. Very often we come to a missed miscarriage again, or a threatened miscarriage, or vomiting of pregnancy (severe and moderately severe), i. e. we observe complete misadaptation of the body» [8]. Our people have very low compliance. Expert 1. I see what you are saying, and I agree with you: on the one hand, some women are ready to perceive the information that we provide them with, and on the other hand, the relations between the doctor and the patient are not always based on complete trust. That, unfortunately, results in the outcome you've described above. That means, this is not an issue of pure medicine. I would love to hear our patients talking about this. Of course, this is a huge stress for any young woman. How did you feel? Expert 6 (patient with a history of NDP who gave birth to a healthy child). You are right, this is a terrible stress. I felt very bad about it for quite a long time, because I am healthy, and my husband is healthy. Of course, we didn't take any tests before pregnancy, hoping that everything would be all right. It was the 5-6th week of my pregnancy when I found out about missed miscarriage. I had a terrible time for two months afterwards, but then I was gradually able to take my mind off this, plunged into work, calmed down, took all the necessary tests together with my husband - we were preparing. It took me 6 months to be pregnant again. Luckily, I gave birth to a healthy child this time. We still don't know anything about the reasons of the first failure. I would also like to add that this accident changed my attitude to the doctor greatly, I lost trust in my gynecologist and had to find a new one. Expert 1. Does it mean that somewhere deep inside you blame the doctor for your missed miscarriage? Expert 6. Of course. My husband was the first one to suspect this. I agreed with him first, but then found some related information in the Internet and change my opinion a little. Expert 1. That's another important problem. Today, we've received another complaint from a patient with missed miscarriage on the 19th week. We've performed medical termination with minimal losses. The patient believes that poor prenatal care has caused missed miscarriage. I hope you understand now that whether your pregnancy will develop doesn't depend on the doctor. Expert 3. Patient-doctor relations is quite a serious issue. An anonymous survey among patients with missed miscarriage shows that patients progressively do not trust the doctor, and most women change their gynecologist after an NDP accident. Monitor. May it be a question of pure superstition, not just mistrust? Expert 3. Yes, of course, even though most surveyed women name low professional qualification of doctors as the main reason for mistrust. This is the opinion of patients, while most doctors, when asked about the reasons for increasing mistrust, named a negative image created by mass media and public availability of medical information which the general public is completely not ready to perceive: women begin self-treatment and lay a foundation for pregnancy failures in the future. Monitor. Well, as far as the role of mass media is concerned: you've said that patients are savvy, but where do they take this information from? From online forums, mostly. Forums for medical staff are not available to general public: in order to receive access, you have to take some kind of a medical knowledge test. Professional information is unavailable to patients, so here come women's forums where they share experiences and opinions: "a friend of mine had a friend, and that friend had it like that...". This information is unreliable. Doctors do not say much about missed miscarriage on web-resources, to my mind. There should be more communication with patients. Do women with a history of missed miscarriage often say that they will not get pregnant again? Or do they, on the contrary, keep trying despite the failures? 44 Expert 7 (a patient with a history of two NDPs, obstetrician-gynecologist, no children). The very first reaction is "I don't want anything anymore". I had two missed miscarriages in a row. My world crashed after the second failure, I didn't want anything, and even couldn't look at children. This lasted for two months, then I became obsessed with my work, it helped a little. I'm a women's doctor myself, I see such patients every day. It's hard not to disengage from this, but sometimes I think that this sad situation may come about for the third time. Monitor. Is there any special work carried out with such patients, those who went through missed miscarriage, or is the doctor both a gynecologist and a psychologist? Expert 4. There's a psychologist at our clinic who determines how many times a woman should visit the doctor to stabilize her condition. Monitor. Did someone like that work with you? Expert 6. No, I had no idea about this option. Expert 7. No, another negative factor is the fact that I do not take a psychologist as someone more competent, as we are colleagues. Monitor. Have you happened to come across anything about the impact of social factors on missed miscarriage, while you explored publications on the same topic of other authors? I have not found anything like that when preparing for this Round table. Expert 1. There are very few works like that, they are mostly non-systematic, even though the issue has already taken the scope of a real global epidemic. The Russian school of missed miscarriage is headed by professor V. E. Radzinsky. Gynecologists and obstetricians from all over the country gather on an annual basis to discuss all medical complications of this condition in great detail. The social aspect of this issue, however, is undeservedly ignored, even though it is obviously important. Monitor. I think the majority doubts that social factors can be changed: they won't go without computers, won't change the society, etc. Whatever society you live in, you can create affirmations and form the behavior. One of our postgraduate students conducted a research to find out that only 4% of women in Russia engage in preconception preparation. Why? Expert 4. Oh, that's easy. Women say that medical examination is expensive while hormones are bad for your body. That is the reason why half of our recommendations are not followed. Monitor. That points to social problems, to my mind. We may dare say that external environment often brings gynecologists' work to naught. Maybe we should give more thought to the idea of implementing personalized medicine. Expert 2. In view of my research, I would like to add that our government spends incredible amounts of money on different screening programs, but no one thinks about using them in the sphere of reproductive health, when the health of a new human is formed. Almost all these programs have a certain age range, while it is certainly important to take care of the reproductive potential of the whole population. Expert 1. Talking about reproductive potential, we mean the age between 10 and 18, when women's health is formed. Later, this potential will either be "exhausted", or saved. We need to teach them do that. Screening programs could be of great use in this young age category. Monitor. Have you noticed how we moved from missed miscarriage to the issue of Pediatric and Adolescent Gynecology and formation of reproductive health? May these be the roots of this pathology? The following conclusions have been made: 1. All experts agree that non-developing pregnancy has both medical and social root causes, so we should not limit ourselves to dealing with medical issues only, if we want to reduce the number of missed miscarriages. 2. Obstetricians and gynecologists should help the patient to be compliant, however s/he cannot resolve all the difficulties related to the genesis of such pathology on their own[4, 10]. Women's clinics nowadays lack social work experts, even though these could supervise public awareness campaigns under control of the consulting gynecologist and coordinate preventive activities [2]. 3. All experts came to a conclusion that more attention should be paid to young girls' health, when their reproductive potential is formed[6]. Public awareness campaigns in the sphere of sexual education for future mothers should be expanded as the roots of missed miscarriage most definitely lie in the childhood. 4. In order to form a relationship based on trust, obstetricians and gynecologists should be more active in 45 mass media in order to articulate the issue and help the society form the correct attitude towards dealing with it [1, 3]. Adding a new subject to the curriculum, "Your future child", for instance, would be a good way to lay a solid foundation to future happy families. 5. Preconception preparation is a strict requirement for all women based on individual pregnancy forecasting and identified risk factors [7, 9]. Lack of professional treatment causes repeated non-developing pregnancies and significantly reduces the reproductive potential of a woman.

About the authors

M. S Selikhova

Volgograd State Medical University

Email: selichovamarina@;yandex.ru
MD, professor of the Department of Obstetrics and Gynecology Volgograd

E. A Zakharova

Volgograd State Medical University

Email: Katryn-K@yandex.ru
postgraduate student, assistant of the Department of Obstetrics and Gynecology Volgograd

O. V Kostenko

Volgograd State Medical University

Email: nns18@yandex.ru
PhD, associate Professor in the Department of Philosophy, Bioethics and Law with the Course of Psychology and Sociology for Medicine Volgograd

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