It may be good old fashioned witchcraft, but it works
Thursday 09 October 1997
"Go-getters who put their unborn babies at risk." "Overtime in stressful job triples miscarriage risk." So screamed the headlines this summer, announcing the latest research on miscarriage from the University of California which found that lawyers who worked a 45-hour week were three times more likely to have suffered a miscarriage than those who worked less than 35 hours. The key factor, it appeared, was stress.
What are pregnant women - and miscarriage sufferers in particular - to make of this? Should they hand in their notice? Work to rule? Since neither option is realistic or desirable it's reassuring to learn that the findings have been greeted with cautious scepticism by British researchers.
Professor James Walker, who runs the recurrent miscarriage clinic at St James's Hospital in Leeds, says "It's too simplistic to say that women who are worried about miscarrying should cut down the stress in their lives. Obviously if they're extra stressed in their job or private life that may be a factor. But miscarriage can cause a lot of problems at work and within marriages, and it's difficult to know how much is due to the stress of the job and how much is due to the stress of the problem."
One in four women miscarry at least once. One in 100 women suffer three or more miscarriages. It is rarely possible to find a cause, particularly for the most common miscarriages which occur before 14 weeks (one in six pregnancies). Even with miscarriages between 14 and 24 weeks (only one in 50 pregnancies) a specific cause is not always found.
Yet inevitably women want to find a reason and too often they feel it's their fault - for having had too much wine, tobacco, or sex, for taking too many, or too few vitamins, for exercising too much or too little (the recent upsurge of interest in pre-conception planning has done much to inflame all this guilt). It's tempting to dismiss the California research as yet another way of making women feel they're to blame.
Yet stress - the high anxiety caused by a previous miscarriage rather than the pressure of a high-powered job - is increasingly acknowledged as a possible contributing factor. Professor Walker says: "Women who miscarry and women who start bleeding in early pregnancy have very high anxiety levels. Most of the care we have set up here is related to reducing that stress as much as we can. The higher the level of psychological support you can give a woman before and in the early stages of any pregnancy subsequent to miscarriage, the lower the chances of another miscarriage occurring. They require a huge amount of TLC - totally non-medical, unproven witchcraft basically - but it's important." His view is supported by two recent studies on the effects of intensive psychological support in Norway and New Zealand.
"TLC" or Tender Loving Care is the rather soppy name given to the support offered to women by St James's. In fact what they get is much more than a sympathetic ear and a reassuring pat on the head. Weekly ultrasound scans - which can pick up a baby's heartbeat just five weeks into the pregnancy - offer physical proof that the baby is still alive, and where it's deemed appropriate, conventional medical treatment is offered. But, Professor Walker says, "It's very difficult to separate the effect of these treatments from psychological support. If you give someone an injection once a week that is a very strong support - they are getting something to help them. There is a huge placebo effect".
Professor Lesley Regan, who runs the largest recurrent miscarriage clinic in the western world, at St Mary's in Paddington, admits that she is also mystified by the fact that patients offered immediate access to medical help seem to do extraordinarily well. "I can't explain it in physiological terms but I do think there is something about helping women to help themselves which is of benefit to them. Most patients want you to find something wrong and it often takes a long time to explain that in fact it's probably better if we don't. But if you're an intelligent, book-reading person and no one can give you an answer it's terribly frustrating. Women become quite depressed because they feel out of control, which they are. Most of my job is putting them back in control."
Her job is also to find more answers and more effective treatments. One of the most significant recent breakthroughs at St Mary's has been the use of low-dose aspirin and the anti-clotting drug Heparin to help prevent early miscarriages in women who carry Lupus antibodies, but who do not exhibit any other symptoms of the disease - about 15 per cent of recurrent miscarriers. The antibodies can cause clotting in the blood vessels that supply the placenta and this leads to the baby's death at any time up to 28 weeks. Drug therapy increases the live birth rate in these women from 10 per cent to 70 per cent - a finding which, unlike many others, has stood the test of time. Professor Regan's team is now looking at whether some women have a genetic predisposition to infections in the womb which are linked with miscarriage, and into hormonal abnormalities.
It all sounds highly optimistic. But the harsh reality for individual women is that there are still only a handful of clinics offering the kind of support pioneered at St James's and St Mary's, although more are now following their example. Most women have to suffer at least three miscarriages before doctors are willing to investigate.
This has particular repercussions for the increasing numbers of women who delay pregnancy until their late 30s and beyond, when the risks of miscarriage become much higher anyway.
Some clinics take a more humane approach to their queuing system than others. But the treatment currently available to women of all ages is still a lottery depending on where they live, their GP's willingness to refer them, and their own determination.
For more information send an sae to The Miscarriage Association, Clayton Hospital, Northgate, Wakefield, West Yorkshire, WF1 3JS. Tel: (01924) 200799.
Professor Lesley Regan's book, `Miscarriage: What Every Woman Needs to Know' is published by Bloomsbury, pounds 7.99
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