Impact of Miscarriage on Perinatal Outcomes Including Breastfeeding among Primiparous Women with Class 3 Obesity

 Analysis:  Fisher’s Exact test or Kruskal-Wallis test.

Interpregnancy intervals and maternal and neonatal outcomes

One hundred one of 144 (70%) women had one miscarriage, 23 (16%) had two and 20 (14%) had three or more. Most of the miscarriages occurred during the first trimester and all of them were consecutive. Of the 17 women with recurrent miscarriages, seven conceived within one year, four during the second and the remaining six after three years. One hundred and thirty-six of the 144 (94%) women were able to provide the date of the closest miscarriage before the live birth. The IPI between the miscarriages and the date of conception of the first live birth were divided into 29 (21%) whose IPI was ≤ 6 months, 32 (24%) with IPI 7-12 months and 75 (55%) with > 12 months. A comparison of perinatal outcomes between the three IPI groups showed that women with ≤ 6 month IPI or > 12 month IPI tend to be older than the 7-12 month IPI women (Table 5). PCOS was also more common in these groups relative to the 7-12 month IPI group. The remaining maternal and neonatal variables were similar including AMA, GDM, PGDM Type 2, CHTN, CHTN on meds, mild preeclampsia, preeclampsia severe, primary cesarean, gestational age, late prematurity, AGA, macrosomia, hypoglycemia, admission to NICU, intention to BF, exclusive BF, partial BF and BF initiation (Table 6).

Discussion

Miscarriage is generally described as the loss of pregnancy before viability [5-7,12]. The difficulty with that definition is that the limits of viability can vary from 20 to 28 weeks of gestation depending on multiple factors [6-7,12]. Considering the above, we defined miscarriage as an intrauterine pregnancy loss which occurred before the end of the first trimester of pregnancy [5,12,17]. The prevalence of miscarriages in the general population is one miscarriage in about 10.8% of women, two in 1.9% and three or more in 0.7% [5-7]. The chances of miscarriage recurrence are between 1-3% and the chances of the following live birth pregnancy range from 50-70% depending on the maternal comorbidities [7]. Relevant to our study, it is widely known that the risk of miscarriage is higher among women with obesity compared to those with a normal prepregnant BMI [1-3,7,12].

Similar to other investigators, we showed a significant increase in the prevalence of miscarriage in women with AMA [19-22]. In the US and other developed countries there is an upward trend toward

AMA that culminated in 2020 in 19% of all pregnancies [12,1923]. Compared with those of younger age pregnant women with AMA are at higher risk for complications such as miscarriages, chromosomal abnormalities, stillbirth, disorders of fetal growth, preeclampsia, preterm delivery, gestational and pregestational diabetes and increased rates of cesarean delivery [19-23]. Concurrently, infants born to women with AMA are at risk of low birth weight, prematurity, low Apgar scores and admission to NICU [18]. On the other hand, women with AMA intend to BF at a similar rate to that of younger women, however, their BF initiation rates are higher [23]. A recent publication suggests that older mothers are better prepared to face lactation difficulties or disappointments and are thus more likely to be successful and continue to BF longer [23].

Our data is in line with other investigators who demonstrated that pregnant women who smoke are at higher risk of miscarriages [24-26]. Smoking during pregnancy also increases the occurrence of orofacial clefts, fetal growth restriction, ectopic pregnancies, placenta previa, placental abruption and other neonatal comorbidities [24-26]. Smoking before or during pregnancy is a significant risk for BF initiation or BF continuation [26]. Several studies have shown that nicotine inhibits prolactin production and affects the milk ejection reflex, decreases milk supply and leads to poor BF outcomes [27-29]. Our data showed that a significant number of former smokers quit prior to or during pregnancy, unfortunately it is known that about 50% are likely to return to smoking within a year postpartum [29]. Pregnant women should not smoke and should avoid secondhand smoke exposure [29]. Years ago, some investigators advanced the paradoxical notion that smoking may have some protective effects on the rate of preeclampsia, however, recent reliable work disputed that idea [30-31].

The American Academy of Pediatrics recommend exclusive BF for approximately six months after birth and a continuation of BF supplemented with complementary foods thereafter for 6-12 months [32]. Long standing data confirmed that otitis media, diarrheal disease, lower respiratory illness, sudden infant death, bowel disease, leukemia, diabetes, obesity, asthma and atopic dermatitis occur less often among infants who BF during their first year [32]. Concurrently, women who BF decrease their risk for Type 2 diabetes, breast and ovarian cancer, endometrial carcinoma and hypertensive disorders among other comorbidities [8-10].

The categorization of women with obesity according to severity showed significant differences in BF initiation [4,33-35]. In the US in 2019, 83.2% of the general obstetrical population initiated partial BF at hospital discharge, thereafter rates of any BF declined to 55.8% at six and to 35.9% at 12 months [34]. Although literature on BF in women with and without obesity is abundant the impact of miscarriages on BF initiation remains unexplored [4,16-18]. The data presented here showed that BF initiation, albeit low, was similar between women with and without history of miscarriages [34].

The strongest predictors of successful BF are intention to BF among primiparous women and prior BF experience among multiparous women [35-38]. In the current study, intention to BF and BF initiation were similar between women with and without a history of miscarriage. The discrepancy between intention to BF and BF initiation highlights the many obstacles that affect not only mothers but also their infants. Similarly, neonatal obstacles that delay, interrupt or discourage BF include prematurity, respiratory disorders, poor latching, ineffective sucking behavior and motherinfant separation [18,38]. Regardless of the rate of BF initiation, fewer than 20% women with obesity BF exclusively at six months and less than 20% continue with any BF at one year [36]. Furthermore, a random forest algorithm found that BMI category, prenatal BF intention and health care insurance are stronger predictors of BF failure [36].

Relevant to our study, a comparison of short (< 6 months) IPI with intermediate and long IPI did not show any significant adverse neonatal outcomes. This observation is in line with that of Kandatharan et al. that reported no risk of adverse outcomes after delaying pregnancy for 6 months or less following a miscarriage [11]. Furthermore, Tessema et al. and Farahi et al. suggested that following a miscarriage or induced abortion, women could attempt pregnancy earlier without increasing their perinatal healthcare risks [12,31].

Early pregnancy losses are common but the psychological sequela for their parents is often overlooked [39-40]. Following miscarriages or ectopic pregnancies women experience posttraumatic stress, anxiety, and depression that can remain clinically significant up to nine months later [39-40]. Recent studies also suggest that perinatal losses might have consequences on parents’ mental health which may persist even following the birth of subsequent children [41-42]. Unfortunately, associations of psychological challenges with miscarriages and lactation remain underreported.

Limitations

Limitations of this investigation are those inherent to a retrospective design and to the lack of follow-up information on infant feeding after discharge. The strength of the present investigation included the definitions of BF at discharge and the data on mothers and infants which were obtained directly from medical records and not from maternal recall. More importantly, to our knowledge, this is the first investigation relating miscarriages to BF initiation in this study population.

Conclusions

Primiparous women with Class 3 obesity with and without a history of miscarriages have similar perinatal outcomes including low BF initiation rates. While the rate of intention to BF was similar to that of the general population, the low BF initiation rates reported here are common in women with obesity, hypertensive disorders, diabetes and other social and demographic factors that included smoking. Additionally, our study highlights the negative impact of smoking on BF initiation and provides a potentially modifiable target for improvement.

Authors’ contributions

LC: Conceptualized and designed the original study, collected data, assisted with data analysis, and drafted the initial and subsequent manuscripts. CAN/MRS:  Assisted with the study design and data analysis and critically reviewed and revised several drafts of the manuscript. EMM: Designed and implemented statistical analysis and revised the manuscript accordingly. MBL/CHB: Review and revise the manuscript for important intellectual contents

All authors approved the final manuscript as submitted and agreed with its publication

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Competing Interests

The authors declare to have no conflict of interest.

Ethics approval and consent to participate

The Ohio State University Biomedical Science IRB (#2010H0198) approved through 4/17/2025 this retrospective study with waivers of informed consent and HIPAA research authorization. All methods were performed in accordance with the relevant guidelines and regulations of the declaration of Helsinki.

References

1. ACOG Practice Bulletin #230. Obesity in pregnancy (2021). Obstet Gynecol 137: e128-37.
2. Creanga AA, Catalano PM, Bateman BT (2022) Obesity in pregnancy. N Engl J Med 387: 248-259.
3. Langley-Evans SC, Pearce J, Ellis S (2022) Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: A narrative review. J Hum Nutr Diet 35: 250-264.
4. Cordero L, Stenger MR, Landon MB, Needleman BJ, Noria S, et al. (2025) Breastfeeding initiation according to the severity of Class 3 obesity. J Neonatal-Perinatal Med 18 : 70-78.
5. ACOG Practice Bulletin #200 (2018) Early Pregnancy loss. Obstet Gynecol 132: e197-e207.
6. Quenby S, Gallos I, Dhillon-Smith RK, Podesek M, Stephenson MD, et al. (2021) Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 397: 1658-1667.
7. Potdar N, Iyasere C (2023) Early pregnancy complications including recurrent pregnancy loss and obesity. Best Pract Res Clin Obstet Gynaecol  90: 102372.
8. Binns C, Lee M, Low WY (2016) The long-term public health benefits of breastfeeding. Asia Pac J of Public Health 28: 7-14.
9. Nguyen B, Jin K, Ding D (2017) Breastfeeding and maternal cardiovascular risk factors and outcomes: A systematic review. PLoS ONE 12: e0187923.
10. Fox R, Kitt J, Leeson P, Aye CYL, Lewandowski AJ (2019) Preeclampsia: Risk factors, diagnosis, management, and the cardiovascular impact on the offspring. J Clin Med 8:1625.
11. Kangatharan C, Labram S, Bhattacharya S (2017) Interpregnancy interval following miscarriage and adverse pregnancy outcomes: systematic review and meta-analysis. Hum Reprod Update 23: 221.
12. Tessema GA, Hȧberg SE, Pereira G, Regan AK, Dunne J, et al. (2022) Interpregnancy interval and adverse pregnancy outcomes among pregnancies following miscarriages or induced abortions in Norway (2008-2016): A cohort study. PLoS Med 19: e1004129.
13. ACOG Practice Bulletin Summary #222 (2020). Gestational hypertension and preeclampsia. Obstet Gynecol 135: e237-e260.
14. ACOG Practice Bulletin #203 (2019). Chronic hypertension in pregnancy. Obstet Gynecol 133: e26-e50.
15. Cordero L, Stenger MR, Landon MB, Nankervis CA (2022) Impact of Excessive Gestational Weight Gain on Exclusive Breastfeeding Among Obese Women with Type 1 and Type 2 Diabetes.  PLoS One 17: e0277599.  
16. Cordero L, Stenger MR, Landon MB, Nankervis CA (2022) Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus. BMC Pregnancy Childbirth 22: 69.
17. Cordero L, Stenger MR, Landon MB, Nankervis CA (2020) Interpregnancy interval, intention to breastfeed and breastfeeding initiation among women with pregestational diabetes mellitus. Int J Women’s Health Wellness 6:114.
18. Cordero L, Ramesh S, Hillier K, Giannone PJ, Nankervis CA (2018) Early feeding and neonatal hypoglycemia in infants of diabetic mothers. SAGE Open Med 1: 6613.
19. ACOG 2002 Society for maternal-fetal medicine (2022). Pregnancy at age 35 years or older. Obstet Gynecol 140: e221-e228.
20. Magnus MC, Wilcox AJ, Morken Nils-Halvdan, Weinberg CR (2019). Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. BMJ 364: l869.
21. Rademaker D, Hukkelhoven CWPM, van Pampus MG (2021) Adverse maternal and perinatal pregnancy outcomes related to very advanced maternal age in primigravida and multigravida in the Netherlands: A population-based cohort. Acta Obstet Gynecol Scand 100: 941-948.
22. Frick AP (2021) Advanced maternal age and adverse pregnancy outcomes. Best Pract Res Clin Obstet Gynaecol 70: 92-100.
23. Sobala AJ, Szablewska AW (2025) Birth satisfaction and breastfeeding attitudes among mothers aged 35 and older. Nutrients 17: 3796.
24. ACOG Committee Opinion #807 (2020). Tobacco and nicotine cessation during pregnancy. Obstet Gynecol 135: e221-e229.
25. Pineles BL, Park E, Samet JM (2014) Systematic review and metaanalysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol 179: 807-823.
26. Scheffers-van Schayck T, Tuithof M, Otten R, Engels R, Kleinjan M (2019) Smoking behavior of women before, during, and after pregnancy: Indicators of smoking, quitting, and relapse. Eur Addict Res 25: 132-144.
27. Godleski SA, Shisler S, Eiden RD, Schuetze P (2020) Maternal Smoking and Psychosocial Functioning: Impact on Subsequent Breastfeeding Practices. Breastfeed Med 15: 246-253.
28. Macci M, Bambini L, Franceschini S, Alexa ID, Agostoni C (2021) The effect of tobacco smoking during pregnancy and breastfeeding on human milk composition – a systematic review. Eur J Clin Nutr 75: 736747.
29. Vlachou M, Kyrkou GA, Vivilaki V, Georgakopoulou VE, Katsaounou P, et al. (2024) Tobacco smoke exposure and lactation. Cureus 16: e73651.
30. Rodriguez-Lopez M, Escobar MF, Merlo J, Kaufman JS (2023) Reevaluating the protective effect of smoking on preeclampsia risk through the lens of bias. J Hum Hypertens 37: 338-344.
31. Farahi N, Mounsey A, Auten B, Guthmann R (2019) Time to conception after miscarriage: How long to wait? J Fam Pract 68: e12-e14.
32. Meek JY, Noble L (2022) section on breastfeeding. Policy statement: Breastfeeding and the use of human milk. Pediatrics 150: e2022057988.
33. Hashemi-Nazari SS, Hasani J, Izadi N, Najafi F, Rahmani J, et al.(2020) The effect of pre-pregnancy body mass index on breastfeeding initiation, intention and duration: A systematic review and doseresponse meta-analysis. Heliyon 6: e05622.
34. Centers for Disease Control and Prevention. Breastfeeding report card 2022.
35. Cordero L, Stenger MR, Landon MB, Jr. CH Backes, Conroy S, et al. (2025) Interpregnancy interval, intention to breastfeed and breastfeeding initiation among women with class 3 obesity. Arch Pediatr 10: 328.
36. Conrey SC, Burrell AR, Staat MA, Washington DA, Taft DH, et al. (2024) Obesity and prenatal intention as predictors of meeting breastfeeding recommendations in an urban birth cohort. Breastfeed Med 19: 98-108.
37. Cordero L, Stenger MR, Blaney SD, Finneran MM, Nankervis CA, et al. (2020) Prior breastfeeding experience and infant feeding at discharge among women with pregestational diabetes mellitus. J Neonatal Perinatal Med 13: 563-570.
38. Huang Y, Ouyang Y, Redding SR (2019) Previous breastfeeding experience and its influence on breastfeeding outcomes in subsequent births: A systematic review. Women Birth 32: 303-309.
39. Farren J, Jalmbrant M, Falconieri N, Mitchell-Jones N, Bobdiwala S, et al. (2020) Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study. Am J Obstet Gynecol 222: 367.e1-367.e22.
40. Hunter A, Tussis L, MacBeth A (2017) The presence of anxiety, depression and stress in women and their partners during pregnancies following perinatal loss: A meta-analysis. J Affect Disord 223: 153-164.
41. Faleschini S, Aubuchon O, Champeau L, Matte-Gagné C (2021) History of perinatal loss: A study of psychological outcomes in mothers and fathers after subsequent healthy birth. J Affect Disord  280: 338-344.
42. Donegan G, Noonan M, Bradshaw C (2023) Parents experiences of pregnancy following perinatal loss: An integrative review. Midwifery 212: 103673.