In the United States (U.S.), an estimated 30%–40% of all pregnancies and 15%–20% of clinically recognized pregnancies end in miscarriage, or the loss of a pregnancy before 20 weeks gestation (1, 2). It is estimated that miscarriage is the most common form of pregnancy loss, with 80% of early pregnancy loss occurring in the first trimester of gestation (3). The risk is multivariate and while there are risk factors (e.g., maternal age, prior obstetrical history, and maternal comorbidities), it is difficult to establish predictors of future pregnancy loss (3).

Latinas, a vulnerable and marginalized population, are often underrepresented in research studies on women who experience miscarriage. Yet, U.S. Latinas face several risk factors for

having a miscarriage when compared to non-Latina White women, including, for example, more severe phenotypes of polycystic ovarian syndrome (4), and higher cases of Chlamydia [524.2 vs. 274.7 per 100,000; (5)] and Gonorrhea infections [88 vs. 65.5 per 100,000; (6)]. Additionally, age of first pregnancy has increased from 2000 to 2014 among Latinas of Cuban (26.5 to 27 years) and Central and South American descent (24.8 to 26.5 years) and are comparable to the age of first pregnancy among non-Latina Whites [which increased from 25.9 to 27 years; (7)]. Most miscarriages (about 60%) occur randomly due to a genetic problem which becomes even more common in women of increased reproductive age (8).

Several studies have also identified an association between miscarriage and intimate partner violence [IPV; (9, 10)], an issue that is quite prevalent in the Latino community (11, 12). Immigration and acculturation to a new culture have been cited as risk factors for IPV due to changes in existing gender roles within Latino families. Acculturation has also been associated with increases in alcohol abuse, unemployment, and socioeconomic issues all of which predict IPV (13). Furthermore, higher levels of acculturation have been associated to increased risk of IPV and adverse pregnancy outcomes including preterm births, preeclampsia or eclampsia, and gestational hypertension (13, 14). Nonetheless, IPV and acculturation have been scarcely studied among Latinas within the realm of miscarriage. Limited data on Latinas who have experienced a miscarriage means that certified nurse midwives have little evidence to guide and tailor their practice to provide adequate care to these women. Thus, this study aimed to analyze and compare sociodemographic characteristics, health-related factors, intimate partner violence, and acculturation among Latina women with and without a history of miscarriage.

This study contributes new data about different characteristics of Latinas who have and have not experienced a miscarriage. In this study, 30% of Latinas experienced at least one miscarriage, which matches the estimated U.S. national rates (30%–40%) of miscarriages (1, 2). In this analysis, Latinas who experienced a miscarriage were significantly older, had more pregnancies, and more children. It is expected that as women age, they may have more pregnancies compared to younger women, thus they might have more children but also, they will have increased risk or likelihood for miscarriage since increased maternal age is a main risk factor for increased genetic malformations to occur (8).

Evidence suggests that higher Latina acculturation is associated to pregnancy complications such as preterm births and gestational hypertension but there is a paucity of research between acculturation and miscarriage (14). In this study, acculturation was not found to be significant between Latinas with and without miscarriage. However, both groups of Latinas scored higher on the Hispanicism dimension indicating a low level of acculturation to the American culture even after having lived in the US for an average of 8 years. In addition to higher Hispanicism, the similar prevalence in miscarriages among Latinas in this study compared to the estimated U.S. national rates, could be related to the “Latina paradox” which is related to the favorable birth outcomes despite social disadvantages, which are associated to cultural, social factors, and the social network that provides protective factors and a behavioral context for healthy births (19, 20). Even when these mechanisms are not completely clear, we know that they are relevant to Latinas who experience several social determinants of health that could decrease their access to health services and screenings to prevent or receive appropriate care if they experience a miscarriage. In this study, women had low income, few had health insurance, and the majority were Spanish speaking which could complicate their access to care when experiencing a miscarriage. Existing literature indicates that poorer patient experiences are reported among those with lower socioeconomic status (21). Future research should explore the role of certified nurse midwives and how they can contribute to reducing these disparities and potentiate protective factors among Latina women as well as on the relationship between acculturation and pregnancy loss among Latinas.

Existing evidence supports the association between intimate partner violence (IPV) and miscarriage in other populations, including minority populations (9, 22). However, in this study, there was no significance found between those with and without history of miscarriage in terms of IPV. This could be because the HITS survey asked about IPV exposure solely during the month prior to study participation and not at other time periods of the participants' life which may have increased the exposure of women to IPV. Furthermore, the prevalence of IPV was high in both groups of Latina women studied. Thus, future studies should assess the relationship between history of IPV and miscarriage and its health-related impacts on larger and varied Latina populations.

Findings from this study indicate that Latinas with history of miscarriage significantly rate their overall health as worse than those without history of miscarriage. There is existing international literature indicating that reproductive history, particularly parity and early vs. late childbearing, influences women's health and their overall self-rated perceptions of health later in life (23–26). However, self-rated health among Latinas has been largely understudied particularly within the realm of miscarriage and pregnancy loss. One study comparing self-rated health among 5,620 White and African American women (another minority group), 50 years old or older, with childbearing history (number of children and pregnancy loss) stated that the African American women consistently reported worse physical and overall health as well as lower education and income than the White women. Furthermore, having six or more children as well as having had a pregnancy loss were both associated with poorer self-reported health for both races with the stronger association being among the African American women (27). Although the current study did not assess this relationship, it would be worthwhile to investigate since self-rated health has consistently predicted future health, functional status, and mortality across cultures and populations (27, 28). Given the scarcity of research regarding self-rated health and pregnancy loss particularly among the Latina population, warrants this type of study.

Nurses and certified nurse midwives have the opportunity to be at the forefront of conducting these needed studies that would help inform the nursing community on how to tailor their care and provide quality patient education that would improve health outcomes for Latinas who have had a miscarriage. Early pregnancy planning, prenatal counseling, and culturally tailored education for Latinas of childbearing age may promote healthy behaviors, decrease risk for miscarriage, and improve overall health status perceptions. The literature shows that patient education is crucial in miscarriage management and should be focused on maternal health, risk factors, preparing for future pregnancy if appropriate, contraception, and mental health among others (3). A caring organizational culture and supportive leadership from certified nurse midwives will ensure early consultation for pregnant Latina women and facilitate care continuity, improving Latina's health outcomes.

This study is one of the few that has investigated characteristics of Latinas who have experienced a miscarriage. Certified nurse midwives are encouraged to provide Latinas with culturally tailored education on the importance of early prenatal care for optimal pregnancy outcomes. Certified nurse midwives also have an important role advocating for Latina's access to health and providing support to navigate the system and the decision-making process in cases of miscarriage. Further research is warranted to determine the role of IPV, acculturation, and overall health perceptions among Latinas who experience miscarriage.