Air Pollution and the Risk of Miscarriage

The Story of Lisa: An 8-year Journey to Get a Child after Seven Miscarriages.

Joe and Lisa got married in 2006 and moved into their matrimonial home in New York City. They did not have children immediately after their marriage because they agreed to wait for a few years to allow Lisa to complete her medical residency. Upon completion, Lisa and Joe decided to start having children. At this time, Lisa was twenty-nine years old. Months later in 2011 she got pregnant and, unfortunately, she miscarried after a few weeks. Little was known about what caused the miscarriage, with medical examination revealing that the child had died during the pregnancy without any symptoms. After recovering from the miscarriage, Lisa got pregnant again in April 2012 at the age of thirty-one. This time she went for an early ultrasound at six weeks. Everything looked normal. Upon going back for a checkup on week nine, a medical examination report revealed that the fetus had no heartbeat and Lisa had miscarried again. This was a silent miscarriage. Over the next six years, Lisa had more cases of miscarriage. All the pregnancies were normal in the early weeks of pregnancy only to turn into a stillbirth or spontaneous abortion.

After the loss of seven pregnancies, the couple chose to relocate to Springfield in western Massachusetts. While at Springfield, Lisa got pregnant again, this time for the eighth time, and the pregnancy survived. The couple welcomed a healthy baby boy. 

New York City, where Lisa lived before, has a significant air pollution problem that is known to cause premature deaths. From a list of twenty-five cities in the United States, New York ranks sixteenth for ozone layer pollution (American Lung Association, 2020).  However, the impact of New York’s polluted air on pregnant women has not been studied in detail. Besides, there is little access to details on the impact of such air pollution on prenatal development among women in New York City. Nevertheless, the assumption is that besides air pollution causing acute and chronic disease in children and adults, it could also be responsible for documented and undocumented miscarriages. Springfield in western Massachusetts, where Joe and Lisa relocated, is less polluted compared to New York City. These observations suggest a causal association between miscarriages and air quality. Therefore, it is possible to infer that difference in air pollution between New York City and Springfield in Massachusetts explain the success of Lisa’s pregnancies. 

Stakeholders’ Input 

Many stakeholders have joined the campaign against air pollution in urban areas and major cities. Citing the impact of air pollution on pregnant women, these stakeholders have fixated their efforts on reducing the concentration of toxic substances in the air. Some of the stakeholders in this initiative include advocacy groups such as Awoken Women Organizations and medical researchers. Advocacy groups have embarked on the use of awareness campaigns to highlight the impact of air pollution on pregnant women. For instance, Awoken Women Organization uses public forums to create awareness by highlighting the experience of some of the women or couples who have firsthand experience on the impact of polluted air on pregnancies. This advocacy group uses the examples to challenge people to get concerned about their health and to champion the cause of a healthy environment by stopping air pollution. One prominent story that this advocacy group has used is the story of Cheng and Wei. Cheng is one of the women who experienced a miscarriage as a result of air pollution (Huang, 2018). Her story represents the story of several other women, many of whom have not had the opportunity to speak out. 

Through public awareness campaigns, Awoken Women Organization and other advocacy organizations have managed to bring to the public’s attention the harmful effects of air pollution on pregnant mothers in urban areas and major cities across the globe. Other sectors have been enjoined in the development of a public health policy to agitate for a reduction of excessive emission of harmful gases to the atmosphere. Thus, the public health system has been able to initiate several measures to address this challenge. Moreover, awareness campaigns by Awoke Women Organization has triggered a multisectoral approach to assist in minimizing the exposure of pregnant women to polluted air. Through well-coordinated cooperation with other sectors, public health is on the path of contributing towards formulation of long term policies and programs aimed at reducing air pollution (World Health Organization, 2020). Therefore, the advocacy groups have secured the attention of the public health systems which has fostered positive cooperation with other agencies and industries such as transport, housing, energy, and manufacturing. 

Advocacy groups have utilized communities as platforms for participatory processes in the awareness campaigns about the impact of air pollution on human health. Through multiple initiatives, a significant number of people who are affected or have an interest in public health issues have been brought on-board. This group also entrenches community support to gain support and legitimacy in pursuit of a healthy environment. This approach has been done by conducting multiple participatory processes to gain all the advantages that it offers. Besides, the participatory approach has helped advocacy groups identify other stakeholders and how they can be brought on-board and at what level. This has helped to build support for clean air initiatives through regular community engagements. 

Medical researchers are also another key stakeholder in the campaign to reduce air pollution and development of public health policy. Through their work in research, they are creating more awareness by sharing knowledge.  This group of stakeholders focuses on the use of research and investigation for knowledge accumulation as a way of creating a credible background to support their contribution towards the development of a comprehensive health policy to safeguard pregnant mothers against the harmful effects of air pollution. 

Researchers have given credibility to calls for the reduction of air pollution by giving irrefutable evidence that reveal the link between air pollution and miscarriage. More importantly, this group of stakeholders plays a vital role in solving unpredictable health issues by looking for solutions through research (Bernadette, 2011). Research conducted over the last nine years in Beijing revealed that there is a positive link between silent miscarriage and increased levels of pollution in the air. Mukhopadhaya reiterates that besides this research, all evidence tabled from previous research also showed that there is a positive link between air pollution and fetal losses (2018). In addition, more studies have been carried out and some useful information has been published in various databases most of which have been used to come up with different policies to help curb air pollution in different areas. Knowledge generated by researchers has been used to draft and initiate comprehensive policies on public health. Thus, research evidences serve as useful tools for cities to learn from each other in matters public health.

Furthermore, researchers strive to find solutions to air pollution by examining possible alternative sources of clean energy. Besides, these researchers also publish their work to speak on their behalf. Most cities in different parts of the world currently rely on the information given by researchers to develop policies.  For instance, a reduction in air pollution is being achieved by reducing the number of vehicles in the cities. Nonetheless, available evidence shows that whereas a significant number of motor vehicles have efficient engines, the power of the engine is still one major contributor to air pollution. To curb this problem, several policies that control air pollution have been put in place to eliminate pollution and stabilize air quality. 

Additionally, other stakeholders have often supported the use of public transport instead of using personal cars. This has been seen as an effective measure that can reduce air pollution in densely populated cities. According to Grippo et l. (2019), reducing the number of cars on roads helps clean up the air which, in turn, reduces the health burden on urban centers. Furthermore, urban transport contributes about twenty-five to seventy percent of urban outdoor air pollution, depending on the city’s population, economic activity, and functions (2019). Action in the energy, building sector, and the industry is, therefore, necessary to help reduce the disease burden from outdoor air pollution.

Through public awareness campaigns by advocacy groups such as Awoken Women Organization and researchers, both public and private institutions have been brought on-board and they are taking steps in cutting toxic emissions into the air. The advocacy group helps in creating public awareness while medical researchers give credibility to the message of advocacy groups. The work of these two stakeholders has achieved more attention over the years and triggered a debate on the need to control air pollution.

Impact on Public Health Leadership Practices

Air pollution in urban areas and major cities across the globe is restructuring public health leadership practices. There is a significant change in public assessment criteria, policy development and public health assurance. In contemporary public health, characterized by multiple challenges such as increased outdoor pollution, there is a need for effective leadership to streamline operations, address emerging challenges and enhance healthcare. Leadership in public health influences, motivates and contributes to the achievement of visions and goals. The current public health issues have also increased calls for changes in the vision and goals of health care system (Yphantides, Escoboza, & Macchione, 2015). Public health practices have to evolve and move from an individualistic approach to community-wide approach to address emerging challenges. This is critical in improving health care as it takes into account modern-day challenges. As a result, there is the need to enhance public health delivery.  

To evaluate the level of exposure to hazards, health outcomes and community concerns, public health leadership practices have had to change, thereby adopting a collaborative approach to promote a good rapport between public health system and other sectors and stakeholders. Through collaboration, constructive evaluations can be carried out to help identify the appropriateness of a health studies and health policies. Public health assessment is the best evaluation tool of choice and it can only be effective when there is collaboration and a better understanding between stakeholders. To bring about significant changes in the health sector, having new leadership practices is necessary. Critical leadership skills focus on global initiatives to drive health care delivery. As such, the assessment of the impact of such issues must target the whole world and not only specific regions. Effective assessment can promote innovations to find solutions to emerging problems only if there is collaboration between public health and other stakeholders. 

The implication of air pollution on miscarriage has compelled public health leadership to adopt emergency approaches by coming up with low cost health care services for pregnant women. In addition, essential measures have also been put in place to help develop women focused clinics to address emerging challenges experienced by expectant women living in areas with polluted air. To guarantee the success of these initiatives, public health leadership has also initiated new alliances aimed at forming partnerships to promote research. Additionally, the alliances are also essential in launching awareness campaigns to help keep the public informed. These partnerships require that all stakeholders take part in the awareness advocacies and campaigns against air pollution. 

Through policy development, air pollution as an emerging public health issue is addressed by incorporating awareness campaigns into the organizational culture public health institutions.  An interdisciplinary approach is another significant approach that public health leadership is using to promote cooperation between different sectors in order to promote public health awareness on emerging health issues. The interdisciplinary leadership is necessary in having a multisector approach to reducing air pollution, thereby reducing miscarriages. 

Furthermore, the effect of air pollution on miscarriages is compelling health policy leadership practices to focus on re-examining the relationship between public health and industrial sector. Industrial activities in the United States have a strong connection with health care sector. Together, both public health and industrial sector emit harmful substances. According to Ha et al. (2017), there are direct and indirect emissions from the health care sector. These causes potentially harmful effects to the public. With the increase in knowledge and awareness about the impact of air pollution on pregnant women, current public health leadership through collaboration with other sectors are focused on getting solutions to emerging health issues.

Moreover, the health care leadership practices are now focusing on coming up with policies that give guidance on emission of harmful substances and disposal of waste (Tait et al, 2020). It is also working jointly with law enforcement agencies to ensure that policy guidelines and directions are followed to help eradicate or minimize emissions. Helping organizations to reduce their ecological footprints is another key responsibility taken up by public health as a result of the menace. The reduction of ecological footprints is focused on enhancing air quality and promoting best practices that help in achieving sustainable development. 

Nevertheless, the United States health care systems is one of the most energy-intensive sectors, coming second after food service facilities. Its energy-intensive activities include heating, cooling, ventilation systems, use of laboratory equipment, and computing (Eckelman & Sherman, 2016). Operations such sterilization, refrigeration, laundry, and food services all form part of the energy-intensive activities. The use of fuels and electricity has also resulted in vast quantities of energy-intensive goods and services, leading to toxic emissions. This makes health care the second-largest emitter of harmful substances into the atmosphere. 

To address the issue of emission from the health sector, the leadership has introduced various practices, many of which focus on quantifying or probing consumption-based emissions. The success of these initiatives requires that leaders in the health care sector expand their relationship beyond their traditional spheres of local and state health department because the required knowledge is much broader for the contemporary health environment. This requires leaders to have an in-depth understanding of current developments. 

The above developments require health care leadership to incorporate a proper working familiarity with other policymakers, strategic planners, and information managers. Proper communication with multiple audiences employing new technology, inter-organizational collaboration, networking abilities, advocacy, and change management are gradually being in-cooperated into modern leadership to help address the reproductive health issues related to air pollution. For these reasons, the implication of air pollution on miscarriages is changing the public health leadership practices 

Evidence and Policy Recommendations

Evidence

Miscarriages, especially spontaneous ones, are common pregnancy complications in countries such as the United States, China, and Canada due to air pollution caused by industrial emissions. For instance, the high levels of pollution in China from the manufacturing industry have resulted in one of the highest cases of miscarriages in the world (Dong, 2017). Nonetheless, despite the prevalence of miscarriage that arises from exposure to polluted air, minimal measures have been put in place to address the issue. Besides, there is a lack of public awareness about the consequences of exposure to polluted air, especially its potential effect on pregnancies. As such, only a few people are aware of the impact of air pollutants on pregnancies. Therefore, it is necessary to make miscarriage prevention a priority by eliminating air pollution in urban areas and major cities in both developed and developing nations across the globe.

Exposure to air pollution causes miscarriage in pregnant women. A study carried out by the university of Utah reveal that there is a link between air pollution and miscarriage in Utah’s Wasatch Front, which is one of the most populous regions in the state (Leiser et al., 2019). This study adds to the body of evidence that implicates polluted air in a number of pregnancy losses across the United states. Air pollution is a leading cause of miscarriage and has a higher risk, causing sixteen percent of miscarriage on a short exposure. The study highlights that key air pollutants in Wasatch area of Utah include particulate matter (PM) and nitrogen dioxide (NO2). The study further showed a significant increase in the number of miscarriage cases for women exposed to high levels of nitrogen dioxide. The findings of this research are not unique to Utah but are a representation of what is happening in other urban areas across the US and other major cities across the world. 

Proximity to major highway increased women exposure to PM air pollution. In a study conducted in 14 States in the US, Glaskin et al. (2019) found that exposure to PM (PM2.5–10, PM10 and PM2.5) in the first and second years before pregnancy was not significantly associated with the risk of spontaneous abortion. Nonetheless, the study provided evidence that women with at least one history of spontaneous abortion within the follow-up periods were found to be at risk of miscarrying as a result of high levels of PM10, PM2.5-10, and PM2.5. Particularly, the odds associated with spontaneous abortion were increased by 12%, 9%, and 10% withy exposure to PM10, PM2.5-10, and PM2.5 respectively. The study concluded by noting suggesting the most vulnerable groups are women with prior spontaneous abortion. Zhang et al. (2019) found that fetus development was hampered by environmental pollutants. These studies indicate that that air pollutants have adverse effects on pregnancies and birth outcomes, especially in major cities. 

Across multiple studies that investigated the relationship between air pollution and miscarriage, there is substantive evidence showing that a significant number of women exposed to high levels of air pollutants have lost their pregnancies. Air pollutants cause the fetus to stop developing without noticeable or serious symptoms, leading to the death. This is already a serious health issue that requires urgent attention.  According to Grippo et al. (2018), women who had miscarriages before had quarter chances of having another miscarriage in the future irrespective of the cause of the miscarriage. This study provided evidence that recurrent patterns of miscarriages due to air pollution increased the risk of miscarriage in future pregnancies. 

Research evidence also indicates that after one miscarriage, the risk of another miscarriage is increased by half. After two miscarriages, the risk is doubled. With this trend, the lives of mothers are also put at risk (BMJ, 2019). Moreover, miscarriage also has life-threatening complications which might lead to death when not addressed urgently and effectively. This is likely to have a lasting impact on society, especially on the health of many mothers. Moreover, the persistence of the problem is also likely to result in a reduced fertility.  Unfortunately, miscarriage caused by air pollution does not have immediate remedy. 

The bottom line of the evidence provided by research studies is that air pollution harms and is responsible for the poor development of the fetus. This increases the risk of premature birth and low birth weight (Leiser et al., 2019). Examination of miscarriages has found air pollutants in placentas. This signifies the effect of possible long-term exposure to dirty air. Studies carried out in China have also shown that there is a strong link between miscarriage and exposure to polluted air. An assessment of short-term exposure to polluted air showed that it increased the risk of miscarriage by sixteen percent. Moreover, the average seven-day NO2 levels indicated that there were about 34 micrograms per cubic meter in the placenta. According to the research, an increase of twenty percent of micrograms per cubic meter of air pollutants was positively associated with a rise in the risk of miscarriage among women in urban centers and major cities (Audrey, 2019). 

Urban areas are already densely populated and this means that the available population is already struggling for fresh air given the various developments that take up space and interfere with the natural ecosystem and air circulation. Having more industries, in these urban areas is, therefore, creating more problems and leading to the loss of many pregnancies where some go unnoticed. There is little awareness of the extent to which air pollution can impact the life of pregnant women. Studies on this subject are just coming up and this is revealing a lot of issues, many of which were previously unknown. At the onset doctors and medical researchers note that the general public knows little about what causes these types of miscarriages (DeFranco et al., 2015: Ha et al., 2017).  This shows that this is an area that requires more attention, given that despite the finding that air pollution leads to miscarriage, little effort has been put in place to address this issue. Researchers observed that the risk of miscarriage varied substantially with the number of weeks, but there is no clear information on why the variation exists. Leiser et al., (2019), reiterates that this information would be obtained if the gestation stage would have been known. This would help get a sense of the point in time when the woman is most at risk.  

Millions of Americans live in areas that have high air pollution levels. This has caused acute and chronic health effects. A majority of those affected are those who live close to industrial air pollution sources and freeways. The suffering meted on these people has captured the attention of different stakeholders such as research participants, the public, and advocacy groups. These stakeholders strive to create awareness and to capture the attention of policymakers concerning outdoor pollution. Outdoor pollution is majorly caused by substances such as CO, SO2, NO2 and PM among others (Davidovich & Saldiva, 2019) These are brought about by the burning of inefficient fossil fuels, power generation, combustion from motor vehicle transport among others (Michelle, 2012). To curb this problem, the input of other stakeholders is vital given that the work of reducing the health effect of air pollution in urban areas and major cities is beyond the control of individuals. Therefore, requires action from both public and private authorities at the international, national, and regional levels.

Recommendations

Addressing the challenges posed by air pollution requires a change in approach from what has always been the norm. There is need to invest in prevention than cure to minimize the number of energy intensive machines required to stabilize patients and serve the high influx of people who need critical care. Public health is one of the most energy intensive sectors in the US lot of energy is used to run heavy machines. To cut the cost of energy which is responsible for a significant percentage of emissions, public health must provide guidelines to designers and supplier to optimize energy performance while maintaining quality in health delivery.  Moreover, since air pollution is prevalent in urban areas and major cities, there is a need for strict compliance to health policy for companies that operate in such areas. To reduce the impact on pregnant women, a public health policy and/or health directive should be put in place to give expectant women maternal leave immediately they get pregnant to avoid instances of miscarriage in the early stages of pregnancy.  Notably, it has been observed that early maternal leave has proved to be effective as noted among women who are in self-employment (Binder and Coad, 2016). To further reduce the impact of air pollution several measures need to be put into place, key among them being the reduction of the use of unclean sources of fuel in domestic homes for cooking purposes. Pregnant women need to be given subsidies to buy clean alternative sources of fuel during pregnancy. This will ensure that even those in lower economic classes afford clean alternative sources of fuel. 

Banning the use of some chemicals and harmful substances is necessary to reduce instances of air pollution. Methane and hydrofluorocarbon emissions are harmful to the ozone layer (Wong et al, 2009). The emission of these gases results in significant damage to both humans and plants. Items, and fuels used which lead to the production of these gases need to be banned and viable alternatives promoted. The reduction of these two gases in the air can significantly increase the air quality in urban areas and major cities and thus reduces instances of miscarriage among pregnant women.  Alternatively too reduce the emission of these gases into their air there is a need for collaborative leadership to bring on board those sectors that utilize chemicals or substances that lead to the production of these gases to forge away forward on how such emissions can be controlled or disposed without polluting the air in urban areas and other densely populated areas. Proper control of emissions can be achieved if there is a proper understanding, cooperation, and collaboration between different sectors. The reduction of methane in the air requires that venting is reduced (Payne et al 2019). The waste sector also needs to minimize the emission from solid wastes at landfills. Agricultural activities also need to be monitored and the use of harmful chemicals banned.  For instance, the reduction of emissions from rice production is also necessary to help enhance air quality. Agriculture is among the largest emitters of harmful substances. To help control this problem, organic farming that is void of the use of chemicals need to be promoted. 

The use of substitute goods (chemicals and fuels) should be made a priority in some area where there are alternatives. To encourage people to use substitute goods, the cost of such goods needs to be subsidized and where possible some tax exemptions can be applied. For instance, hydrofluorocarbons (HFCs) can be substituted with other refrigerants. This will help reduce the reliance on air HFCs. 

Addressing the challenge brought about by air pollution requires collaboration from all stakeholders. Such a cooperation should provide guidelines that comprise of banning some substances, substitution others that can be substituted and making changes in various policies that are no longer relevant in the twenty-first century. A change in policies is essential to address the emission of black carbon into the atmosphere. Black carbon is a dangerous air pollutant that warms the atmosphere. There is need for new health policies make an end to the emission of such harmful substances permanently. Putting in place more stringent measures is necessary, but this needs to be made universal, so that one part of the world does not put the other at a risk. Tao Xue, (2019) argues, that banning the emission of black carbon global can help eliminate some health problems permanently as compared to when the ban only applies to a given section or region of the world. For these measures to work and bring about a positive result, law enforcement must be brought on board in every corner of the globe to help enforce the policies and guidelines that have been put in place.

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