Asiya Dawood had a clear vision of what the rest of her life would look like from an early age. She would marry at 23, have her first baby at 25 and then have two more by 30.
At first, everything was going according to plan. She married and was pregnant within six months. Then her luck ran out.
“From being married at 23, I had my first living child, I call it, at 36,” Dawood, an education worker from west London, says.
What should have been the happiest years of her newly married life turned into more than a decade of agony, punctuated by four miscarriages.
Each happened in the second trimester, the final one at 23 weeks.
“The grief I was carrying was something beyond, like I couldn’t even imagine. I would never wish this upon anyone,” Dawood, now 42, says.
“Miscarriage is a very lonely experience, where a lot of people don’t know what to say.”
The pain Dawood endured will be familiar to women from across the country, with as many as one in four pregnancies ending in miscarriage.
One of the most pressing questions of our time is why women all over the world, rich and poor, are opting out of having children.
Far less attention has been paid to what can be done to avoid pregnancy loss among those desperate to become parents or have another child.
Many miscarriages cannot be prevented, happening because of chromosomal abnormalities in the embryo. But some researchers believe far more could be done to improve pregnancy outcomes where it is possible.
Jan Brosens, a professor of obstetrics and gynaecology at the University of Warwick, is blunt in his assessment.
“It is a female disease. If there were an equivalent for males, it would have been solved by now,” he says.
His research shows that among 100 pregnant 34-year-old women, 10 will miscarry.
Five of those miscarriages will be impossible to prevent, while the remaining five could have been avoided.
“What we do in the clinic hasn’t changed from 20 years ago,” Brosens says. “And 20 years ago, it hadn’t changed from 20 years before that. It’s a field that is completely stagnant.”
He adds: “The whole uterus and endometrium must be the most under-studied tissue in the human body.
“One of the most accessible tissues – you can take easy biopsies – and yet one of the most understudied. And the whole of reproduction, the whole survival of the species, is dependent on it.”
The UK does not officially record the number of miscarriages that women experience. This, in itself, matters.
‘Patriarchal attitude in medicine’
“Without regular reporting of miscarriages, it is not possible to set commitments to reduce the number of miscarriages,” says Dr Clea Harmer, the chief executive at charity Sands.
Campaigners warn that women face a postcode lottery, with many offered no support until after the third miscarriage – a number Brosens describes as “arbitrary”.
“If you are 38 and have one miscarriage, then your prognosis is worse than if you’re 25 and have had three miscarriages,” he says. “So it doesn’t cater for patients who are at the highest risk.”
Having a miscarriage at all also raises the risk of it happening again, he says. Therefore, the best option would be to intervene before conception.
The biggest problem, he believes, is a misconception within medicine of what causes miscarriages.
“The standard approach when you experience miscarriages for the last 40 to 50 years, say you see a doctor, [is that] he or she will do a lot of blood tests, testing you for anything and everything. If they find some small imbalance, then they say, ‘Oh, we found it.’ There’s just no evidence for that approach,” he says.
“In my view, it’s a legacy of a very patriarchal attitude in medicine,” Brosens says. “It’s barely understood how embryos implant and what the dynamics are at the time of implantation.”
His research has led to the development of a test of the endometrium before pregnancy.
“If we find that this ability to transition to pregnancy tissue is likely compromised, then we treat before pregnancy. To assess whether treatment was successful, we can retest before pregnancy,” he says.
The waiting lists for his clinic have grown so long that he has had to close it to new patients.
Jonathan Sher, a founding partner of Scotland’s Coalition for Healthier Pregnancies, Better Lives, meanwhile, points to an approach tested in the US, where all women of childbearing age are asked whether they want to conceive in the next year during doctors’ visits.
“If the answer is yes, I do, then there’s a whole protocol of preconception health, education and care that can be invoked, because if they’re not pregnant yet, that gives time for the preconception messages and activities to get underway and to have meaning and impact,” he says.
Other doctors are not quite as convinced that preventing miscarriages could help stem the fall in birth rates.
“Most miscarriages happen because of a mistake right at the beginning when the egg and the sperm join together, and therefore it doesn’t matter what you do,” says Colin Duncan, the chairman of reproductive medicine and science at the University of Edinburgh.
“That pregnancy right from the word go has been destined to miscarry, and that’s the most common cause of miscarriages.”
However, he agrees that far more research is needed, including looking at the male partner’s contribution to miscarriage.
“I’m very much of the opinion that women’s health is underfunded research-wise, and that includes miscarriage. There’s a mismatch on how common things are and how much money is spent on them,” he says.
“Most people who have a miscarriage will go on to have a normal baby in the future. And the question is: do people who have had miscarriages feel as though they’ve had the number of babies that they wanted to have?”
As more couples have children in their mid-to-late 30s, their chance of experiencing a miscarriage will grow.
The gap between how many children people want to have and how many they end up with has, meanwhile, more than doubled since 2011.
For Dawood, her four miscarriages ultimately meant she became a mother to one rather than three children, as she had hoped in her early 20s.
In the end, it was not her doctor who helped to solve the mystery of why she kept miscarrying. Through her own research, she discovered that a cervical stitch might be the solution.
“I ended up having my husband’s colleague tell me about [cervical stitches]. I went into doing research myself and then approaching the hospital myself, saying this is what’s going on, this is what I think I need.”
As a result, she was able to have her first child at age 36 – more than a decade after she started trying.
“It shouldn’t be like that, because I’m not a medical professional, but being on this journey has kind of made me a medical professional, because of all the research and educating that I’ve had to do for myself,” she says.
If a doctor had suggested this to her sooner, it would have saved her years of pain, which forced her to temporarily leave her job in education to avoid being around children amid her grief. Even just being out amongst other people could be difficult, Dawood says.
“You’re walking down the road, and you see a pregnant woman walk past, and it triggers you,” she says. “You just long to be that woman walking down the road with a pregnant belly, and you’re not.”
Anyone affected by pregnancy or baby loss can contact Sands at sands.org.uk/support for support.