Depression, Anxiety, and Stress in Kazakhstani Women with Recurrent Pregnancy Loss: A Case–Control Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Subjects and Recruitment
2.2. Study Instrument
Assessment of the Instrument
2.3. Ethical Considerations
2.4. Statistical Analysis
3. Results
3.1. Study Population
3.2. Assessment of the Instrument
3.3. Prevalence of Symptoms of Depression, Anxiety, and Stress
3.4. Regression Analysis
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- ESHRE Guideline Group on RPL; Bender Atik, R.; Christiansen, O.B.; Elson, J.; Kolte, A.M.; Lewis, S.; Middeldorp, S.; Nelen, W.; Peramo, B.; Quenby, S.; et al. ESHRE guideline: Recurrent pregnancy loss. Hum. Reprod. Open 2018, 2018, hoy004. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. WHO: Recommended definitions, terminology and format for statistical tables related to the perinatal period and use of a new certificate for cause of perinatal deaths. Modifications recommended by FIGO as amended 14 October 1976. Acta Obstet. Gynecol. Scand. 1977, 56, 247–253. [Google Scholar]
- RCOG. The Investigation and Treatment of Couples with Recurrent First-Trimester and Secondtrimester Miscarriage Royal College of Obstetricians & Gynaecologists. 2011. Available online: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_17.pd (accessed on 16 March 2022).
- Practice Committee of the American Society for Reproductive Medicine. Evaluation and treatment of recurrent pregnancy loss: A committee opinion. Fertil. Steril. 2012, 98, 1103–1111. [Google Scholar] [CrossRef] [PubMed]
- Aimagambetova, G.; Hajjej, A.; Malalla, Z.H.; Finan, R.R.; Sarray, S.; Almawi, W.Y. Maternal HLA-DR, HLA-DQ, and HLA-DP loci are linked with altered risk of recurrent pregnancy loss in Lebanese women: A case-control study. Am. J. Reprod. Immunol. 2019, 82, e13173. [Google Scholar] [CrossRef] [PubMed]
- Bahia, W.; Soltani, I.; Abidi, A.; Haddad, A.; Ferchichi, S.; Menif, S.; Almawi, W.Y. Identification of genes and miRNA associated with idiopathic recurrent pregnancy loss: An exploratory data mining study. BMC Med. Genom. 2020, 13, 75. [Google Scholar] [CrossRef]
- Bahia, W.; Finan, R.R.; Al-Mutawa, M.; Haddad, A.; Soua, A.; Janhani, F.; Mahjoub, T.; Almawi, W.Y. Genetic variation in the progesterone receptor gene and susceptibility to recurrent pregnancy loss: A case-control study. BJOG Int. J. Obstet. Gynaecol. 2018, 125, 729–735. [Google Scholar] [CrossRef] [Green Version]
- Dendana, M.; Bahia, W.; Finan, R.R.; Al-Mutawa, M.; Almawi, W.Y. Association of adiponectin gene variants with idiopathic recurrent miscarriage according to obesity status: A case-control study. J. Transl. Med. 2018, 16, 76. [Google Scholar] [CrossRef] [Green Version]
- Almawi, W.Y.; Al-Shaikh, F.S.; Melemedjian, O.K.; Almawi, A.W. Protein Z, an anticoagulant protein with expanding role in reproductive biology. Reproduction 2013, 146, R73–R80. [Google Scholar] [CrossRef] [Green Version]
- Magdoud, K.; Herbepin, V.G.; Touraine, R.; Almawi, W.Y.; Mahjoub, T. Plasminogen activator inhibitor 1 4G/5G and -844G/A variants in idiopathic recurrent pregnancy loss. Am. J. Reprod. Immunol. 2013, 70, 246–252. [Google Scholar] [CrossRef]
- Hong Li, Y.; Marren, A. Recurrent pregnancy loss: A summary of international evidence-based guidelines and practice. Aust. J. Gen. Pract. 2018, 47, 432–436. [Google Scholar] [CrossRef] [Green Version]
- Pirtea, P.; Cicinelli, E.; De Nola, R.; de Ziegler, D.; Ayoubi, J.M. Endometrial causes of recurrent pregnancy losses: Endometriosis, adenomyosis, and chronic endometritis. Fertil. Steril. 2021, 115, 546–560. [Google Scholar] [CrossRef]
- Vomstein, K.; Feil, K.; Strobel, L.; Aulitzky, A.; Hofer-Tollinger, S.; Kuon, R.J.; Toth, B. Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art. J. Clin. Med. 2021, 10, 869. [Google Scholar] [CrossRef]
- Quenby, S.; Gallos, I.D.; Dhillon-Smith, R.K.; Podesek, M.; Stephenson, M.D.; Fisher, J.; Brosens, J.J.; Brewin, J.; Ramhorst, R.; Lucas, E.S.; et al. Miscarriage matters: The epidemiological, physical, psychological, and economic costs of early pregnancy loss. Lancet 2021, 397, 1658–1667. [Google Scholar] [CrossRef]
- Jairajpuri, D.S.; Malalla, Z.H.; Mahmood, N.; Khan, F.; Almawi, W.Y. Differentially expressed circulating microRNAs associated with idiopathic recurrent pregnancy loss. Gene 2021, 768, 145334. [Google Scholar] [CrossRef]
- Jauniaux, E.; Farquharson, R.G.; Christiansen, O.B.; Exalto, N. Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage. Hum. Reprod. 2006, 21, 2216–2222. [Google Scholar] [CrossRef] [Green Version]
- Khalife, D.; Ghazeeri, G.; Kutteh, W. Review of current guidelines for recurrent pregnancy loss: New strategies for optimal evaluation of women who may be superfertile. Semin. Perinatol. 2019, 43, 105–115. [Google Scholar] [CrossRef]
- Abdukassimova, M.; Kanabekova, P.; Bauyrzhanova, Z.; Ukybassova, T.; Kaldygulova, L.; Imankulova, B.; Aimagambetova, G.; Almawi, W.Y. Association of Human forkhead box protein 3 (FOXP3) gene polymorphisms with idiopathic recurrent pregnancy loss among Kazakhstani women. Gene 2021, 801, 145835. [Google Scholar] [CrossRef]
- Arias-Sosa, L.A.; Acosta, I.D.; Lucena-Quevedo, E.; Moreno-Ortiz, H.; Esteban-Pérez, C.; Forero-Castro, M. Genetic and epigenetic variations associated with idiopathic recurrent pregnancy loss. J. Assist. Reprod. Genet. 2018, 35, 355–366. [Google Scholar] [CrossRef]
- Donnely, P.; Friedmanellie, B.; Lathi, R.B. Incidence of moderate to severe depression in recurrent pregnancy loss patients. Fertil. Steril. 2011, 95, S22. [Google Scholar] [CrossRef]
- Craig, M.; Tata, P.; Regan, L. Psychiatric morbidity among patients with recurrent miscarriage. J. Psychosom. Obstet. Gynaecol. 2002, 23, 157–164. [Google Scholar] [CrossRef]
- Adib-Rad, H.; Basirat, Z.; Faramarzi, M.; Mostafazadeh, A.; Bijani, A. Psychological distress in women with recurrent spontaneous abortion: A case-control study. Turk. J. Obstet. Gynecol. 2019, 16, 151–157. [Google Scholar] [CrossRef] [PubMed]
- Gong, X.; Hao, J.; Tao, F.; Zhang, J.; Wang, H.; Xu, R. Pregnancy loss and anxiety and depression during subsequent pregnancies: Data from the C-ABC study. Eur. J. Obstet. Gynecol. Reprod. Biol. 2013, 166, 30–36. [Google Scholar] [CrossRef] [PubMed]
- Kolte, A.M.; Olsen, L.R.; Mikkelsen, E.M.; Christiansen, O.B.; Nielsen, H.S. Depression and emotional stress is highly prevalent among women with recurrent pregnancy loss. Hum. Reprod. 2015, 30, 777–782. [Google Scholar] [CrossRef] [PubMed]
- Qaddourah, R.H.; Magdoud, K.; Saldanha, F.L.; Mahmood, N.; Mustafa, F.E.; Mahjoub, T.; Almawi, W.Y. IL-10 gene promoter and intron polymorphisms and changes in IL-10 secretion in women with idiopathic recurrent miscarriage. Hum. Reprod. 2014, 29, 1025–1034. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Parker, V.J.; Douglas, A.J. Stress in early pregnancy: Maternal neuro-endocrine-immune responses and effects. J. Reprod. Immunol. 2010, 85, 86–92. [Google Scholar] [CrossRef]
- Hoffman, M.C.; Mazzoni, S.E.; Wagner, B.D.; Laudenslager, M.L.; Ross, R.G. Measures of Maternal Stress and Mood in Relation to Preterm Birth. Obstet. Gynecol. 2016, 127, 545–552. [Google Scholar] [CrossRef] [Green Version]
- Bapayeva, G.; Aimagambetova, G.; Issanov, A.; Terzic, S.; Ukybassova, T.; Aldiyarova, A.; Utepova, G.; Daribay, Z.; Bekbossinova, G.; Balykov, A.; et al. The Effect of Stress, Anxiety and Depression on In Vitro Fertilization Outcome in Kazakhstani Public Clinical Setting: A Cross-Sectional Study. J. Clin. Med. 2021, 10, 937. [Google Scholar] [CrossRef]
- Turdybekova, Y.G.; Kopobayeva, I.L.; Kultanov, B.Z. Comparative Assessment of Women’s Reproductive Health in the Areas Bordering with the Aral Sea Region. Open Access Maced. J. Med. Sci. 2017, 5, 261–265. [Google Scholar] [CrossRef] [Green Version]
- Henry, J.D.; Crawford, J.R. The short-form version of the Depression Anxiety Stress Scales (DASS-21): Construct validity and normative data in a large non-clinical sample. Br. J. Clin. Psychol. 2005, 44 Pt 2, 227–239. [Google Scholar] [CrossRef] [Green Version]
- Almawi, W.; Tamim, H.; Al-Sayed, N.; Arekat, M.R.; Al-Khateeb, G.M.; Baqer, A.; Tutanji, H.; Kamel, C. Association of comorbid depression, anxiety, and stress disorders with Type 2 diabetes in Bahrain, a country with a very high prevalence of Type 2 diabetes. J. Endocrinol. Investig. 2008, 31, 1020–1024. [Google Scholar] [CrossRef]
- Lovibond, S.H.; Lovibond, P.F. Manual for the Depression Anxiety & Stress Scales, 2nd ed.; Psychology Foundation: Sydney, Australia, 1995. Available online: https://maic.qld.gov.au/wp-content/uploads/2016/07/DASS-21.pdf (accessed on 4 November 2022).
- Nunnally, J.C.; Bernstein, I. Psychometric Theory; McGraw-Hill: New York, NY, USA, 1994. [Google Scholar]
- Bandura, A. Social Foundations of Thought and Action; Englewood Cliffs: East Orange, NJ, USA, 1986; pp. 23–28. [Google Scholar]
- Kessler, R.C.; Gruber, M.; Hettema, J.M.; Hwang, I.; Sampson, N.; Yonkers, K.A. Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychol. Med. 2008, 38, 365–374. [Google Scholar] [CrossRef]
- Sunderland, M.; Mewton, L.; Slade, T.; Baillie, A.J. Investigating differential symptom profiles in major depressive episode with and without generalized anxiety disorder: True co-morbidity or symptom similarity? Psychol. Med. 2010, 40, 1113–1123. [Google Scholar] [CrossRef] [Green Version]
- Nater, U.M. Recent developments in stress and anxiety research. J. Neural Transm. 2021, 128, 1265–1267. [Google Scholar] [CrossRef]
- Daviu, N.; Bruchas, M.R.; Moghaddam, B.; Sandi, C.; Beyeler, A. Neurobiological links between stress and anxiety. Neurobiol. Stress 2019, 11, 100191. [Google Scholar] [CrossRef]
- Kinser, P.A.; Lyon, D.E. A conceptual framework of stress vulnerability, depression, and health outcomes in women: Potential uses in research on complementary therapies for depression. Brain Behav. 2014, 4, 665–674. [Google Scholar] [CrossRef]
- Liu, R.T.; Alloy, L.B. Stress generation in depression: A systematic review of the empirical literature and recommendations for future study. Clin. Psychol. Rev. 2010, 30, 582–593. [Google Scholar] [CrossRef] [Green Version]
- StataCorp. Stata Statistical Software: Release 15; StataCorp LLC: College Station, TX, USA, 2017. [Google Scholar]
- R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. 2022. Available online: https://www.R-project.org/ (accessed on 29 September 2022).
- Bashiri, A. Recurrent Pregnancy Loss; Harlev, A., Agarwei, A., Eds.; Springer: Berlin/Heidelberg, Germany, 2016. [Google Scholar]
- Dimitriadis, E.; Menkhorst, E.; Saito, S.; Kutteh, W.H.; Brosens, J.J. Recurrent pregnancy loss. Nat. Rev. Dis. Prim. 2020, 6, 98. [Google Scholar] [CrossRef]
- Cramer, D.W.; Wise, L.A. The Epidemiology of Recurrent Pregnancy Loss. In Seminars in Reproductive Medicine; Thieme Medical Publishers Inc.: New York, NY, USA, 2000; Volume 18, pp. 331–340. [Google Scholar]
- Mahdi, N.; Al-Ola, K.; Khalek, N.A.; Almawi, W.Y. Depression, anxiety, and stress comorbidities in sickle cell anemia patients with vaso-occlusive crisis. J. Pediatr. Hematol. Oncol. 2010, 32, 345–349. [Google Scholar] [CrossRef]
- Wang, Y.; Meng, Z.; Pei, J.; Qian, L.; Mao, B.; Li, Y.; Li, J.; Dai, Z.; Cao, J.; Zhang, C.; et al. Anxiety and depression are risk factors for recurrent pregnancy loss: A nested case-control study. Health Qual. Life Outcomes 2021, 19, 78. [Google Scholar] [CrossRef]
- He, L.; Wang, T.; Xu, H.; Chen, C.; Liu, Z.; Kang, X.; Zhao, A. Prevalence of depression and anxiety in women with recurrent pregnancy loss and the associated risk factors. Arch. Gynecol. Obstet. 2019, 300, 1061–1066. [Google Scholar] [CrossRef]
- Hedegaard, S.; Landersoe, S.K.; Olsen, L.R.; Krog, M.C.; Kolte, A.M.; Nielsen, H.S. Stress and depression among women and men who have experienced recurrent pregnancy loss: Focusing on both sexes. Reprod. BioMedicine Online 2021, 42, 1172–1180. [Google Scholar] [CrossRef] [PubMed]
- Tavoli, Z.; Mohammadi, M.; Tavoli, A.; Moini, A.; Effatpanah, M.; Khedmat, L.; Montazeri, A. Quality of life and psychological distress in women with recurrent miscarriage: A comparative study. Health Qual. Life Outcomes 2018, 16, 150. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Wenzel, E.S.; Gibbons, R.D.; O’Hara, M.W.; Duffecy, J.; Maki, P.M. Depression and anxiety symptoms across pregnancy and the postpartum in low-income Black and Latina women. Arch. Women’s Ment. Health 2021, 24, 979–986. [Google Scholar] [CrossRef] [PubMed]
- Thomeer, M.B.; Moody, M.D.; Yahirun, J. Racial and Ethnic Disparities in Mental Health and Mental Health Care During The COVID-19 Pandemic. J. Racial Ethn. Health Disparities 2022, 22, 1–16. [Google Scholar] [CrossRef]
- Koert, E.; Malling, G.; Sylvest, R.; Krog, M.C.; Kolte, A.M.; Schmidt, L.; Nielsen, H.S. Recurrent pregnancy loss: Couples’ perspectives on their need for treatment, support and follow up. Hum. Reprod. 2019, 34, 291–296. [Google Scholar] [CrossRef]
- Hajjej, A.; Abdrakhmanova, S.; Turganbekova, A.; Almawi, W.Y. Distribution of HLA Class I and Class II alleles and haplotypes in German and Uzbek minorities in Kazakhstan, and relationship to other populations. HLA 2020, 96, 615–620. [Google Scholar] [CrossRef]
- Almawi, W.Y.; Hajjej, A.; Abdrakhmanova, S.; Turganbekova, A. Distribution of HLA-A, -C, -B, -DRB1, and -DQB1 polymorphisms in the Korean minority in Kazakhstan, and relatedness to neighboring and distant populations. Gene 2022, 823, 146386. [Google Scholar] [CrossRef]
- Kelly, R.H.; Russo, J.; Katon, W. Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive and anxiety symptom amplification revisited? Gen. Hosp. Psychiatr. 2001, 23, 107–113. [Google Scholar] [CrossRef]
- Lindgren, K. Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy. Res. Nurs. Health 2001, 24, 203–217. [Google Scholar] [CrossRef]
Variable | Total (n = 178) | Controls (n = 78) | RPL Cases (n = 70) | t/χ2 | p-Value |
---|---|---|---|---|---|
Age in years, mean ± SD | 34.8 ± 7.1 | 35.7 ± 7.0 | 33.6 ± 7.0 | t = 1.82 | 0.07 |
BMI in kg/m2, mean ± SD | 24.5 ± 4.1 | 24.6 ± 4.2 | 24.5 ± 4.1 | t = 0.15 | 0.91 |
BMI categories, n (%) | χ2 = 0.01 | 0.55 | |||
<25 kg/m2 | 90 (60.8) 3 | 47 (60.3) | 43 (61.4) | ||
≥25 kg/m2 | 57 (38.5) | 31 (39.7) | 26 (37.1) | ||
Ethnicity, others n (%) | 13 (8.8) | 5 (6.4) | 8 (11.4) | χ2 = 0.62 | 0.43 |
Education, n (%) | χ2 = 9.62 | 0.009 | |||
Elementary | 31 (20.9) | 24 (30.8) | 7 (10.0) | ||
Secondary | 21 (14.2) | 11 (14.1) | 10 (14.3) | ||
University | 94 (63.5) | 43 (55.1) | 51 (72.9) | ||
Family income, n (%) | χ2 = 1.18 | 0.51 | |||
Low | 29 (19.6) | 18 (23.1) | 11 (15.7) | ||
Middle | 108 (73.0) | 55 (70.5) | 53 (75.7) | ||
High | 10 (6.8) | 5 (6.4) | 5 (7.1) | ||
Menarche in years, mean ± SD | 13.5 ± 1.2 | 13.6 ± 1.2 | 13.4 ± 1.2 | t = 1.23 | 0.22 |
Gynecological illnesses, n (%) | 25 (16.9) | 14 (17.9) | 11 (15.7) | χ2 = 0.01 | 0.54 |
Number of pregnancies, mean ± SD | 3.8 ± 1.8 | 3.3 ± 1.5 | 4.5 ± 1.9 | t = −4.37 | <0.001 |
Para, mean ± SD | 1.7 ± 1.2 | 2.4 ± 0.9 | 0.9 ± 1.1 | t= 9.14 | <0.001 |
Medical history | |||||
Toxoplasma gondii, n (%) | 23 (15.5) | 12 (15.4) | 11 (15.7) | χ2 = 2.37 | 0.20 |
HCMV, n (%) | 23 (15.5) | 13 (16.7) | 10 (14.3) | χ2 = 2.77 | 0.17 |
Chlamydia trachomatis, n (%) | 22 (14.9) | 12 (15.4) | 10 (14.3) | χ2 = 3.40 | 0.13 |
Rubella, n (%) | 25 (16.9) | 12 (15.4) | 13 (18.6) | χ2 = 2.70 | 0.28 |
Ureaplasma, n (%) | 25 (16.9) | 12 (15.4) | 13 (18.6) | χ2 = 11.98 | 0.003 |
Previous oral contraceptives, n (%) | 23 (15.5) | 15 (19.2) | 8 (11.4) | χ2 = 1.02 | 0.15 |
Smoking, n (%) | 6 (4.1) | 3 (3.8) | 3 (4.3) | χ2 = 0.00 | 1.00 |
Alcohol, n (%) | 5 (3.4) | 4 (5.1) | 1 (1.4) | χ2 = 0.55 | 0.09 |
History of a chronic disease, n (%) | 12 (8.1) | 5 (6.4) | 7 (10.0) | χ2 = 0.25 | 0.62 |
Family history of a chronic disease, n (%) | 10 (6.8) | 5 (6.4) | 5 (7.1) | χ2 = 0.00 | 1.00 |
Hypertension, n (%) | 7 (4.7) | 3 (3.8) | 4 (5.7) | χ2 = 0.02 | 0.88 |
Thyroid disease, n (%) | 16 (10.8) | 5 (6.4) | 5 (7.1) | χ2 = 0.24 | 0.62 |
Variable | Total (n = 148) | Controls (n = 78) | RPL Cases (n = 70) | t/χ2 | p-Value |
---|---|---|---|---|---|
DASS-21 stress score continuous, mean ± SD | 6.46 ± 5.11 | 4.83 ± 4.60 | 8.27 ± 5.07 | t = −4.30 | <0.001 |
DASS-21 stress severity, n (%) | χ2 = 3.58 | 0.773 | |||
Normal | 135 (91.2) | 72 (92.3) | 63 (90.0) | ||
Mild–moderate | 13 (8.8) | 6 (7.7) | 7 (10.0) | ||
DASS-21 anxiety score continuous, mean ± SD | 4.33 ± 4.48 | 2.74 ± 3.30 | 6.10 ± 4.95 | t = −4.80 | <0.001 |
DASS-21 anxiety severity, n (%) | χ2 = 11.91 | 0.003 | |||
Normal | 119 (80.4) | 70 (89.7) | 49 (70.0) | ||
Mild–moderate | 23 (15.5) | 8 (10.3) | 15 (21.4) | ||
Severe–extreme | 6 (4.1) | 0 (0.0) | 6 (8.6) | ||
DASS-21 depression score continuous, mean ± SD | 4.58 ± 4.83 | 2.92 ± 3.37 | 6.43 ± 5.52 | t = −4.60 | <0.001 |
DASS-21 depression severity, n (%) | χ2 = 15.55 | <0.001 | |||
Normal | 127 (85.8) | 75 (96.2) | 52 (74.3) | ||
Mild–moderate | 20 (13.5) | 3 (3.8) | 17 (24.3) | ||
Severe–extreme | 1 (0.7) | 0 (0.0) | 1 (1.4) |
DASS-21 Stress | DASS-21 Anxiety | DASS-21 Depression | ||||
---|---|---|---|---|---|---|
Variable | Coefficient (95% CI) | p | Coefficient (95% CI) | p | Coefficient (95% CI) | p |
No RPL history | Reference | Reference | Reference | |||
RPL history | 3.67 (2.00; 5.35) | <0.001 | 3.66 (2.21; 5.10) | <0.001 | 3.81 (2.25; 5.37) | <0.001 |
Age | 0.02 (−0.10; 0.14) | 0.73 | 0.02 (−0.08; 0.12) | 0.66 | 0.00 (−0.11; 0.11) | 0.99 |
BMI < 25 | Reference | Reference | Reference | |||
BMI ≥ 25 | 1.02 (−0.66; 2.74) | 0.24 | 0.83 (−0.64; 2.29) | 0.27 | 1.26 (−0.32; 2.85) | 0.12 |
Elementary education | Reference | Reference | Reference | |||
Secondary education | −1.57 (−4.31; 1.17) | 0.56 * | −1.36 (−3.72; 1.00) | 0.52 * | −1.05 (−3.60; 1.50) | 0.84 * |
University education | −1.44 (−3.51; 0.63) | 0.36 * | −1.19 (−2.98; 0.59) | 0.38 * | −1.75 (−3.68; 0.17) | 0.16 * |
Ethnicity | 0.78 | 0.82 | ||||
Kazakhs | Reference | |||||
Others | 0.41 (−2.45; 3.27) | 0.28 (−2.18; 2.74) |
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Issakhanova, A.; Issanov, A.; Ukybassova, T.; Kaldygulova, L.; Marat, A.; Imankulova, B.; Kamzayeva, N.; Almawi, W.Y.; Aimagambetova, G. Depression, Anxiety, and Stress in Kazakhstani Women with Recurrent Pregnancy Loss: A Case–Control Study. J. Clin. Med. 2023, 12, 658. https://doi.org/10.3390/jcm12020658
Issakhanova A, Issanov A, Ukybassova T, Kaldygulova L, Marat A, Imankulova B, Kamzayeva N, Almawi WY, Aimagambetova G. Depression, Anxiety, and Stress in Kazakhstani Women with Recurrent Pregnancy Loss: A Case–Control Study. Journal of Clinical Medicine. 2023; 12(2):658. https://doi.org/10.3390/jcm12020658
Chicago/Turabian StyleIssakhanova, Assylzhan, Alpamys Issanov, Talshyn Ukybassova, Lyazzat Kaldygulova, Aizada Marat, Balkenzhe Imankulova, Nazira Kamzayeva, Wassim Y. Almawi, and Gulzhanat Aimagambetova. 2023. "Depression, Anxiety, and Stress in Kazakhstani Women with Recurrent Pregnancy Loss: A Case–Control Study" Journal of Clinical Medicine 12, no. 2: 658. https://doi.org/10.3390/jcm12020658