Recurrent pregnancy loss (RPL) is defined as ≥2–3 consecutive losses of clinical pregnancy documented by ultrasound or histopathologic exam (1–3). Primary RPL refers to no prior live births or pregnancies beyond 20–24 weeks gestation (4). Secondary RPL refers to ≥1 previous live birth or pregnancy beyond 20–24 weeks gestation (4). Clinically recognized pregnancy loss is reported in about 15–25% of pregnancies (1), and the reported prevalence of RPL is 1–4% of all patients who achieve pregnancy (4). A large-scale study in China (299,580 women) revealed a rate of RPL of 1.92% (5). In Lanzhou (China), the natural miscarriage rate is 14.64% (6). The cause of RPL is reported to be idiopathic in 50–75% of cases, although it may be associated with increasing parental age (1–4). Antiphospholipid antibodies are reported in 8–42% of patients with RPL, embryonic chromosomal abnormalities are reported in 30–57%, and congenital uterine malformation is reported in 1.8–37.6% (1, 2, 4). The general management considerations for all couples/patients with RPL include psychological support and counseling, dietary and lifestyle changes (3), and referral to a specialist clinic (2). Genetic counseling is recommended, while in vitro fertilization with preimplantation genetic testing is not recommended to treat RPL because it has not been shown to improve live birth rates (2–4). Patients with identified causes of RPL (e.g., thrombophilia, metabolic or hormonal abnormalities, and uterine abnormalities) should first have their condition managed (3).

Hence, the management of RPL requires the active participation of the women. Indeed, women with RPL should seek psychological and genetic counseling. The management of RPL also involves changes in lifestyle habits, including taking multivitamins and vitamin D supplements, stopping smoking, attaining and maintaining a normal range body mass index (BMI), and limiting alcohol consumption (2). Women should also advise their spouses to make the same changes in lifestyle habits (3). Therefore, the management of RPL actively involves self-management. Still, a basis of self-management is a proper knowledge of the disease and its management (7). The results of knowledge, attitude, and practice (KAP) can be used to design educational interventions to improve the management of a specific condition (8, 9). Knowledge is the basic information and data required as the basis to have motivation toward a given subject and practice. Attitude is the motivation toward a given subject and is the force driving practice (8, 9). Practice is the actions taken to perform and apply the subject. The KAP theory entails that practices can be changed by modulating attitudes through knowledge.

In Saudi Arabia, about 50% of women had knowledge of RPL, but the KAP was generally poor (10), as supported by another study from Egypt (11). A previous study in Qatar revealed numerous misconceptions about RPL (12). Healthcare providers are often a primary source of medical information for patients, and such professionals often display poor knowledge of miscarriage (13). Still, KAP is highly dependent upon the culture, society, economic status, and customs and can vary among countries. No KAP data regarding RPL are available from China.

China participates in the Millennium Development Goals (MDGs). As one of the biggest developing countries, China achieved great progress in improving maternal health by achieving the MDG 5.A (i.e., reducing maternal mortality by 75% between 1990 and 2015) and MDG 5.B (i.e., universal access to reproductive health services) (14, 15). China also applies the Sustainable Development Goals (SDGs) 3, which entails that a country makes efforts to achieve universal health coverage with equal access to affordable, accountable, and appropriate health services of certified quality (16, 17). China offers life-round preventive and curative health services to women, with universal access to reproductive health services (14). Still, the reproductive health workforce has been shown to be unequally distributed in the country (15), and efforts are being taken to remedy the situation. The present study was performed in Lanzhou, the capital of Gansu Province. The per-capita gross domestic product ranks 134 among 659 Chinese cities.

The China Consensus on the Diagnosis and Treatment of Recurrent Abortion (2022) (18) emphasizes that post-pregnancy psychological factors, lifestyle, and post-pregnancy monitoring and management should not be overlooked and should be inquired during the miscarriage workup. The exposure to adverse lifestyles and environmental factors should be documented. Psychological assessments and counseling should be provided. Unhealthy lifestyle habits should be corrected. The patients should be closely monitored in early pregnancy with regular checkups and examinations.

Therefore, this study aimed to examine the KAP of patients with RPL toward RPL in Lanzhou. In the context of the present study, knowledge is the knowledge about what recurrent pregnancy loss is, the possible causes, and the possible management methods. Attitude represents what the women think about multiple biochemical pregnancies, the management of RPL, the biological meaning of RPL, the importance of identifying the causes of RPL, the women’s worries about themselves and their spouses, and the women’s trust in physicians. Practice is what the women are actually doing regarding RPL, i.e., if they participate in training, what they do if an abortion is inevitable, and their life behaviors.

This study suggested that women with RPL in Lanzhou show poor knowledge, moderate attitude, and proactive practice toward RPL. This study identified specific KAP items that would require improvements. The study also identified categories of patients who would need more attention.

Few data regarding the KAP toward RPL are available in the literature. In Saudi Arabia, Tyagi et al. (10) reported that about 50% of the women had some knowledge of RPL and that 60% had positive attitudes, but the study identified several points to be improved, especially regarding the roles of lifting heavy objects, previous contraception methods, and sexually transmitted diseases. Practice regarding medical help also had to be improved. In Egypt, Salama et al. (11) showed that >50% of the women had poor knowledge, but about 67% had positive attitudes. In the present study, the knowledge was poor, but attitudes were moderate, and practice was proactive. Hence, these results suggest that many women followed the physicians’ recommendations without understanding why they performed specific actions to improve their chances of pregnancy.

Age is a major factor affecting fertility, and women are aware that advancing age toward inexorable menopause decreases their chances of having a baby (22, 23). Accordingly, the present study showed that in women younger than 32, age was positively associated with knowledge, attitude, and practice, while after 32, age was negatively associated with attitude and practice, suggesting that with advancing age, the women with RPL are losing confidence in eventually achieving a pregnancy and pay less attention to the self-management to increase the likelihood of pregnancy. On the other hand, although Salama et al. (11) did not analyze age and attitude using non-linear regression, they showed that the frequency of negative attitudes was much more frequent in younger women. It could be due to social differences between Egypt and China and the social, spouse, and peer pressure to achieve a pregnancy. Bailey et al. (24) also showed that women hoped for a pregnancy but expected the worst, especially with advancing age. Tavoli et al. (25) also showed that women generally gained more negative attitudes with the number of recurrent abortions, which was not observed in the present study, but the number of abortions and age are inevitably covariates, and the statistical significance could be lost.

The present study showed that the women with higher education and income had better KAP toward RPL. It is generally supported by the fact that health literacy is directly related to socioeconomic status (26). Accordingly, and supporting the poor knowledge observed in the present study, Munakampe et al. (27) reported poor knowledge of reproductive health in low- and middle-income countries. On the other hand, Campillo et al. (28) reported no association between education and the risk factors for spontaneous abortion, but their study only enrolled university students.

According to the KAP theory, knowledge is the basis for practice, while attitude is the force driving practice (8, 9). In the present study, the Pearson and SEM analyses showed that knowledge positively influenced attitude and practice, and attitude positively influenced practice. Hence, improving knowledge should directly impact attitude and practice. Especially, the definition of RPL, the etiology of RPL, and the management of comorbidities that can increase the risk of RPL should be properly taught to the general population. Such misconceptions were also previously observed in Saudi Arabia (10) and Qatar (12). Still, a study showed that Flemish midwives had a poor knowledge of RPL (13). Since healthcare providers are a major source of medical information for many people, such providers working with pregnant women should be properly trained on RPL.

This study has limitations. The study was conducted at a single center, limiting the sample size and the generalizability of the study. Indeed, healthcare literacy and KAP are often associated with socioeconomic status (26), which varies widely among geographical areas in China (29, 30). Although it was a prospective study, the questionnaire was self-designed by the investigators according to the local practices and policies, limiting generalizability. The study was cross-sectional, preventing any analysis of causality. A SEM analysis was performed to provide some clues about causality, but the causality was statistically inferred rather than observed, and such results must be interpreted with caution. In addition, the results represent the KAP at a precise point in time but could be used as a historical baseline to examine the impact of future education interventions. All KAP studies are at risk of social desirability bias, in which the participants can be tempted to answer what they know they should do instead of what they are doing (31, 32). Considering that the practice scores were high, that bias is a possibility. Multicenter studies and pre/post-intervention studies should be performed to confirm the results.

In conclusion, women with RPL in Lanzhou show poor knowledge, moderate attitude, and proactive practice toward RPL, and patients’ age displays a non-linear relationship with KAP. This study identified specific KAP items that would require improvements. The study also identified categories of patients who would need more attention.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by the ethics committee of the Second Hospital of Lanzhou University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

FM: Conceptualization, Writing – original draft. TH: Data curation, Writing – original draft. KW: Data curation, Writing – original draft. FW: Conceptualization, Data curation, Writing – review & editing.