• Users Online: 141
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 17  |  Page : 19-24

Lifestyle and risk factors associated with threatened miscarriage in elsaudi maternity hospital, Khartoum, Sudan (2018)

1 Department of Obstetrics and Gynaecology, Elsaudi Maternity Hospital, Ahfad University for Women, Omdurman, Sudan
2 Department of Obstetrics and Gynaecology, Elbaha University, Al Bahah, Saudi Arabia

Date of Submission10-May-2020
Date of Decision11-Sep-2020
Date of Acceptance23-Nov-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
(MD, MRCOG) Mohammed Eltayeb
Department of Obstetrics and Gynaecology, Elsaudi Maternity Hospital, Ahfad University for Women, Omdurman
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nnjcr.nnjcr_11_20

Rights and Permissions

Background: Threatened miscarriage is a relatively common complication during pregnancy, occurring in approximately 20% of all pregnancies. Objectives: The objective of this study is to determine the risk factors associated with threatened miscarriage at Elsaudi Maternity Hospital, Sudan in 2018. Materials and Methods: This is nonmatched single center, case–control study. Results: Overall, of 139 women were enrolled in our study distributed as 68 controls and 63 cases with vaginal bleeding. Risk factors for threatened miscarriage were age <20 (odds ratio [OR] 1.7), age over 40 (OR 1.4), rural residency (OR 1.3), first pregnancy (OR 1.6), unplanned pregnancy (OR 1.6), smoking (OR 2.2), mobile phone usage of more than 6 h (OR 2.4), having high stress level (OR 1.6), being a work in women (OR 1.3), having pre-existing medical condition (OR 1.5), nausea and vomiting during current pregnancy (OR 5.8), having previous miscarriage (OR 2.2), and using oral contraception (OR 1.3). Education and normal body mass index reduce the risk of having threatened miscarriage. Conclusion: Identifying risk factors for threatened miscarriage may aid in the prevention and treatment. We should raise awareness among women about the importance of prepregnancy counseling to identify pregnancies at risk.

Keywords: Early pregnancy bleeding, miscarrige threatened miscarriage

How to cite this article:
Eltayeb M, Mustafa EA. Lifestyle and risk factors associated with threatened miscarriage in elsaudi maternity hospital, Khartoum, Sudan (2018). N Niger J Clin Res 2021;10:19-24

How to cite this URL:
Eltayeb M, Mustafa EA. Lifestyle and risk factors associated with threatened miscarriage in elsaudi maternity hospital, Khartoum, Sudan (2018). N Niger J Clin Res [serial online] 2021 [cited 2023 Dec 4];10:19-24. Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/19/314594

  Introduction Top

Threatened miscarriage is a relatively common complication during pregnancy, occurring in approximately 20% of all pregnancies.[1] Vaginal bleeding during the first trimester is associated with an approximate 5.5%–42.7% risk for subsequent complete miscarriage.[2] Women who experience such bleeding, but do not experience a subsequent complete miscarriage, still have an increased risk for other adverse outcomes such as antepartum hemorrhage (APH), preterm delivery, low birth weight, and the potential need for assisted delivery.[3] The risk factors for the progression of a normal pregnancy to a complete miscarriage in the first trimester are fairly well established. The common risk factors include increased maternal age, high prepregnancy body mass index (BMI), and low serum progesterone levels.[4] More recently, lifestyle factors such as caffeine intake, exercise, stress, exposure to cigarette smoke, and alcohol consumption have also been implicated as risk factors.[5]

Approximately 50% of women who experienced threatened miscarriage eventually suffer miscarriages.[6] Many studies[7],[8] have reported that threatened miscarriage is associated with an increased obstetric complication, such as APH, preterm delivery, cesarean delivery, preeclampsia, placenta previa, and placenta abruption, and adverse perinatal outcomes, such as small for gestational age and early neonatal death.

A threatened miscarriage occurs when a pregnant patient, at <20 weeks gestation, presents with vaginal bleeding. The cervical os is closed on a physical examination. The patient may also experience abdominal cramping and pain. Vaginal bleeding usually begins first followed by cramping abdominal pain hours to days later. Bleeding is the most predictive risk factor for pregnancy loss. More than half of threatened abortions will abort. The risk of spontaneous abortion, in a patient with a threatened abortion, is less if fetal cardiac activity is present.[9]

The importance of identifying the risk factors for threatened miscarriage has a role in the prevention and treatment of the condition. Age, obesity, stress level, previous history of miscarriage, and presence of medical disorders have been well-established risk factors. A prospective cohort study by Kouk,[10] showed that women aged ≥34 years were more likely to miscarry (hazard ratio [HR] = 1.95). Compared to women whose partner was 20–30 years of age, women whose partner was ≥41 years of age also had a higher likelihood of experiencing a miscarriage (HR = 8.33). However, they reported nausea and a high perceived stress level were associated with a reduced likelihood of miscarriage.

Another case–control study about lifestyle risk factors associated with threatened miscarriage,[5] smoke exposure, computer usage, mobile-phone usage (>1 h/day), and caffeine consumption were associated with increased risk.

Socio and demographic data have also contributed to threatened miscarriage as reported in this brief review about miscarriage and associated risk factors in India.[11] Furthermore, a follow-up study[12] about risk factors for miscarriage from a prevention, reported, the potentially modifiable prepregnant risk factors associated with increased miscarriage risk were: age of 30 years or more at conception, underweight, obesity, and smoking,[13] whereas a large prospective study including 24,608 pregnancies could not demonstrate an association between smoking and miscarriage.[14],[15]

In another meta-analysis about environmental risk factors of pregnancy outcomes,[16] they reported statistically significant associations between environmental exposures such as environmental tobacco smoke, air pollution, and chemicals and pregnancy outcomes.

Research objectives

General objectives

To determine the risk factors that are associated with threatened miscarriage in Omdurman new hospital, Sudan in 2018.

Specific objectives

  • To determine the social and demographic factors in association with threatened miscarriage
  • To determine the role of medical disorder and previous miscarriage with threatened miscarriage.

  Materials and Methods Top

Study design

This is nonmatched single center case–control study conducted in 2018 at Elsaudi hospital.

Study population

The population of the study are women with first trimester threatened miscarriage attending Saudi hospital during the study period (case) and women with normal pregnancy in their first trimester who presented for antenatal care (ANC) were enrolled as control.

Study duration

The period of the study was from January 2018 to November 2018.

Including criteria

  1. Single-tone pregnancy
  2. Viability confirmed on ultrasound.

Exclusion criteria

Women refused to enroll in our study.

Data collection methods

Data collected using structured questionnaire, women presented with vaginal bleeding in first trimester and viability confirmed in ultrasound scan were enrolled as cases, after they had been informed about the study, and women presented for just for ANC in their first trimester at our clinic were enrolled as control, after also being informed and consented for participation.

Sample size

Sample size was calculated using the following formula:

Study sample was distributed as 68 control and 63 cases.

Ethical consideration

Written consent was obtained from Ministry of Health and Elsaudi Maternity Hospital. Furthermore, written consent was obtained from our participants.

  Results Top

[Table 1] Shows distribution of women according to their personal information, in both control and cases, age distribution was mainly between 30-40 years in control group and between 20-30 in cases. Odd ratio for threatened miscarriage in women more than 40 was 1.4 (95%CI 0.6-3.5), and odd ratio for women less than 20 was 1.7 (95%CI 0.5-5.1). Furthermore, husband age more than 40 was associated with increased risk for threatened miscarriage (Odd ratio 2.3, (95%CI 1.1-4.2). Moreover, educational level in our study showed more than 40% with secondary and above education, high level of education was found as preventive factor for threatened miscarriage (odd ratio 0.4 (95% CI 0.3-0.7). Also, homeworker and urban resident associated with increased risk for threatened miscarriage (odd ration 1.3, 1.3) respectively. [Table 2], where it describes a different risk factors for threatened miscarriage, its shows that having nausea and vomiting in current pregnancy was associated with greater risk for threatened miscarriage (odd ratio 5.8), other risk factors includes: primiparity (odd ratio 1.6), unplanned pregnancy (1.6), gestational age between 8-10 weeks, patient with known medical disorder (odd ratio 1.5), caffeine consumption (odd ratio 1.9), and previous history of miscarriage (odd ration 2.2). However, having a normal BMI was found to decrease the risk for threatened miscarriage. [Table 3], also describe different risk factors for threatened miscarriage, it shows that heavy mobile usage per day was associated with increased risk of having threatened miscarriage (odd ration 1.6), moreover, high level of perceived stress was also a risk (odd ratio 2.2). smoker patients were at risk for threatened miscarriage (odd ratio 2.2) as well as history of contraceptive usage.
Table 1: Distribution of cases and control according to personal information along with the odd ratio

Click here to view
Table 2: Different risk factors for threatened miscarriages in both cases and controls

Click here to view
Table 3: Different risk factors for threatened miscarriages in both cases and controls

Click here to view

  Discussion Top

This is an unmatched case–control study of 139 women, aiming to determine the risk factors that are associated with threatened miscarriage, conducted at Omdurman New Hospital in 2018.

Extreme maternal age was found as a significant risk factor for threatened miscarriage in the present study, maternal age <20 or over 40 were increase the risk of threatened miscarriage by 1.7 and 1.4, respectively, this is consistent with previous studies, which showed that the risk of miscarriage is higher in pregnant women at extreme age,[5],[8],[17] Furthermore, paternal age has also founded as a risk factor for threatened miscarriage which correspond to the study of de La Rochebrochard and Thonneau,[18] were they confirmed the impact of paternal age in adverse pregnancy outcome in terms of miscarriage, this has been attributed to decreased sperm quality and DNA changes in the sperm of older men. Studies have also shown that both the age of the mother and father are closely linked, and the advanced age of both parents is associated with a worse prognosis for the baby.[19]

In our study, being rural resident increase the odds of having threatened miscarriage (odd ratio 1.3), furthermore educated patients were less likely to have threatened miscarriage, this may reflect their awareness about pregnancy complication, prevention, and follow-up. Our finding is consistent with the study of Kebede et al.,[20] in Ethiopia were they reached to conclusion of well-established association between residency, low educational level, and adverse pregnancy outcome.

Furthermore, in our study, primigravida has been found as risk factor for threatened miscarriage (odds ratio [OR] 1.6, 95% confidence interval [CI] 0.7–3.6), the combination of poor nutrition and early child bearing expose young women to serious health-risks during pregnancy, childbirth, including damage to the reproductive tract, pregnancy-related complications, such as anemia, pregnancy-induced hypertension, preterm labor, cephalopelvic disproportion, maternal mortality, perinatal and neonatal mortality, and low birth weight. Our finding corresponded to the other studies.[21],[22]

Unplanned pregnancy in our study was found to increase the odds of threatened miscarriage (1.6, 95% CI 1.3–2.0), as apparent that pregnancy begun without some degree of planning and intent often precludes individual women and couples from participating in preconception risk identification and management, certain specific diseases and conditions with serious consequences, such as diabetes, are best managed among pregnant women when care is begun before conception. Our finding is consistent with Danish et al.,[21] where they reported a high rate of adverse pregnancy complication including miscarriage in unbooked patients. Furthermore, Yazdkhasti et al.[23] sustained on the importance of planned pregnancy and well-known association of unplanned pregnancy with social and health problems. Raising the women awareness regarding the importance of planned pregnancy should be taken through their attendance to their care provider.

Smoker status in our study was found also to increase the odds of getting threatened miscarriage by (2.2, 95% CI 0.9–9.5), there is well-known association between smoking and overall adverse pregnancy outcome which may include abortion, low birth weight, placental abruption, and sudden infant death syndrome.[24]

Moreover, mobile phone usage for more than 6 hour per day was associated with increased odds of having threatened miscarriage (OR 2.4, 95% CI 1.1–5.1). Tan,[5] came to the same conclusion were they found that mobile phones and computer usage increase the odds of threatened miscarriage by 6 folds. From such evidence in order to reduce the risk, women should be educated and informed during their follow up about the importance of avoiding spending more time to their phones. A recent study conducted in Spain found that children born to women who had excessive mobile phone usage during pregnancy were 40% more likely to develop behavioral problems.[25]

In order to decrease such risk, also randomized trial should be conducted to confirm such findings.

On another hand, Perceived stress level was found to have significant association with threatened miscarriage in our study, as Psychological stress can influence well-being through associated health-impairing behaviors and through physiological responses which affect vascular, immune, metabolic or neuroendocrine functions. Our result corresponded to the meta-analysis of Bonde et al.,[26] about The association between psychological stress and miscarriage, where they confirmed a strong contribution of stress level to pregnancy outcome, and furthermore the reproductive function, this may require to establish a strict protocol to screen and support women during pre-conceptional periods and during their pregnancy.

Our study also revealed that being a women worker may increase the odds of threatened miscarriage OR 1.3, which is corresponded to the study of Bonde et al.,[26] although they lessen its role in affecting the pregnancy, but the strength on the importance of the balance and stable work environment.

Having normal weight in our study was found to decrease the odds of threatened miscarriage, Its one of the element of the pre pregnancy care to advice women to have normal weight as its improve pregnancy outcome, our result is consistent to the study of Zhou et al.,[27] were they reported extreme weight as risk factor for miscarriage.

Existence of medical disorder and previous history of miscarriage were both found to increase the odd of threatened miscarriage, additionally, women who have experienced a pregnancy loss are more likely to experience an adverse mental health problem such as depression and anxiety following the loss, on the other hand evidence linking preexisting maternal medical conditions and pregnancy complications with maternal and child health over the life-course is well established.[28],[29],[30]

In our study the highest reported risk factor for threatened miscarriage was nausea and vomiting in current pregnancy (OR 5.4 95% CI 2.6–12.7), the impact of such condition may effect women health, as nutritional deficiency, stress, electrolyte disturbance, weight loss, de-arrange other organ function, prevention, early treatment and support may aid to lessen the adverse outcome. Furthermore, caffeine consumption in our study was also found to be associated with threatened miscarriage. Our result in agreement with other studies.[31],[32]

Finally, history of contraception usage prior to pregnancy was associated with threatened miscarriage OR 1.3, contraception can alter the endogenous hormonal milieu, even after discontinuation and disruptions in hormones, especially those that are directly involved in the menstrual cycle,[33] our result is different to the study of Kristen et al.,[34] were they found no relation between contraception use and risk of miscarriage, however García et al.,[35] reported usage of oral contraception of more than 2 years increase the risk of miscarriage.

  Conclusion Top

  • Risk factors for threatened miscarriage were maternal age <20, more than 40, paternal age more than 40, rural residency, and primigravida
  • Also unplanned pregnancy, smoking, mobile phone usage >6 h, high stress level and being a women worker increase the odds of getting threatened miscarriage
  • Preexisting medical condition, caffeine use, and contraception usage prior to pregnancy increase the odds of threatened miscarriage
  • Having normal BMI before pregnancy and educated women decrease the odds of threatened miscarriage
  • Nausea and vomiting with pregnancy were found to be the highest risk factors to get threatened miscarriage
  • Inferences about causal relationships between the assessed risk factors and threatened miscarriage must be drawn with caution because of the study limitations. However, we identified new potential factors worthy of further examination in future, prospective and larger cohorts.


  • Raising women awareness about risk factors for threatened miscarriage may aid in prevention
  • Strict advice women about the importance of prepregnancy clinic and to have planned pregnancy as it helps in the identification of high risk pregnancies and providing an appropriate interventions
  • Setting up mental health clinic will aim in lessen the adverse effect of stress, anxiety, and other psychiatric disorders
  • Education about the hazards of nausea and vomiting with pregnancy, with appropriate advice about prevention and early treatment
  • Identify women with existing medical conditions and sharing their management with suitable joint specialized team will aid in reducing its adverse outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Weiss JL, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study. Am J Obstet Gynecol 2004;190:745-50.  Back to cited text no. 1
El-Zibdeh MY, Yousef LT. Dydrogesterone support in threatened miscarriage. Maturitas 2009;65 Suppl 1:S43-6.  Back to cited text no. 2
Wijesiriwardana A, Bhattacharya S, Shetty A, Smith N, Bhattacharya S. Obstetric outcome in women with threatened miscarriage in the first trimester. Obstet Gynecol 2006;107:557-62.  Back to cited text no. 3
Johns J, Jauniaux E. Threatened miscarriage as a predictor of obstetric outcome. Obstet Gynecol 2006;107:845-50.  Back to cited text no. 4
Tan TC. Lifestyle risk factors associated with threatened miscarriage: A case control study. Journal of fertilization: In vitro, ivf-worldwide, reproductive medicine, genitics & stem cell biology. JFIV Reprod Med Genet 2014;2:2.  Back to cited text no. 5
Park C, Kang MY, Kim D, Park J, Eom H, Kim EA. Correction: Prevalence of abortion and adverse pregnancy outcomes among working women in Korea: A cross-sectional study. PLoS One 2017;12:e0188673.  Back to cited text no. 6
Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S. Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: A systematic review. BJOG 2010;117:245-57.  Back to cited text no. 7
Lee HJ, Norwitz E, Lee B. Relationship between threatened miscarriage and gestational diabetes mellitus. BMC Pregnancy Childbirth 2018;18:318.  Back to cited text no. 8
Mellerup N, Sørensen BL, Kuriigamba GK, Rudnicki M. Management of abortion complications at a rural hospital in Uganda: A quality assessment by a partially completed criterion-based audit. BMC Womens Health 2015;15:76.  Back to cited text no. 9
Kouk LJ. A prospective study of risk factors for first trimester miscarriage in Asian women with threatened miscarriage. Singapore Med J 2013;54:425-31.  Back to cited text no. 10
Kamble G, Bhattacharya BM. Miscarriage and associated risk factors in India: A brief review. MOJ Womens Health 2017;4:84-6.  Back to cited text no. 11
Feodor Nilsson, S, Andersen, PK, Strandberg-Larsen, K, Nybo Andersen, A-M. Risk factors for miscarriage from a prevention perspective: a nationwide follow-up study. BJOG 2014; 121: 1375– 1385.  Back to cited text no. 12
Saravelos SH, Regan L. The importance of preconception counseling and early pregnancy monitoring. Semin Reprod Med 2011;29:557-68.  Back to cited text no. 13
Wisborg K, Kesmodel U, Henriksen TB, Hedegaard M, Secher NJ. A prospective study of maternal smoking and spontaneous abortion. Acta Obstet Gynecol Scand 2003;82:936-41.  Back to cited text no. 14
Cohain JS, Buxbaum RE, Mankuta D. Spontaneous first trimester miscarriage rates per woman among parous women with 1 or more pregnancies of 24 weeks or more. BMC Pregnancy Childbirth. 2017;17:437.  Back to cited text no. 15
Nieuwenhuijsen MJ, Dadvand P, Grellier J, Martinez D, Vrijheid M. Environmental risk factors of pregnancy outcomes: A summary of recent meta-analyses of epidemiological studies. Environ Health 2013;12:6.  Back to cited text no. 16
Cleary-Goldman J, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Impact of maternal age on obstetric outcome. Obstet Gynecol 2005;105:983-90.  Back to cited text no. 17
de La Rochebrochard E, Thonneau P. Paternal age and maternal age are risk factors for miscarriage; results of a multicentre European study. Hum Reprod 2002;17:1649-56.  Back to cited text no. 18
Jaleel R, Khan A. Paternal factors in spontaneous first trimester miscarriage. Pak J Med Sci 2013;29:748-52.  Back to cited text no. 19
Kebede AS, Muche AA, Alene AG. Factors associated with adverse pregnancy outcome in Debre Tabor town, Northwest Ethiopia: A case control study. BMC Res Notes 2018;11:820.  Back to cited text no. 20
Danish N, Fawad A, Abbasi N. Assessment of pregnancy outcome in primigravida: Comparison between booked and un-booked patients. J Ayub Med Coll Abbottabad 2010;22:23-5.  Back to cited text no. 21
Mukhopadhyay P, Chaudhuri RN, Paul B. Hospital-based perinatal outcomes and complications in teenage pregnancy in India. J Health Popul Nutr 2010;28:494-500.  Back to cited text no. 22
Yazdkhasti M, Pourreza A, Pirak A, Abdi F. Unintended Pregnancy and Its Adverse Social and Economic Consequences on Health System: A Narrative Review Article. Iran J Public Health 2015;44:12-21.  Back to cited text no. 23
Pineles BL, Park E, Samet JM. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol 2014;179:807-23.  Back to cited text no. 24
Divan HA, Kheifets L, Obel C, Olsen J. Cell phone use and behavioural problems in young children. J Epidemiol Community Health 2012;66:524-9.  Back to cited text no. 25
Bonde JP, Jørgensen KT, Bonzini M, Palmer KT. Miscarriage and occupational activity: A systematic review and meta-analysis regarding shift work, working hours, lifting, standing, and physical workload. Scand J Work Environ Health 2013;39:325-34.  Back to cited text no. 26
Zhou H, Liu Y, Liu L, Zhang M, Chen X, Qi Y. Maternal pre-pregnancy risk factors for miscarriage from a prevention perspective: A cohort study in China. Eur J Obstetr Gynecol Reprod Biol 2016;206:57-63.  Back to cited text no. 27
Chojenta C, Harris S, Reilly N, Forder P, Austin MP, Loxton D. History of pregnancy loss increases the risk of mental health problems in subsequent pregnancies but not in the postpartum. PLoS One 2014;9:e95038.  Back to cited text no. 28
Malcolm J. Through the looking glass: Gestational diabetes as a predictor of maternal and offspring long-term health. Diabetes Metab Res Rev 2012;28:307-11.  Back to cited text no. 29
Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: Systematic review and meta-analysis. Eur J Epidemiol 2013;28:1-9.  Back to cited text no. 30
NICHD. Couples' Pre-Pregnancy Caffeine Consumption Linked to Miscarriage Risk. NICHD; 2016. Available from: https://www.nichd.nih.gov/news/releases/Pages/032416-miscarriage-caffeine.aspx. [Last accessed on 2017 Jul 24].  Back to cited text no. 31
Weigel MM, Weigel RM. Nausea and vomiting of early pregnancy and pregnancy outcome. An epidemiological study. Br J Obstet Gynaecol. 1989 Nov;96(11):1304-11. doi: 10.1111/j.1471-0528.1989.tb03228.x. PMID: 2611169.  Back to cited text no. 32
Li HW, Wong CY, Yeung WS, Ho PC, Ng EH. Serum anti-mullerian hormone level is not altered in women using hormonal contraceptives. Contraception 2011;83:582-5.  Back to cited text no. 33
Bonnen KI, Tuijje DN, Rasch V. Determinants of first and second trimester induced abortion - results from a cross-sectional study taken place 7 years after abortion law revisions in Ethiopia. BMC Pregnancy Childbirth. 2014;14:416. Published 2014 Dec 19. doi:10.1186/s12884-014-0416-9.  Back to cited text no. 34
García-Enguídanos A, Martínez D, Calle ME, Luna S, Valero de Bernabé J, Domínguez-Rojas V. Long-term use of oral contraceptives increases the risk of miscarriage. Fertil Steril. 2005 Jun;83(6):1864-6. PubMed PMID: 15950668.  Back to cited text no. 35


  [Table 1], [Table 2], [Table 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded6    
    Comments [Add]    

Recommend this journal