Grand multiparity: is it still a risk in pregnancy?

BMC Pregnancy and Childbirth Grand multiparity: is it still a risk in pregnancy? Andrew H Mgaya 0 Siriel N Massawe 1 Hussein L Kidanto 0 1 Hans N Mgaya 1 0 Department of Obstetrics and Gynaecology, Muhimbili National Hospital , PO Box 65000, Dar es Salaam , Tanzania 1 Department of Obstetrics Background: The association of grand multiparity and poor pregnancy outcome has not been consistent for decades. Classifying grand multiparous women as a high-risk group without clear evidence of a consistent association with adverse outcomes can lead to socioeconomic burdens to the mother, family and health systems. We compared the maternal and perinatal complications among grand multiparous and other multiparous women in Dar es Salaam in Tanzania. Methods: A cross-sectional study was undertaken at Muhimbili National Hospital (MNH). A standard questionnaire enquired the following variables: demographic characteristics, antenatal profile and detected obstetric risk factors as well as maternal and neonatal risk factors. Predictors of adverse outcomes in relation to grand multiparous women were assessed at p = 0.05. Results: Grand multiparas had twice the likelihood of malpresentation and a threefold higher prevalence of meconium-stained liquor and placenta previa compared with lower-parity women even when adjusted for age. Neonates delivered by grand multiparous women (12.1%) were at three-time greater risk of a low Apgar score compared with lower-parity women (5.4%) (odds ratio (OR), 2.9; 95% confidence interval (CI), 1.5-5.0). Grand multiparity and low birth weight were independently associated with a low Apgar score (OR, 2.4; 95%, CI 1.4-4.2 for GM; OR, 4.2; 95% CI, 2.3-7.8) for low birth weight. Conclusion: Grand multiparity remains a risk in pregnancy and is associated with an increased prevalence of maternal and neonatal complications (malpresentation, meconium-stained liquor, placenta previa and a low Apgar score) compared with other multiparous women who delivered at Muhimbili National Hospital. Grand multiparity; Pregnancy outcome; Diabetes mellitus; Hypertension; Malpresentation; Abruptio placentae; Placenta previa - Background The term grand multipara was introduced in 1934 by Solomon, who called grand multiparas the the dangerous multiparas [1]. In general, the older literature defines grand multiparity (GM) as parity >7 [2,3]. More recent reports select a definition of GM to start from a parity of 5 because the threshold of risks of any obstetric complication, neonatal morbidity, and perinatal death increase markedly at parity 5 [4,5]. Developed countries have a low prevalence of GM (34% of all births) [6] as a result of unlimited access to not only contraceptives but also antenatal care, skillful medical practitioners and adequate facilities for safe delivery. Hence, high parity is not considered to be a risk factor for pregnancy-related complications [7-9]. Conversely, a high prevalence of GM has been reported in developing countries [10-12]. In Tanzania, guidelines set by the Maternal and Child Health section of the Ministry of Health and Social welfare consider GM to be an obstetric risk. Furthermore, high parity has been deemed a burden to the family and health systems [13]. The Tanzania Demographic Health Survey (TDHS) for 2005 revealed a total fertility rate (TFR) of 5.7, which is statistically at the same level as rates estimated by the TDHS in 1996 (5.8 births) and 1999 (5.6 births). These data implied that, on average, a Tanzanian woman will bear 6 children [14]. The unmet need for family planning is 20%. Moreover, a study completed in rural Tanzania revealed that 60% of health workers were unaware of the definition of GM [15]. Despite good coverage of healthcare in Tanzania (90% of the population is <10 km from a healthcare facility), provision of health services remains inadequate because of poor accessibility and lack of equipment within health facilities [16]. Priorities in the allocation of health-service resources based on disease burden and evidence-based medicine within the health sector includes the identification of women whose pregnancies are at increased risk of complications. Hence, the few medical resources that are available are allocated to those in the greatest need. Hindrance to appropriate distribution of healthcare resources to mothers and children include a lack of recent accurate data on the magnitude and factors that influence adverse maternal and neonatal outcomes. High parity and reduced inter-pregnancy interval are reported to be risk factors for poor maternal and perinatal outcome. These factors together or independently may predispose the mother to anemia, diabetes mellitus (DM), hypertension, malpresentation, abruptio placentae, placenta previa, post-partum hemorrhage due the uterine atony, and uterine rupture [17-19]. Poor perinatal outcomes include low birth weight, prematurity and perinatal mortality [20-23]. GM has also been associated with previous loss of pregnancy such as intrauterine fetal death and perinatal death [24]. Absence of risk related to GM has been reported in some studies [7-9] and partly supported in others [25-28], which related GM to poverty, social deprivation, late booking at antenatal clinics, and preexisting chronic illnesses (including chronic hypertension and DM). Advanced maternal age of grand multiparas has been reported to be an independent risk factor of gestational DM, ante-partum hemorrhage, fetal distress, prematurity, low birth weight, perinatal mortality and chromosomal congenital abnormalities (particularly Down syndrome) [29,30]. In this regard, consideration of the confounding effect of advanced age of the grand multiparas is pivotal when analyzing the maternal and neonatal outcome of GM. For that reason, it is important to note that some studies [31,32] have associated high parity with an elevated risk to the pregnancy without adjusting for age in the analysis. In the absence of clear and consistent evidence of the association of GM with adverse pregnancy outcomes, classifying grand multiparas as a high-risk group could increase the cost burden to families and health systems as well as physical and psychological stress to the mother and family. The present study intended to answer the following research question: Is GM a risk factor for adverse pregnancy outcome? Our null hypothesis was: There is no difference in pregnancy outcome in grand multiparous women compared with low-parity women (parity = 24) We wished to estimate and compare the specified maternal and perinatal complications among grand multiparas and other multiparous women delivered at Muhimbili National Hospital (MNH; Dar es Salaam, Tanzania) and identify their associated risk factors for poor maternal and perinatal outcome. Methods Setting and design of the study This was a prospective cross-sectional study done at MNH. MNH is a National referral hospital which also serves as a teaching hospital for the Muhimbil (...truncated)