Grandmultiparity--not to be feared? An analysis of grandmultiparous women receiving modern antenatal care

Maternal risk exposure during pregnancy and infant birth weight

BACKGROUND

Birth weight is an important determinant of an infant's immediate and future health.

AIM

This study examined associations between selected maternal psychosocial and environmental risk factors during pregnancy and subsequent infant birth weight, utilising data from the South African Birth to Twenty Plus (Bt20+) birth cohort study.

SUBJECTS

Exposure to nine maternal risks were assessed in 1228 women who completed an antenatal questionnaire and whose infants were delivered within a seven-week period.

OUTCOME MEASURES

The outcome of interest was infant birth weight. Birth weight z-scores (BWZ) were calculated using the World Health Organization Child Growth Standards. Bivariate analyses and multiple regression models were used to identify significant risk factors.

RESULTS

The mean infant birth weight was 3139g (SD 486g), with a significant advantage in mean birth weight for male infants of 73g (p=0.008). Being unsure or not wanting the pregnancy was associated with a ~156g reduction in infant birth weight (β=-0.32; 95% CI -0.51; -0.14). Tobacco use during pregnancy was also negatively associated with BWZ (β=-0.32; 95% CI -0.59; -0.05). Exposure to both significant risk factors (tobacco use and pregnancy wantedness) was associated with cumulative reductions in birth weight, particularly among boys.

CONCLUSIONS

This study reinforces the importance of risks related to maternal attitudes and behaviours during pregnancy, namely unwanted pregnancy and tobacco use, which significantly lowered birth weight. Both identified risks are amenable to public health policy and programme intervention.

Grand multiparity: is it still a risk in pregnancy?

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.

Residual confounding explains the association between high parity and child mortality

Background

This study used data from recent Demographic and Health Surveys (DHS) to examine the impact of high parity on under-five and neonatal mortality. The analyses used various techniques to attempt eliminating selection issues, including stratification of analyses by mothers’ completed fertility.

Methods

We analyzed DHS datasets from 47 low- and middle-income countries. We only used data from women who were age 35 or older at the time of survey to have a measure of their completed fertility. We ran log-binominal regression by country to calculate relative risk between parity and both under-five and neonatal mortality, controlled for wealth quintile, maternal education, urban versus rural residence, maternal age at first birth, calendar year (to control for possible time trends), and birth interval. We then controlled for maternal background characteristics even further by using mothers’ completed fertility as a proxy measure.

Results

We found a statistically significant association between high parity and child mortality. However, this association is most likely not physiological, and can be largely attributed to the difference in background characteristics of mothers who complete reproduction with high fertility versus low fertility. Children of high completed fertility mothers have statistically significantly increased risk of death compared to children of low completed fertility mothers at every birth order, even after controlling for available confounders (i.e. among children of birth order 1, adjusted RR of under-five mortality 1.58, 95% CI: 1.42, 1.76). There appears to be residual confounders that put children of high completed fertility mothers at higher risk, regardless of birth order. When we examined the association between parity and under-five mortality among mothers with high completed fertility, it remained statistically significant, but negligible in magnitude (i.e. adjusted RR of under-five mortality 1.03, 95% CI: 1.02-1.05).

Conclusions

Our analyses strongly suggest that the observed increased risk of mortality associated with high parity births is not driven by a physiological link between parity and mortality. We found that at each birth order, children born to women who have high fertility at the end of their reproductive period are at significantly higher mortality risk than children of mothers who have low fertility, even after adjusting for available confounders. With each unit increase in birth order, a larger proportion of births at the population level belongs to mothers with these adverse characteristics correlated with high fertility. Hence it appears as if mortality rates go up with increasing parity, but not for physiological reasons.

The associations of parity and maternal age with small-for-gestational-age, preterm, and neonatal and infant mortality: a meta-analysis

Background

Previous studies have reported on adverse neonatal outcomes associated with parity and maternal age. Many of these studies have relied on cross-sectional data, from which drawing causal inference is complex. We explore the associations between parity/maternal age and adverse neonatal outcomes using data from cohort studies conducted in low- and middle-income countries (LMIC).

Methods

Data from 14 cohort studies were included. Parity (nulliparous, parity 1-2, parity ≥3) and maternal age (<18 years, 18-<35 years, ≥35 years) categories were matched with each other to create exposure categories, with those who are parity 1-2 and age 18-<35 years as the reference. Outcomes included small-for-gestational-age (SGA), preterm, neonatal and infant mortality. Adjusted odds ratios (aOR) were calculated per study and meta-analyzed.

Results

Nulliparous, age <18 year women, compared with women who were parity 1-2 and age 18-<35 years had the highest odds of SGA (pooled adjusted OR: 1.80), preterm (pooled aOR: 1.52), neonatal mortality (pooled aOR: 2.07), and infant mortality (pooled aOR: 1.49). Increased odds were also noted for SGA and neonatal mortality for nulliparous/age 18-<35 years, preterm, neonatal, and infant mortality for parity ≥3/age 18-<35 years, and preterm and neonatal mortality for parity ≥3/≥35 years.

Conclusions

Nulliparous women <18 years of age have the highest odds of adverse neonatal outcomes. Family planning has traditionally been the least successful in addressing young age as a risk factor; a renewed focus must be placed on finding effective interventions that delay age at first birth. Higher odds of adverse outcomes are also seen among parity ≥3 / age ≥35 mothers, suggesting that reproductive health interventions need to address the entirety of a woman’s reproductive period.

Funding

Funding was provided by the Bill & Melinda Gates Foundation (810-2054) by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group.

Effect of high parity on occurrence of some fetal growth indices: a cohort study

The objective of this retrospective cohort study was to explore the potential causal relation between parity and fetal growth indices, including low birth weight (LBW), macrosomia, and prematurity. The study was nested on a community trial in a city in Oman. The study analyzed 1939 pregnancies among 479 participants. Of these, 944 pregnancies (48.7%) were high parity (≥5). Obtained newborns with outcomes of interest were as follows: 191 LBW, 34 macrosomic, and 69 premature. Associations were measured using multilevel logistic regression modeling. Compared to low parity (LP, defined as <5), high parity was found to be associated with less risk of LBW (relative risk [RR] = 0.76; 95% confidence interval [CI]: 0.44–1.1) and prematurity (RR = 0.82; 95% CI: 0.54–1.27), but greater risk of macrosomia (RR = 1.8; 95% CI: 1.2–2.4). This study provides evidence that with increasing parity, risks of LBW and prematurity decrease, while risk of macrosomia increases.

Effect of grand multiparity on intrapartum and newborn complications in young women

OBJECTIVE

To examine the effect of high parity on complications in young women, aged 18-34 years.

METHODS

Seven years of Utah birth certificate data were reviewed (1995-2001). Young nulliparas and primiparas were compared with young grand and great grand multi-paras by using logistic regression. Young grand multiparas were compared with older grand multiparas.

RESULTS

Young grand multiparas were more likely to have a preterm delivery and less likely to experience fetal distress, instrumented delivery, cesarean delivery, and any intrapartum complication than young nulliparas or primiparas. Young grand multiparas were less likely to experience many complications than their older counterparts.

CONCLUSION

Among young women, grand and great grand multiparity does not increase the risk for most intrapartum and newborn complications. Young grand and great grand multiparas are at significantly decreased risk for many complications when compared with young women of lower parity and older grand and great grand multiparas.

LEVEL OF EVIDENCE

II-2.

High Parity and Fetal Morbidity Outcomes

OBJECTIVE

We investigated the association between high parity and fetal morbidity outcomes.

METHODS

We analyzed 22,463,141 singleton deliveries at 20 weeks or more of gestation in the United States from 1989 through 2000. Adjusted odds ratios generated from logistic regression models were used to approximate relative risk for neonatal morbidity in women with 1-4 (moderate parity or type I; referent group), 5-9 (high parity or type II), 10-14 (very high parity or type III) and 15 or more (extremely high parity or type IV) prior live births. Main outcome measures included low and very low birth weight, preterm and very preterm birth, and small and large for gestational age delivery.

RESULTS

The overall crude rates for low birth weight, very low birth weight, preterm birth, very preterm birth, and small and large for gestational age were 55, 11, 97, 19, 83, and 129 per 1,000 live births, respectively. The adjusted odds ratios for low birth weight, very low birth weight, preterm, and very preterm delivery increased consistently and in a dose-effect fashion with ascending parity (P for trend < .001). In the case of large for gestational age delivery, the adjusted odds ratio showed an inverted-U pattern, being highest among women in the type III parity cluster. The findings with respect to small for gestational age were inconclusive.

CONCLUSION

High parity is a risk factor for adverse fetal outcomes. However, the impact of heightened parity is more manifest as shortened gestation rather than physical size restriction. These findings could prove beneficial for counseling women of high parity.

High parity and adverse birth outcomes: exploring the maze

BACKGROUND

Despite extensive literature on the topic, it is uncertain if grand (para > or = 5) and great grand (para > or = 10) multiparity are associated with adverse birth outcomes. We critically evaluate the evidence for and against the existence of adverse maternal and/or fetal outcomes in high parity women.

METHODS

An electronic search of MEDLINE and other bibliographic databases (Current Contents, EMBASE, and CAB) was conducted, and all relevant articles in English language were retrieved.

RESULTS

Findings on the association between high parity and maternal-fetal birth outcomes are not consistent. Although the older literature tends to suggest that multiparity is a risk factor for negative birth outcomes, more recent reports are not supportive. Comparison across studies was further complicated by confounding factors like maternal age, socioeconomic status, and levels of prenatal care, as well as by variations in study designs and in the definition of parity itself. Furthermore, most studies that examined women of extreme parity (para > or = 10) were handicapped by inadequate power.

CONCLUSIONS

After accounting for quality, culture, and degrees of associations, the preponderance of evidence seems to point to possible existence of heightened risk for certain medical complications and placental pathologies among women of extreme parity. The literature also provides reasonable evidence for a higher-than-expected likelihood for occurrence of fetal macrosomia with advanced parity.

Extreme grandmultiparity: is it an obstetric risk factor?

OBJECTIVE

To examine the perinatal outcome in women of extreme grandmultiparity (EGMP) in a setting with good socio-economic conditions and modern perinatal care.

METHODS

About 1015 pregnant women with a parity of 10 and above who delivered at Al-Mafraq hospital, Abu Dhabi between 1992 and 1998 were compared with 2044 women of parity <5 and 1662 with parity of 5-9.

RESULTS

Pregnant women with parity of 10 and above had an increased incidence of gestational diabetes (P<0.001) and macrosomia (P<0.001) and a reduced incidence of preterm delivery (P<0.0001) and induction of labor (P<0.0001). There were no significant differences between the groups regarding, antepartum hemorrhage, cesarean section rate and neonatal outcomes.

CONCLUSION

Extreme grandmultiparity does not appear to be an independent risk factor for adverse perinatal outcome in the setting of good perinatal care.

Peripartum complications in grand multiparous women: para 6-9 versus para > or =10

OBJECTIVE

To assess the importance of birth order and advanced maternal age on maternal and peripartum complications.

STUDY DESIGN

The study population consisted of 12 296 multiparous women (six deliveries or more) with singleton gestation. Patients were classified into two groups according to the birth order: grand multiparous (between six and nine deliveries) and huge multiparous (ten or more deliveries). Peripartum complication was defined when at least one of the following conditions occurred: massive hemorrhage, uterine rupture, abruptio placentae, dysfunctional labor or malpresentations. Logistic regression analysis was used to evaluate the relationship between birth order and maternal age and peripartum complications.

RESULTS

Among the study population, 9587 (78%) were grand multiparous and the remaining 2709 were huge multiparous women. The rate of peripartum complications was higher in huge multiparous than in grand multiparous women: malpresentation (6.2% versus 5%, P<.005), massive hemorrhage (0.7% versus 0.4%, P<.001) and dysfunctional labor (6.4% versus 3.5%, P<.001). Huge multiparous women also had a higher rate of the following complications than grand multiparous women: cesarean section (14.4% versus 10.4%, P<.01), chronic hypertension (7.9% versus 3%, P<.001), severe pregnancy induced hypertension (2.6% versus 1.1%, P<.01), diabetes class A (10.7% versus 7.5%, P<.005), diabetes class B-R (4.3% versus 2%, P<.01) congenital anomalies (3.3% versus 2.6%, P<.05) and large for gestational age infant, (17% versus 12.4%, P<.01). When adjusted for maternal age, high birth order remained strongly associated with the occurrence of peripartum complications.

CONCLUSIONS

Huge multiparity was associated with a higher rate of maternal and peripartum complications than grand multiparity. Higher birth order remained an independent risk factor for peripartum complications after adjustment for maternal age.

Vaginal delivery in the grand multipara following previous lower segment cesarian section

OBJECTIVE

To examine the effect of attempting vaginal birth after cesarian section in the grand multipara with one previous cesarian section scar in the uterus.

METHOD

Over 5-year period (1990-1994) mothers with 6 or more previous deliveries and with a previous section scar in the uterus were identified. The outcome in these patients who attempted vaginal birth was reviewed.

RESULTS

Of the 85 patients with the combination of both grand multiparity and a previous cesarian section scar in the uterus, 45 attempted a trial of labor. Twenty-seven patients (60%) achieved successful uncomplicated vaginal delivery. There was a relatively high incidence of serious complications.

CONCLUSION

Vaginal birth after cesarian section can be achieved in some grand multiparas with a previous scar in the uterus. There is an increased risk of serious complications. The labor should be very closely supervised and early intervention arranged if there is not smooth rapid progress.

Great grand multiparity--beyond the 10th delivery

OBJECTIVE

To investigate the perinatal outcome and obstetric complications of women delivering for the 10th time or more.

METHODS

Four hundred twenty women of great grand multiparity were analyzed in a modern health care setting and compared with our general population of obstetric patients, with regard to past history, maternal age, gestational age, mode of delivery, fetal outcome and intercurrent medical/obstetric problems.

RESULTS

The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality. There was a slightly higher incidence of twin births compared with the general population.

CONCLUSION

It is probable that women capable of reaching their 10th delivery are basically healthy. If offered adequate perinatal care, they are not a high-risk group during subsequent deliveries.

Screening for gestational diabetes in a multi-ethnic population

A multi-ethnic population was screened for gestational diabetes mellitus (GDM) using a venous plasma glucose estimation, 1 h following a standard 50 g glucose load. A significant difference in the ethnic distribution of screen-positivity was found. Amongst the screen-positive group the odds ratio (OR) for special care baby facility (SCBU) admission and birthweight > 3999 g were both increased (OR = 1.87 and 1.99). Only limited diagnostic testing by a glucose tolerance test (GTT) could be achieved for the screen-positive population. For patients with confirmed GDM (two or more abnormal values on a GTT) the OR for SCBU admission was further increased to 5.1, while the OR for increased birthweight was only 1.34. Clinical attention should be directed towards outcome assessment in order to properly evaluate the nature of and place for screening for GDM in multi-ethnic populations.