Abstract

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Background: Grandmultiparity has been described as an independent risk factor for a variety of obstetric complications, especially in developing countries with inadequate health facilities.
Aim: To compare the pregnancy outcomes of grandmultiparas with that of multiparas at the Imo State University Teaching Hospital, Orlu.
Patients and Methods: The antenatal complications and pregnancy outcomes among booked grandmultiparas who delivered in our labour ward were compared with those of booked multiparae who delivered immediately after a grandmultipara.
Main outcome measures: These were obstetric factors of maternal age and parity, antepartum and postpartum haemorrhage, foetal malpresentations and malpositions, gestational age at delivery, mode of delivery and maternal mortality. Medical complications were diabetes mellitus, hypertension, anaemia and heart disease. Foetal outcome measures were birth weight, neonatal jaundice, birth asphyxia, congenital malformations and perinatal mortality.
Results: The age range of the grandmultiparae was between 23 and 45 years, with a mean of 31.6±2.1 years. The parity range was between 5 and 12, with a mean of 8.6±1.1. Diabetes mellitus, hypertension, heart disease, anaemia, multiple pregnancy, antepartum haemorrhage, foetal malpositionings and malpresentations, cephalopelvic disproportion, congenital malformations and macrosomia were significantly associated with grandmultiparae.
Conclusion: The effects of these complications can be minimized by good antenatal care, adequate counseling to improve patients awareness, efficient social welfare support services and efficient blood banking system.
Ultimately, female education and empowerment, acceptance and utilization of modern contraceptive methods will eradicate grandmultiparity.
Keywords:  Grandmultiparity, obstetric performance, Orlu, Nigeria.

Introduction

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Even though there is no universally adopted definition of grandmultiparity, most authorities will regard a grandmultipara as a woman who has had five or more viable babies (1,2). Grandmultiparity has been described as an independent risk factor for a variety of obstetric complications (3). High parity is still common with dire consequences to the foetus, the family and the society(4). Pregnancy after the fifth delivery is viewed with anxiety, especially by Obstetricians in developing countries working with inadequate facilities. The problem of high parity in developing countries is further compounded by a high prevalence of low socio-economic status, poor female literacy, and social deprivation, as well as poor utilization of contraceptive services(5). On the contrary, in developed countries with improved and optimal obstetric services, grandmultiparity is not regarded as a major risk for adverse obstetric and perinatal outcomes (5,6).
The International Safe Motherhood Conference convened in Nairobi, Kenya in 1987 by African Heads of State to address the unacceptable high maternal mortality rate in Africa, identified grandmultiparity as a real risk, with a score of 2 out of a maximum of 3, which depends on their potential impact on pregnancy outcome (5). Because of the gamut of problems, maternal and perinatal morbidity and mortality are relatively increased in these group of patients.
Despite government’s population policies that favour a small family size, high parity still remains an everyday feature of the Obstetric practice in developing countries with rates greater than 14.5% in Nigeria (7).
The relative ease with which some grandmultiparae deliver has given rise to laxity on the part of the parturient and relaxation of surveillance on the part of the Obstetrician, and this has partly contributed to the increased maternal and perinatal morbidity and mortality in this group of patients (8).
How the grandmultiparae fare in pregnancy and labour is an indicator of the level of obstetric care in that environment.
This case control study compares the pregnancy outcomes of grandmultiparas with that of multiparas at the Imo State University Teaching Hospital after control for confounding effects of age and other variables. The result will help in making recommendations towards reducing the prevalence and improving the feotomaternal outcome among the grandmultiparae in our environment.

Patients/Methods

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This is a prospective descriptive study conducted at the department of obstetrics and gynaecology of the Imo state University Teaching Hospital over a period of seven years from June 2004 to June 2011. Only booked grandmultiparae who delivered in our hospital during the study period were included in the study. Booked multiparae (parae 1-4) who delivered soon after a grandmultiparae were used as control. The obstetric performances of the two groups were comparatively studied.
The main maternal outcome measures were maternal age and parity, antepartum and postpartum haemorrhage, foetal malpresentations and malpositions, mode of delivery, gestational age at delivery, ruptured uterus, multiple pregnancy and maternal mortality. Medical disorders in pregnancy included hypertensive disorders, diabetes, anaemia, and heart disease.
Foetal outcome measures were birth weight, birth asphyxia, neonatal jaundice, congenital malformations and perinatal mortality.
Antenatal foetal monitoring using serial symphysiofundal height measurements and foetal heart auscultation with Pinard stethoscope was carried out. Folic acid and iron supplements were routinely given to all the women. Labour was managed actively using the partograph. The third stage was also routinely managed actively.
The data collated was analyzed using the WHO EPI Info Version 6 programme for statistical analysis. A chi-square test was used to compare the data for statistical significance. A P-value of < 0.05 was taken as significant.

Results

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Total obstetrical admission during the study period was 2101 with booked grandmultiparae constituting 210 (10.0%) of these deliveries.
The age distribution of the women is depicted in table 1. The age range of the grandmultiparae was 23 and 45 years, with a mean of 31.6 ± 2.1 years. Most of the patients were aged 26- 30 years. The age range amongst the multiparae was 16-42years, with a mean of 24.3±2.2 years. Majority of them aged 21-25years.
The parity distributions of the patients are shown in table 2. The parity range amongst the grandmultiparae was between 5 and 12, with a mean of 8.6±1.1. Majority of them were between para 5 and 6. Amongst the multiparae, the range was 1-4, with a mean of 2.6 ± 0.2. Majority of the multiparae were para 2.
The pregnancy and labour complications are summarized in table 3. There is a statistically significant difference in the occurrence of diabetes mellitus, hypertension, heart disease, anaemia, foetal malpresentations, antepartum haemorrhage, multiple pregnancy and cephalo-pelvic disproportion between the two groups (P
The other complications did not show statistical difference between the two groups (P>0.05).
There were 4 maternal deaths in the grandmultiparae group and 2 in the multiparae group.
The foetal outcomes are summarized in table 4. Only foetal macrosomia, congenital malformations and birth asphyxia showed statistically significant difference between the two groups (P< 0.01).

Discussion

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The prevalence of 10% for booked grandmultiparae in this study is similar to the 10.2% found in Kano(1), but is higher than the 2.0% and 6.1% reported from Cosmopolitan towns of Lagos(6) and Ibadan(4). This may be accounted for by the high prevalence of early marriage, tendency towards large family size, and poor acceptance and utilization of modern contraceptive methods in semi- urban towns like our environment when compared to Cosmopolitan towns and Cities like Ibadan and Lagos(5). This may also explain the mean age of grandmultiparae of 31.6 years which is lower than 33.3 years reported from Lagos where marriage is usually delayed.
Grandmultiparae tend to have more complications in pregnancy and labour in this study when compared with multiparae. This might be accounted for by the older age of grandmultiparae which predispose them to medical disorders of pregnancy and abruption placentae, while high parity predisposed them to anaemia, placenta praevia, and foetal malpresentations. This is also the experience of other authors(9-11). Cephalopelvic disproportion as a cause of difficult labour in grandmultiparae has been explained as being due to the tendency for babies to get larger with successive pregnancies(12).
Occasionally contracted pelvis can secondarily occur in the grandmultipara as a result of the high angle of pelvic inclination resulting from associated lordosis of the spine, the occasional subluxation forwards of the sacrum upon the sacro- iliac joint so that the Sacral promontory advances and the true Conjugate is effectively reduced and finally osteomalacia which accompany age  and high parity(13). Malpresentations are favoured by pendulous abdomen and lordosis of the lumbar spine. Multiple pregnancies are partly explained by the patients’ high degree of fertility(13). Cord prolapsed is favoured by the increased frequency of malpresentation and malposition is these women.
Uterine rupture constitutes one of the gravest risks of grandmultiparity(13). Uterine contractions tend to be better co-ordinated and more forceful in multiparous labour, whereas the strength of the myometrium to withstand any obstruction has been weakened by successive pregnancies. Moreover, the presence of a large baby further increases the strain.
The high incidence of grandmultiparity on this study amongst predominantly illiterate patients from low socioeconomic strata compares well with that reported in communities of similar background (2, 8). This accounts for the delay in intervention and poor prognosis in the event of complications in this group.

Conclusion(s)

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The antenatal complications and foetal outcomes among grandmultiparae were compared with those of multiparae in this study because the multiparae are reported to have the best pregnancy outcome(5, 15, 16). Good antenatal care and quality delivery services, adequate counseling to improve patient’s awareness, an efficient and effective social welfare support services, and an efficient blood banking system will go a long way in reducing the pregnancy and labour risks of booked grandmultiparae to levels comparable to that of the multipara.
If Millennium Development goals 4 and 5 are to be achieved, efforts should be intensified in preventing grandmultiparity through quality antenatal care and hospital confinement, female education and empowerment, acceptance and utilization of effective and efficient modern antenatal care.

References

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Source(s) of Funding

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The authors involved funded the article through their contribution. No grant was gotten from any individual or external body.

Competing Interests

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The authors declare that they do not have any competing interest.

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