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ORIGINAL RESEARCH |
From the Departments of 1Family and Preventive Medicine, and 2Obstetrics and Gynecology, University of Utah Health Science Center, Salt Lake City, Utah
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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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
Numerous obstetric complications have been independently associated with progressive maternal age, yet most studies of grand multiparity have failed to consider this potentially confounding effect in their analysis. The small number of studies that have controlled for age have yielded conflicting results,1–4,10,14 and no published studies have focused on the unique risks associated with grand multiparity in young women. To address this issue, we conducted a retrospective review of birth certificate data for singleton deliveries occurring in the state of Utah between 1995 and 2001. The rates of intrapartum and newborn complications in young grand multiparas (aged 18–34 years) were compared with those in women of lower parity. In addition, the rates of complications in young grand multiparas were compared with those in older (aged >> 35 years) grand multiparas.
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MATERIALS AND METHODS |
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Deliveries were classified into 5 parity groups based on the number of previous liveborn infants as defined by the National Center for Health Statistics18: 0, 1, 2–4 combined, 5–9 combined, and 10 or more combined. The rates of complications with each level of parity were initially examined for trends. Deliveries in parity groups 5–9 and 10+ were collapsed into 2 categories because of the small number of events in these groups. Review of relative risk estimates for individual versus collapsed parity groups revealed consistent results; thus, the collapsed parity group 2–4 was also used for ease of presentation. The rates of complications by age were also examined for trends. The rates of many complications increased in women over 35 years of age. Thus, the decision to use age 35 as the cutoff for "young women" was made. Deliveries were separated into 2 maternal age categories: young (ages 18–34) and older (ages >> 35). We examined birth certificate indicators of sociodemographic and lifestyle factors, intrapartum complications, and neonatal outcomes in young women and compared the risk for these complications in young grand multiparas with the risk in older grand multiparas.
Sociodemographic and intrapartum variables were collected from de-identified Utah birth certificate data. Sociodemographic and lifestyle factors used in this analysis include age, years of education, race (Caucasian, African American, Native American, Asian/Pacific Islander), ethnicity (Hispanic versus non-Hispanic), marital status (married versus not married), self-reported tobacco use during pregnancy (yes/no), self-reported alcohol use during pregnancy (yes/no), and trimester of prenatal care initiation (first trimester versus second/third trimester). Intrapartum complications include placental abruption, placenta previa, excessive intrapartum vaginal bleeding, breech/malpresentation, cord prolapse, fetal distress (including persistent abnormal fetal heart rate patterns, low scalp pH, significant meconium staining of amniotic fluid, low cord pH, 1-minute Apgar score less than 3, or 5-minute Apgar score less than 5), primary cesarean delivery, repeat cesarean delivery, and instrumented delivery (forceps and/or vacuum, excluding failed instrumented deliveries that ended with cesarean delivery). Neonatal outcomes included preterm birth (delivery at < 37 weeks of gestation), newborn transfer to a hospital facility or newborn intensive care unit, meconium aspiration, assisted ventilation for more than 30 minutes, hyaline membrane disease, and birth injury. Two composite variables were also created, one representing any intrapartum event and one representing any newborn event. These variables were created to evaluate whether grand multiparity is a risk factor for any intrapartum or newborn complication.
Data were analyzed with SAS 9.1.2 (SAS Institute, Cary, NC) statistical software. Chi square tests were used to identify significant differences in sociodemographic factors between parity groups and between young and older women of high parity. Odds ratios comparing complications by parity in young women (using parity 1 as the referent category) were calculated using logistic regression, controlling for age, years of education, marital status, race, ethnicity, trimester of prenatal care initiation, and self-reported maternal tobacco use during pregnancy. Self-reported alcohol use was not included in the final model because, when comparing Utah state birth certificate data with data from Utah Pregnancy Risk Assessment Monitoring System,17 we determined that alcohol consumption during pregnancy was likely underreported in the birth certificate database. The models for all intrapartum complications and most newborn complications were also adjusted for induction of labor, augmentation of labor, preeclampsia, and gestational diabetes. The models for most newborn complications were also adjusted for birth weight. Parity 1 (primiparity) was selected as the referent group for this analysis because of the high rates for a number of complications observed among women having their first live birth (parity 0 or nulliparas). Grand (parity 5–9) and great grand multiparas (parity >> 10) were also compared with nulliparas to determine which group was at higher risk. Finally, adjusted odds ratios were calculated to compare the risk of complications between young and older grand and great grand multiparas.
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RESULTS |
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When compared with young primiparas, young grand multiparas (parity 5–9) were at significantly increased risk for preterm delivery and at significantly decreased risk for any intrapartum complication, fetal distress, primary and repeat cesarean delivery, and instrumented delivery. Young grand multiparas were not at significantly increased risk for a number of complications. Sufficient power (> 80%) was available to detect differences in the rates of placental abruption, malpresentation, and any newborn complication, and no significant differences were found. Insufficient power was available to detect differences in the remainder of complications studied, including placenta previa, vaginal bleeding, umbilical cord prolapse, newborn hospital transfer, meconium aspiration, assisted ventilation, hyaline membrane disease, and birth injury (Table 2).
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When compared with young primiparas, young great grand multiparas (parity >> 10) were at significantly decreased risk for any intrapartum complication, repeat cesarean delivery, and instrumented delivery. There were no cases of placental abruption, placenta previa, umbilical cord prolapse, meconium aspiration, assisted ventilation, or birth injury among great grand multiparas. Thus, odds ratios could not be calculated. Great grand multiparas were not at significantly increased risk for the remainder of complications, but there was insufficient power to detect differences because of the small number of great grand multiparas included in this analysis (Table 2).
Among young women, those delivering their first baby (nulliparas) have a significantly increased risk for a large number of complications compared with primiparas. These complications include any intrapartum complication, vaginal bleeding, fetal distress, primary cesarean delivery, malpresentation, instrumented delivery, any newborn complication, preterm delivery, meconium aspiration, assisted ventilation for more than 30 minutes, hyaline membrane disease, and birth injury (Table 2). The significantly increased risks remained when nulliparas were compared with grand and great grand multiparas for the following complications: fetal distress (adjusted odds ratio [AOR] 3.23, 95% confidence interval [CI] 2.86–3.70), primary cesarean delivery (AOR 11.11, 95% CI 10.00–12.50), malpresentation (AOR 1.92, 95% CI 1.69–2.22), instrumented delivery (AOR 5.88, 95% CI 5.26–6.25), any intrapartum complication (AOR 7.69, 95% CI 7.14–8.33), preterm delivery (AOR 1.45, 95% CI 1.33–1.61), assisted ventilation for more than 30 minutes (AOR 1.69, 95% CI 1.32–2.17), birth injury (AOR 1.72, 95% CI 1.23–2.44), and any newborn complication (AOR 1.47, 95% CI 1.30–1.59). Young grand and great grand multiparas were at significantly increased risk for placental abruption (AOR 1.28, 95% CI 1.01–1.63) and umbilical cord prolapse (AOR 1.79, 95% CI 1.09–2.94) when compared with nulliparous young women.
Multivariate analyses comparing young grand and great grand multiparas with their older counterparts revealed that young women of parity 5 or higher were significantly less likely to experience any intrapartum complication, placental abruption, fetal distress, primary and repeat cesarean delivery, malpresentation, instrumented delivery, and meconium aspiration than older women of the same parity. These analyses showed a trend toward decreased risk for placenta previa, newborn hospital transfer, assisted ventilation, and birth injury, but there was insufficient power to detect differences in the rates of these complications (Table 3).
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DISCUSSION |
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We conducted a PubMed search for papers published in English before August 2004, using the keyword "grand multiparity." This study is among the first to specifically examine the risk for intrapartum and newborn complications in young grand and great grand multiparas compared with young women of low parity and older grand and great grand multiparas. Our study included a larger number of grand multiparas (n = 11,351) than any previously reported study.
The use of population-based data, one of this study’s major strengths, also involves inherent limitations. Information on Utah state birth certificates is abstracted from prenatal and delivery records by hospital clerks and relies on International Classification of Diseases, 9th Revision (ICD-9) codes. In order for an intrapartum complication to be listed on a Utah birth certificate, the complication must be documented on the medical record by a physician. Thus, the quality of Utah state birth certificate data may suffer from data entry errors and underreporting of complications. No validation studies have been conducted on Utah birth certificate data, but a small number of complications have been compared with self-reports obtained through the Utah Pregnancy Risk Assessment Monitoring System.19 In this comparison, 95.1% agreement was reported for gestational diabetes, and 93.6% agreement was reported for placenta previa and placental abruption. These complications occurred more frequently by self-report than in birth certificate data. We have no reason to believe that differential underreporting occurred by parity in these data; thus, underreporting should not affect the quality of our reported risk ratios. However, the existence of underreporting may reduce the rates of complications in our data and could decrease the comparability of our findings with those of other studies. If the frequency of reporting were to vary with parity, it is probable that underreporting would be least common among grand and great grand multiparas because physicians may have a heightened concern for these patients. This could result in an underestimation of complication rates in women of low parity and in a more conservative odds ratio estimate, which would not change our overall conclusions. However, after examining the rates for each complication by parity, we concluded that there is no trend associated with overreporting among high parity women in our data.
We did not have unique identifiers for individuals in our data set. Therefore, we were unable to control for multiple deliveries by the same woman during the 5 years studied. This lack of independence in our data could influence the findings by increasing the rate ratios by year for complications that are more common in grand multiparas and decreasing rate ratios by year for complications that are less common in grand multiparas. However, after examining the rate ratios for each of the complications by year, we found no increasing or decreasing trends in our data and concluded that this issue has a minimal impact on our results.
An additional limitation of this study involves the definition of parity. The National Center for Health Statistics defines a woman’s parity as her total number of live births.18 This definition of parity was used in this study. In contrast, the clinical definition of parity includes all previous pregnancies reaching more than 20 weeks of gestation.20 Utah birth certificate data contains only information about the number of previous live births and "other terminations," including both spontaneous and induced losses at any time after conception. Thus, it is impossible for a parity measurement obtained from Utah birth certificate data to contain the number of stillborn infants over 20 weeks of gestation. We examined the rates of previous terminations and stillbirths among women by age and parity and found higher rates among older women and among grand multiparas. This may result in an underestimation of parity and, subsequently, an additional underestimation of risk in older and higher parity women. A final limitation of the study is the possibility that potential confounders were not included in the analysis. A number of variables were included in the multivariate models to control for confounding, but there is a chance that important confounders were excluded from the models.
The literature is contradictory regarding the maternal and newborn risks associated with grand multiparity and age. Historically, the definition of grand multiparity has varied in the obstetric literature, as has the combination of complications included in various studies. This makes comparison between studies difficult. In addition, very few studies have controlled for maternal age in their analyses, and none have examined the unique risks in young grand and great grand multiparas, despite evidence that advanced maternal age is an independent risk factor for a number of complications, including placenta previa,14,21–22 placental abruption,14,21–22 malpresentation,23 cesarean delivery,21,23 and prematurity.21,23
Using a methodology similar to ours, Bai et al10 used a population-based surveillance system to study 510,989 singleton births in New South Wales, Australia. Their study included 6,884 deliveries in women of parity 5 or greater. The authors stratified subjects into 8 parity groups: 0–6 individually and 7–8 combined. They compared the risk of obstetric complications, neonatal morbidity, and perinatal death between the groups, using parity 1 as the referent group and controlling for a number of sociodemographic factors, including age. They found an increased risk of neonatal morbidity, perinatal death, and any obstetric complication among nulliparous women and women with parity of 4 or more. Many of the complications included in the study by Bai et al, such as gestational diabetes, pregnancy-induced hypertension, prelabor rupture of membranes, postpartum hemorrhage, and third-degree laceration were not included in our analysis. None of the complications that were increased among grand multiparas in Bai et al’s study (antepartum hemorrhage, any obstetric complication, and neonatal morbidity as defined by admission to a neonatal intensive care unit) were found to be significantly associated with high parity among young grand multiparas in our study.10
In his 1934 article, Solomons wrote, "My main object is to remove, if possible, once and for all, the idea that a primigravida means a difficult labor but a multipara means an easy one. It is altogether a mistake to suppose that in childbearing, practice makes perfect."5 Our data support Solomons’ assertion that nulliparity is associated with an increased risk of intrapartum and newborn complications but show that, in young women, grand multiparity is not an independent risk factor for most adverse perinatal outcomes. When compared with young primiparas, young grand multiparas are at significantly increased risk only for preterm delivery, but at significantly decreased risk for a number of intrapartum complications. In addition, young grand and great grand multiparas are at lower risk than young nulliparas for many intrapartum and newborn complications. It is our hope that this information will be used by clinicians to provide grand multiparas with adequately aggressive care for select complications while avoiding unnecessary medical procedures and costs.
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Footnotes |
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The authors thank Nan Streeter, Lois Bloebaum, and Shaheen Hossain for their help in designing the study and providing the Utah state birth certificate data. The authors also thank Robert Satterfield and Clint Thompson for their help with preliminary data cleaning and analysis.
Corresponding author: Sara M. Ellis Simonsen, RN, MSPH, Department of Family and Preventive Medicine, 375 Chipeta Way, Salt Lake City, UT 84101; e-mail: sellis{at}dfpm.utah.edu
doi:10.1097/01.AOG.0000175839.46609.8e
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