Al-Shaikh et al.

BMC Pregnancy and Childbirth (2017) 17:310

DOI 10.1186/s12884-017-1508-0

RESEARCH ARTICLE Open Access

Grand multiparity and the possible risk of

adverse maternal and neonatal outcomes:
a dilemma to be deciphered
Ghadeer K. Al-Shaikh1, Gehan H. Ibrahim2*, Amel A. Fayed3,4 and Hazem Al-Mandeel1

Abstract
Background: The relation between grand multiparity (GMP) and the possible adverse pregnancy outcomes is not
well identified. GMP (parity ≥5 births) frequently occurs in the Arab nations; therefore, this study aimed to identify
the correlation between GMP and the different adverse maternal and neonatal outcomes in the Saudi population.
Method: This cohort study was conducted on a total of 3327 women from the labour ward in King Khaled University
Hospital, Riyadh, Saudi Arabia. Primiparous, multiparous and grand multiparous females were included. Socio-demographic
data and pregnancy complications like gestational diabetes or hypertension, preeclampsia and intrauterine
growth restriction were retrieved from the participants’ files. In addition, the labour ward records were used
to extract information about delivery events (e.g. spontaneous preterm delivery, caesarean section [CS]) and
neonatal outcomes including anthropometric measurements, APGAR score and neonatal admission to the
intensive care.
Results: Primiparas responses were more frequent in comparison to multiparas and GMP (56.8% and 33%,
and 10.2% respectively). In general, history of miscarriage was elevated (27.2%), and was significantly higher
in GMP (58.3%, p < 0.01). Caesarean delivery was also elevated (19.5%) and was significantly high in the GMP
subgroup (p < 0.01). However, after adjustment for age, GMP were less likely to deliver by CS (odds ratio: 0.6,
95% CI: 0.4–0.8; p < 0.01). The two most frequent pregnancy-associated complications were gestational diabetes and
spontaneous preterm delivery (12.6% and 9.1%, respectively). The former was significantly more frequent in the GMP
(p < 0.01). The main neonatal complication was low birth weight (10.7%); nevertheless, neonatal admission to ICU was
significantly higher in GMP (p = 0.04), and low birth weight was more common in primiparas (p < 0.01). Furthermore,
logistic regression analysis revealed an insignificant increase in the maternal or neonatal risks in GMP compared to
multiparas after adjustment for age.
Conclusion: Grand multiparous Saudi females have similar risks of maternal and neonatal complications compared to
the other parity groups. Advanced age might play a major role on pregnancy outcomes in GMP. Nevertheless, grand
multiparty might not be discouraged as long as women are provided with good perinatal care.
Keywords: Grand multiparity, Maternal outcome, Neonatal outcome, Pregnancy outcome, Prenatal care, Risk

* Correspondence: [email protected]; [email protected]

2
Department of Medical Biochemistry, Faculty of Medicine, Suez Canal
University, Round Road, Ismailia 41511, Egypt
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Al-Shaikh et al. BMC Pregnancy and Childbirth (2017) 17:310 Page 2 of 7

Background Inclusion and exclusion criteria

Grand multiparity (GMP) was defined in the older litera- In the period between November 2013 and November
ture as giving birth seven times or higher [1]. More recent 2014, a total of 3327 women who had singleton births
reports describe it as parity of five or more [2]. With the were recruited from the labour ward in King Khaled
widespread application of family planning in developed University Hospital (KKUH), Riyadh, Saudi Arabia. Par-
countries, GMP has decreased in Western society and its ticipants were classified into three groups according to
prevalence became very low (~4% of all births) [3]. In parity: primipara [one birth], multipara [2–4 births], and
many parts of the world, GMP is associated with higher grand multipara [5 or more births]. Exclusion criteria
risks of obstetric complications such as gestational dia- included: pregnant women with multiple gestations; ill-
betes, gestational hypertensive disorders [4, 5], maternal nesses that might increase the pregnancy adverse out-
anemia, postpartum hemorrhage, congenital malforma- comes such as renal and cardiac diseases, and previous
tions and perinatal mortality [6]. However, other studies uterine scar. Females presented with any form of fetal
found a lower incidence of these complications in grand malpresentation were also ruled out from the study. An
multiparous women [7]. Furthermore, obstetric risks informed verbal consent was obtained from all partici-
might also be attributed to the advanced maternal age in pants prior to their participation in the study.
addition to high parity. Therefore, maternal age must be
examined as a confounder while interpreting the risk of
maternal and neonatal complications in GMP women [6]. Data collection
GMP is seen frequently in Arab nations like the Saudi Socio-demographic details, maternal health, and infor-
population. Kumari and Badrinath [8] reported a signifi- mation about pregnancy, delivery and perinatal out-
cant increase in gestational diabetes and macrosomia in comes were collected from all subjects. Paper medical
a sample of Arabic grand multiparous [8]. Therefore, records were abstracted to ascertain the women’s med-
GMP is expected to represent a risk factor of pregnancy ical status throughout gestation. Adverse pregnancy out-
related complications in Saudis as grand multiparity is comes (e.g. Anemia, gestational diabetes, gestational
still prevalent. The main point of interest for obstetri- hypertension [De novo hypertension alone after 20 weeks
cians in a case of GMP is how this might alter labour gestation in a previously normotensive woman], pre-
and delivery expectations, in addition to the risk of ma- eclampsia [new onset of hypertension after 20 weeks
ternal morbidity and mortality [4]. Two decades ago, gestation with proteinuria (≥300 mg/24 h)], placental
Fayed et al. [9] excluded obstetric risks in Saudi GMP pathologies, intrauterine growth restriction and antepar-
women if they are provided with a high socioeconomic tum hemorrhage) were retrieved from their files. Deliv-
environment and receive high standard perinatal care. ery events (e.g. spontaneous preterm delivery [birth
Later on, a scanty number of studies investigated the ef- before 37 weeks of gestation], need for induction of
fect of parity on the pregnancy complications in Saudi labour, mode of delivery, cesarean section (CS), postpar-
population [10, 11], while neonatal outcomes have not tum hemorrhage, perinatal deaths. And maternal admis-
been explored yet. sion to the intensive care unit [ICU]) and birth
Grand multiparty will continue to exist in Saudi outcomes (e.g. anthropometric birth outcomes, APGAR
Arabia as the concept of having large families is score in the 5th minute after delivery, congenital malforma-
highly accepted. Further research is needed to clarify tions and newborn admission to the ICU) were noted after
the impact of GMP on pregnancy and neonatal out- delivery. A newborn birth weight of <2500 g was consid-
comes as previous data are not conclusive. The ered low, in addition low APGAR score corresponded to a
current study was conducted to determine the inci- score < 7 in the 5th minute after delivery [12].
dence of adverse maternal and neonatal outcomes in
different parity status and to evaluate the effect of
GMP on these complications in Saudi females with Statistical analysis
comparison to primiparity and multiparity. Data were analyzed using the SPSS software v.20.0 for
Windows® (SPSS Inc., Chicago, IL, USA). Univariate ana-
lysis and differences between groups were assessed using
Methods the one way Analysis of Variance (ANOVA), or Chi-
This cohort study was designed to examine the relation- square (χ2) test when appropriate. Multiple logistic
ship between parity and overall rates of maternal and regression analysis was used to adjust for the age differ-
neonatal complications. The study was conducted in ac- ence among the studied groups and adjusted odds ratios
cordance with the guidelines in the Declaration of were calculated for maternal and neonatal outcomes. All
Helsinki and was approved by the Institutional Review statistical tests were two-tailed, and a p value <0.05 was
Board (IRB) of King Saud University. considered statistically significant.
Al-Shaikh et al. BMC Pregnancy and Childbirth (2017) 17:310 Page 3 of 7

Results multiparas (p < 0.01). Most of the pregnancy complica-

During the study period, there were 3327 deliveries, out tions were more frequent in GMP group compared to the
of which 341 (10.2%) were grand multiparas and the rest other parity sub-groups. GMP women were more likely to
included primiparas and multiparas (56.8% and 33%, re- have gestational diabetes (p < 0.01), gestational hyperten-
spectively). Table 1 shows the socio-demographic data, sion (p = 0.01), and ICU admission (p = 0.03) (Table 2).
pregnancy and neonatal outcomes of the total study’s On the other hand, preeclampsia and intrauterine growth
participants. The majority of women aged from 25 to restriction were more common in primipara compared to
30 years (58.4%) and they were mostly Saudis (91.4) and the other parity groups, yet the difference in preeclampsia
housewives (85.8%). Unfortunately, positive history of was not statistically significant (p = 0.07 and 0.02, respect-
miscarriage among the participants was high (27.2%). ively). Preterm delivery, the second most common preg-
The main pregnancy-associated complications were ges- nancy complication in the total participants, was higher in
tational diabetes and spontaneous preterm delivery GMP group compared to primipara and multipara, yet the
(12.6% and 9.1%, respectively). Gestational hypertensive difference did not reach statistical significance (p = 0.05).
disorders, intrauterine growth restriction and maternal In addition, the frequency of CS was higher in GMP when
admission to the ICU showed a frequency lower than 2% compared to the other parity groups (p < 0.01) (Table 2).
each. Furthermore, 19.5% of our study population deliv- Comparison of the neonatal complications in the three
ered by CS. Neonatal complications identified in the parity group showed that neonatal admission to ICU was
study were low birth weight (10.7%), followed by neo- significantly higher in the GMP group (p = 0.04), while
natal admission to the ICU (4%), low APGAR score low birth weight was more common in the primipara
(1.5%) and congenital anomalies (1.3%). group (p < 0.01) (Table 2).
Stratification of the study population according to parity Logistic regression analysis was conducted to test the
showed that grand multiparous females were more likely risk of pregnancy and neonatal outcomes in GMP in
to be of advanced age (p < 0.01) and to be housewives comparison to multiparas after adjustment for age.
(p < 0.01) (Table 2). History of miscarriage was signifi- There was an insignificant increase in the maternal or
cantly higher in GMP group compared to primiparas and neonatal risks in GMP compared to multiparas. Fortu-
nately, GMP were less likely to deliver by CS (OR: 0.6,
Table 1 Socio-demographic data, medical health and reproductive 95% CI: 0.4–0.8; p < 0.01) (Table 3).
information of the study population (n = 3327)
Age groups (n, %) Discussion
< 25 years 819 (24.6) With the advancement of family planning, grand multi-
25–35 years 1944 (58.4
parity decreased tremendously in the Western countries.
Though the incidence of GMP has declined in the Saudi
> 35 years 564 (17)
population as well, it decreased from 29% [10] to 5.3% in
Nationality (n, %) a more recent study [11] and 10.2% in the current re-
Saudi 3057(91.4) search, GMP remains frequent due to different factors.
Non Saudi 290(8.6) The impact of culture cannot be dismissed when consid-
Education (n, %) ering this topic. Throughout the Middle Eastern region,
School 2665(79.6)
India, Pakistan, and Africa, large families are highly val-
ued and are a measure of high fertility [13]. In addition,
University or higher 682(20.4)
the practice of early marriages and religious beliefs that
Working Status (n, %) do not support the use of contraception are considered
Housewife 2365(85.2) serious challenges that cause an increase in the inci-
Employee 398(14.3) dence of GMP in the Saudi population. Whether this
Student 14(0.5) represents an obstetric problem or not should be exten-
Smoking (n, %) 84(3.0)
sively investigated as the risk of complications is thought
to be minimized in high-income countries as they
Gestational age at delivery (mean ± SD) 38.6 ± 2.2
provide a high quality health-care system [14]. In
BMI at delivery (Kg/m2; mean ± SD) 31.5 ± 6 addition, there are few data on the relation and na-
History of miscarriage (n, %) 899 (27.2) ture of maternal and neonatal complications with
History of multiple pregnancy (n, %) 115 (3.4) GMP, especially in Saudis.
History of chronic diseases (n, %) The current study identified different pregnancy and
Hypertension 34(1.0)
neonatal complications in different parity groups with
comparison of their prevalence and their potential risk
Diabetes mellitus 46(1.4)
in association with GMP. History of miscarriage was
Al-Shaikh et al. BMC Pregnancy and Childbirth (2017) 17:310 Page 4 of 7

Table 2 Comparison of the study participants demographic data, pregnancy and neonatal outcomes according to parity
Primipara Multipara Grand Multipara P value
N = 1889 N = 1097 N = 341
Age (years; mean ± SD) 26.3 ± 4.4 31.6 ± 4.8 38.2 ± 3.7 <0.01
Age groups:
< 25 years 728(38.5) 85(7.7) 6(1.8) <0.01
25–35 years 1091(57.8) 780(71.1) 73(21.4)
> 35 years 70(3.7) 232(21.1) 262(76.8)
Nationality
Saudi 1734(91.8) 979(89.2) 327(95.9) <0.01
Non Saudi 155(8.2) 118(10.8) 14(4.1)
Education
School 1467(77.7) 886(80.8) 294(86.2) <0.01
University or higher 422(22.3) 211(19.2) 47(13.8)
Working Status
Housewife 1329(84.0) 773(85.5) 252(90.3) 0.01
Employee 240(15.2) 130(14.4) 27(9.7)
Student 13(0.8) 1(0.1) 0(0.0)
Smoking 45(2.8) 29(3.1) 10(3.5) 0.73
BMI at delivery (Kg/m2; mean ± SD) 30.4 ± 5.6 32.4 ± 6.1 34.6 ± 6.3 <0.01
Gestational age at delivery (years; mean ± SD) 38.7 ± 2.3 38.6 ± 2.0 38.4 ± 2.3 0.12
History of multiple pregnancy 59(3.1) 46(4.2) 10(2.9) 0.3
History of miscarriage 296(15.8) 406(37.3) 197(58.3) <0.01
Pregnancy outcomes
Gestational diabetes 174(9.3) 156(14.4) 85(25.2) <0.01
Pre-existing hypertension 12(0.6) 14(1.3) 8(2.4) 0.02
Gestational hypertension 31(1.6) 16(1.5) 14(4.1) 0.01
Preeclampsia 25(1.3) 5(0.5) 3(0.9) 0.07
Intrauterine growth restriction 50(2.6) 16(1.5) 3(0.9) 0.02
Spontaneous preterm delivery 173(9.4) 81(7.6) 39(11.8) 0.05
Induction of labour 372(19.8) 130(11.9) 54(15.8) <0.01
Mode of delivery
Spontaneous delivery 1356(72.7) 838(76.8) 251(74.9) <0.01
Instrumental delivery 173(9.3) 17(1.6) 4(1.2)
Cesarean section 335(18.0) 236(21.6) 80(23.9)
Maternal admission to ICU 8(0.4) 4(0.4) 5(1.5) 0.03
Neonatal outcomes
Baby gender (male) 921(49.0) 562(51.4) 166(49.3) 0.46
Birth weight (mean ± SD) 3.0 ± 0.5 3.2 ± 0.5 3.1 ± 0.5 <0.01
Baby’s length (mean ± SD) 49.4 ± 2.6 49.6 ± 3.1 49.3 ± 2.9 0.10
Low birth weight 236(12.7) 92(8.5) 30(9.0) <0.01
APGAR at 5 min <7 28(1.6) 15(1.4) 8(2.4) 0.42
Neonatal admission to ICU 84(4.5) 32(2.9) 19(5.6) 0.04
Congenital Anomalies 23(1.2) 16(1.5) 7(2.1) 0.45
Data are expressed as number (percentage) unless specified
Al-Shaikh et al. BMC Pregnancy and Childbirth (2017) 17:310 Page 5 of 7

Table 3 Logistic regression analysis showing the risk of maternal gestational diabetes in GMP group of the current study, as
and neonatal complications in GMP in the study population in well as the total participants, can be attributed to the high
reference to multiparas prevalence of DM in the general population. According to
Adjusted odds ratios P value the latest WHO estimates, Saudi Arabia ranked the 2nd in
(95% CI)
the Middle East and the 7th worldwide regarding the rate
Pregnancy outcomes of diabetes mellitus [20].
Gestational diabetes 1.2 (0.78–1.8) 0.4 The current study showed that the rate of CS was high
Gestational hypertension 1.1 (0.39–2.88) 0.9 (~20%). This is higher than the one suggested by the
Preeclampsia 0.97 (0.17–6.62) 0.9 WHO indicating that it should not exceed 15% [21].
Similar percentage was documented by a study con-
Intrauterine growth restriction 0.66 (0.12–3.5) 0.6
ducted on another cohort of Saudi GMP females [22].
Spontaneous preterm delivery 1.5 (0.86–2.69) 0.2
This increase in CS incidence has been attributed to sev-
Induction of labour 1.2 (0.79–1.87) 0.4 eral reasons. Grand multiparity was suggested as one of
Cesarean section 0.6 (0.4–0.8) <0.01 the main socio-demographic factors in CS decision mak-
Maternal admission to ICU 2.3 (0.3–19.8) 0.4 ing [23]. An interesting finding of our study is that grand
Neonatal outcomes multiparity favors normal delivery. Similar results were
demonstrated in several studies [24–26], while few
Neonatal admission to ICU 1.8 (0.8–4.3) 0.1
showed no difference [2] or a slight increase in CS rate
Congenital Anomalies 1.6 (0.5–5.3) 0.4
[6]. Given the adverse effects of CS, obstetricians should
Low birth weight 1.1 (0.6–1.9) 0.9 take these data into consideration to avoid unnecessary
APGAR at 5 min <7 1.2 (0.3–4.3) 0.8 CS in grand multiparous women.
Adjusted odds ratios are calculated in comparison to the reference group, The increase in the frequency of spontaneous preterm
multiparous women, whose odds ratios equal 1 for each variable delivery among the study GMP women was also re-
ported previously by Mgaya et al. [12] and Tai & Ur-
elevated in the GMPs in addition to the high prevalence quhart [27]. On the other hand, low birth weight was
of gestational diabetes, while anemias associated with less frequent in GMP compared to other parity groups,
pregnancy and placental pathologies were not identified. yet these two adverse pregnancy outcomes are more
Cesarean deliveries and spontaneous preterm delivery likely to be related. In agreement to our results, a sys-
were the most common obstetric complications in temic review involving a meta-analysis of 41 studies
GMPs in addition to maternal admission to ICU that found no association between GMP and low birth
was highly frequent in this parity group. Moreover, neo- weight. The latter was significantly increased in primipa-
natal admission to the ICU was more frequent in GMPs ras [28]. Moreover, it should be noted that fetal growth
and unexpectedly low birth weight was more common is influenced by other variables like chronic maternal
in primiparas. In general, grand multiparous females had diseases, e.g. anemia, DM and hypertension [29]. An-
similar risk of pregnancy and neonatal complications other important factor that should be considered is the
compared to multiparas. However, it seems that GMP maternal health, a problem that is correlated with sev-
decreases the likelihood for CS delivery. eral adverse pregnancy outcomes. Recurrent pregnancies
Different maternal and neonatal complications have been as well as breastfeeding predispose to poor maternal nutri-
described in the literature. The more common adverse ef- tion [30]. These findings, in addition to the high frequency
fects consistently linked to GMP were gestational diabetes, of miscarriage reported herein, might be explained by the
anemia, placenta previa, malpresentation, low birth weight, possible fear of the physician, and also the mother, from
and increased perinatal mortality [12, 15–17]. However, it fetal loss. It might represent an attempt for any early deliv-
should be noted that gestational diabetes, a common preg- ery to end the pregnancy successfully.
nancy complication in this study, was more frequent in Factors that influence adverse maternal and neonatal
GMPs. However, in regression models controlling for age, outcomes should be identified through evidence-based
GMP was not associated with higher risk of gestational dia- medicine. Considering the high prevalence of GMP and
betes. Similarly, Fowler-Brown et al. [18] found that the the unmet need for family planning in Saudi Arabia, an
risk of diabetes in GMP was reduced after adjustment for intensive and adequate health services should be provided
the maternal age as well as the body mass index (BMI). to these women to reduce the potential risk of com-
The authors highlighted the effect of old age and increased plications. Furthermore, health education regarding
BMI on the risk of diabetes mellitus (DM) development. weight control and healthy nutrition among GMP women
On the other hand, GMP had a 27% increased risk of type with older age might help reduce the risk of possible ma-
2 diabetes mellitus in a large cohort of Caucasian and ternal and neonatal complications. Health care providers
African-American women [19]. The elevated percentage of should implement policies and design appropriate health
Al-Shaikh et al. BMC Pregnancy and Childbirth (2017) 17:310 Page 6 of 7

education plans to reduce preventable maternal and Author details

1
neonatal complications and to improve the quality of Obstetrics and Gynecology Department, College of Medicine, King Khalid
University Hospital, King Saud University, Riyadh, Saudi Arabia. 2Department
prenatal care. of Medical Biochemistry, Faculty of Medicine, Suez Canal University, Round
Road, Ismailia 41511, Egypt. 3College of Medicine, Princess Nourah Bint
Abdulrahman University, Riyadh, Saudi Arabia. 4Department of Biostatistics,
Conclusion High Institute of Public Health, Alexandria University, Alexandria, Egypt.
To date, the findings on the association between GMP
and maternal/neonatal outcomes are not conclusive. Received: 27 May 2016 Accepted: 14 September 2017
Our study showed that grand multiparous Saudi females
have similar rates of maternal and neonatal complica-
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