The grandmultipara: Is she still a risk?

Clinical Articles The grandmultipara: Is she still a risk? Arthur I. Eidelman, MD, Raymond Kamar, MD, MichaelS. Schimmel, MD, and Elchanan Bar-On, MD Bronx, New York, and jerusalem, Israel Grandmultiparity is reported to increase both maternal and perinatal mortality and morbidity. Unique religious and demographic factors in Jerusalem allowed us to analyze a population wherein parity could be dissociated from socioeconomic status. A total of n85 mothers was studied, 889 (11.5%) of whom were grandmultiparas. Comparison of grandmultiparous mothers with all others revealed no increase in the incidence of hypertension, diabetes, uterine atonia, antenatal or postnatal hemorrhage, cesarean sections, stillbirth rate, or congenital malformations. The grandmultipara had significantly lower nenonatal mortality and low birth weight rates and a significantly higher incidence of multiple births and trisomy 21 (p < 0.01 ). These results strongly suggest that grandmultiparity in and of itself in a healthy, economically stable population afforded modern medical care is not a major risk factor and that previous reports primarily reflected social class factors and not parity per se. (AM J OBSTET GvNECOL 1988;158:389-92.)

Key words: Grandmultiparity, perinatal risk factors, perinatal morbidity, perinatal outcome

The grandmultipara, defined as a mother delivering after the twentieth week of gestation after five or more previous viable pregnancies, has traditionally been considered a high-risk obstetric patient. More than 50 years ago Solomons 1 coined the phrase, "the dangerous multipara" and added, "it is a mistake to suppose that in childbearing practice makes perfect." This notion of increased risk has persisted in more recent publications from the United States/ France, 5 Canada,• Sudan/ and Israel. 6 All these reports have stressed that there is both an increase in maternal and perinatal mortality and morbidity in these patients. In fact, the latest edition of Williams' Obstetrics7 states that "parity acts independently to increase the risk of childbearing." The current validity of this dictum, however, remains to be proved. Because the incidence of grandmultiparity has decreased dramatically in most Western countries in recent years, there is a relative sparsity of data on the outcome of grandmultiparity in the era of modern perinatal care. In addition, the populations previously studied have uniformly been of low socioeconomic status, 2"6 and thus the conclusions have suf-

From the Department of Pediatrics, Albert Einstein College of Medicine, Yeshiva University, and the Departments ofNeonatology and Obstetrics, Shaare Zedek Medical Center. Presented in part at the Annual Meeting of the Society for Pediatric Research, Washington, D.C., May 5-8, 1986. Receivedforpublication]une 16, 1987; accepted August 30, 1987. Reprint requests: Arthur I. Eidelman, MD, Shaare Zedek Medical Center P. 0. Box 3235, jerusalem, Israel91031.

fered from inevitable selection bias in attributing the outcome variables to parity per se rather than to parity's interrelationship with social class factors. Therefore the experience in Jerusalem, Israel, is unique in that the religious and social dynamics of the society have led to a continuing high incidence of grandmultiparity in a relatively healthy and economically stable population. As a result, we were afforded the opportunity to study the reproductive outcome in a grandmultiparous population in a setting of modern medical care and ascertain if the routine grave pronouncements are still valid. Methods The records of all deliveries at Shaare Zedek Medical Center for 1982 and 1983 were reviewed. The medical center is a 400-bed, university-affiliated community hospital with comprehensive tertiary perinatal care facilities. All comparisons were made between all grandmultiparas and the remaining obstetric population, parity 0 to 5 (nongrandmultiparas). Mothers were characterized by ethnic background and ranked by social class. The uniqueness of the jerusalem population precluded the standard ranking by a combination of parental education, family income, and housing density, and thus social class ranking, 1 to 6, of Harlap 8 that was based solely on paternal employment was used. The outcome variables studied were previously reported as adverse effects of grandmultiparity2-• and are tabulated in Tables I to III. Since there was no difference in-

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390 Eidelman et al.

Table III. Neonatal outcome (per 1000 livebirths)

Table I. Prenatal complications GMP (%) = 899)

NGMP(%) (n = 6886)

Hypertension Diabetes Antenatal hemorrhage Placenta previa Preeclampsia/toxemia Oligohydramnios Polyhydramnios Abnormal presentation (total) Breech Transverse Face Compound

(n

NGMP

GMP

56 (0.8) 10 (0.1) 116 (1.7)

6 (0.7) 3 (0.3) 13 (1.4)

NS NS NS

Livebirths

6920

LBW

451 (65)

28 (31)

SIG

29 (0.4) 84 (1.2) 7 (0.1) 35 (0.5) 157 (2.3)

5 (0.6) 5 (0.1) 1 (0.1) 3 (0.3) 27 (3.0)

NS NS NS NS NS

NICU admissions

543 (78)

20 (22)

SIG

Multiple births

62 (9)

22 (24)

SIG

Neonatal deaths

21 (3)

1 (1.1)

SIG

128 (1.9) 16 (0.2) 10 (0.1) 3 (0.04)

20 (2.2) 3 (0.3) 3 (0.3) 1 (0.1)

NS NS NS NS

Stillbirths

28 (4.1)*

3 (3.3)*

NS

NS = Not significant; GMP = grandmultipara; NGMP = nongrandmultipara.

918

GMP = Grandmultipara; NGMP = nongrandmultipara; SIG = p < 0.01; NS = not significant; LBW = low birth weight. *Per 1000 total births.

Table II. Labor and delivery complications

I Prolonged labor (>24 hr) Fetal distress Cord prolapse Postpartum hemorrhage Uterine atonia Uterine rupture Cesarean section Forceps + vacuum Maternal deaths

NGMP (%) ~n = 6886)

I

GMP (%) = 899)

(n

174 (2.4)

5 (0.6)

SIG

188 (2.7) 35 (0.5) 71 (1.0)

28 (3.1) 3 (0.3) 6 (0.6)

NS NS NS

9 (0.9) 0 (0.0) 463 (6.7) 420 (6.1) 0 (0.0)

1 (0.1) 0 (0.0) 65 (7.2) 24 (2.7) 0 (0.0)

NS NS NS SIG NS

NS = Not significant; SIG = significant (p < 0.01); GMP = grandmultipara; NGMP = nongrandmultipara.

outcome within each group when analyzed by social class or ethnic background, all the data presented is based on a comparison of the total grandmultiparous population and the nongrandmultiparous population. Statistical analysis was performed with the X2 test with significance defined asp< 0.05.

Results A total of 7785 delivered infants was studied, 899 whom were born to grandmultiparous mothers (11.5%). The ethnic distribution was Ashkenazic Jews 70%, Sephardic Jews 26%, Arab 1%, mixed Ashkenazic-Sephardic parentage 1%, and 2% unknown. Paternal employment is summarized in Table IV and indicates a very high percentage (63%) of students in rabbinic seminaries or serving as religious functionaries. The social ranking per Harlap's categories revealed that more than 78% of the grandmultiparous population were in social classes 1 to 3. This is in contrast to the social class distribution of the entire Jerusalem population reported by Harlap in

1977 wherein only 57% were in social classes 1 to 3. Less than 1% of the grandmultiparas were under 25 years of age, whereas 31% were over 35 years old (Table V). Parity distribution is summarized in Table VI and indicates that 23% of the deliveries were the ninth delivery or more. All mothers received prenatal care: 70% in community health clinics and 30% in private physician's offices. Eighty-five percent were delivered by midwives and 15% by physicians. There was no significant difference between the grandmultiparous and the nongrandmultiparous mothers regarding prenatal complications or type of presentation (Table I). Grandmultiparas, however, had significantly fewer cases of prolonged labor and a significantly reduced incidence of obstetric manipulations with forceps or vacuum (Table II). The neonatal outcome in the grandmultiparous group indicated a significantly lower low birth weight rate, neonatal mortality, and admissions to the neonatal intensive care unit, but a higher incidence of multiple births (Table III). There were no differences between the two groups regarding the incidence of major congenital anomalies, including cardiac anomalies, except for the significant (p < 0.01) increase in the incidence of trisomy 21 in the grandmultiparous group (11128 deliveries) compared with the nongrandmultiparous group (111721 deliveries). This significant difference was present even when only mothers older than 30 years were studied (11111 grandmultiparous deliveries versus 111867 nongrandmultiparous deliveries). Similarly, in the stratified group between 30 and 35 years, there was a significant difference; grandmultiparas, 11123 deliveries versus nongrandmultiparas, 111453 deliveries (p < 0.01). None of the significant differences between the two

Perinatal outcome in grandmultipara 391

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Table IV. Paternal employment and social class in a grandmultiparous population Employment Religious student/functionary Blue collar White collar Academidprofessional Farmer Unemployed/unskilled Unknown

I

Table V. Age distribution of grandmultiparas

I

Age

Class

%

2

63

4/5 3 1 4 6

10 9 6

n

I

1 122 492 284

<25 25-29 30-35 >35

% <1 13.6 54.8 31.6

2 1

10

Table VI. Parity distribution of grandmultiparas Birth order

groups varied with either maternal or paternal ethnic background or social class.

Comment Our findings are striking in that none of the previously reported morbidity or mortality associated with grandmultiparity was noted in our population. The only exceptions were an increased incidence of multiple births, which was unaccompanied by any increase in perinatal morbidity, and an increased incidence of trisomy 21 even when the populations were corrected for age. This increased incidence of multiple births has been previously reported by Palliez et aP Since this is the only grandmultiparous population studied in the 1980s, that is, the era of modern perinatal care, and is the only reported population predominantly not oflow social class, our results strongly suggest that the previously reported poor prognosis of grandmultiparous mothers reflected the interrelationship of social class factors and parity and not parity per se. Analysis of the two most recent reviews on the subject of grandmultiparity clearly demonstrates the contrasts of our study population and those previously reported. Baskett• described a population in which nearly 25% of the mothers did not receive adequate prenatal care and in which 30% were of extremely low social class. In his terms, the mothers were "weary, anemic, obese ... (with a) high incidence of associated medical disorders." Fuchs et al. 6 studied a predominantly immigrant Israeli Sephardic population who were "99% oflow social class." In contrast, our population was 70% Ashkenazi, and more than 78% were in social classes 1 to 3 (actually 87% of the population that could be characterized) and only 1% were in social class 6. Thus it is clear that our study population was relatively homogeneous regarding social class and received a standard uniform high level of medical care that allowed us to focus on the issue of parity without confounding variables. Kiely et al. 9 recently analyzed the effect of maternal parity on various components of perinatal mortality and found that among grandmultiparas "in-

6 7 8 9 10 11

12 >13

I

n

%GMP

%TD

296 253 151 84 57 32 12 14

32.9 28.1 16.8 9.3 6.3 3.6 1.3 1.6

3.8 3.2 1.9 1.1

0.7 0.4 0.2 0.2

GMP = Grandmultipara deliveries; TD = total deliveries.

trapartum fetal deaths" was the only outcome to significantly increase. This effect of parity was significant after adjustment for prior fetal loss, maternal age, education, social class, and race. The current study did not note any increase in the total stillbirth rate in the grandmultiparous population, but the small number (n = 3) of stillbirths precluded any analysis of antepartum versus intrapartum fetal death rates. Our study did not adjust for maternal age except for analysis of the incidence of trisomy 21. Despite this lack of adjustment, no significant adverse outcome was noted in the grandmultiparous population that was, as expected, older on the average than the nongrandmultiparous population. This is not surprising, since Kirz et al. 10 recently presented data that "women of advanced maternal age ... who are delivered in a modern tertiary center may be of no higher risk for adverse outcome ... than younger parturients." Thus it is clear that previous pronouncements regarding the risks of grandmultiparity are no longer valid since they reflect the outcome of social class interacting with parity. In such low socioeconomic class populations, medical problems exist, and when combined with poor access to medical are, inevitably lead to poor perinatal outcome. Thus one cannot generalize, as has been done, from these high-risk populations to the general population of grandmultiparas. In fact, our findings strongly support the concept that in an economically stable and healthy population, those who choose to become pregnant and are afforded modern medical care, grandmultiparity is not an inherent risk. Given the increased incidence of trisomy 21, we sug-

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Eidelman et al.

gest, however, screening for chromosomal disorders beginning at a maternal age of 30 years. Of course, one should not, in turn, generalize from this study to all populations, but rather use these results for appropriate health planning in general and individual family guidance in particular. REFERENCES 1. Solomons B. The dangerous multipara. Lancet 1934;2: 8-11. 2. Ziel HA. Grand multiparity-its obstetric complications. AM] 0BSTET GYNECOL 1962;84:1427-41. 3. Palliez R, Delecour M, Monnier JC, et al. La grande multipare. Gynecol Obstet (Paris) 1971;70:317-32, 421-32. 4. Baskett TF. Grand multiparity-a continuing threat: a 6 year review. Can Med AssocJ 1977;116:1001-4.

February 1988 Am J Obstet Gynecol

5. Aziz FA. Pregnancy and labor of grandmultiparous Sudanese women. IntJ Gynaecol Obstet 1980;18:144-6. 6. Fuchs K, Peretz BA, Marcovici R, Paldi E, Timor-Trsh I. The "grand multipara"-is it a problem? A review of 5785 cases. lntJ Gynaecol Obstet 1985;23:321-5. 7. Pritchard JA, MacDonald PC, Grant NF, eds. Williams' Obstetrics. 17th ed. Norwalk, Connecticut: AppletonCentury-Crofts, 1985:3. 8. Harlap S, Davies AM, Grover NB, Prywes R. The Jerusalem perinatal study: the first decade 1964-1973. Isr J Med Sci 1977;13:1073-91. 9. Kiely JL, Paneth N, Susser M. An assessment of the effects of maternal age and parity in different components of perinatal mortality. Am J Epidemiol 1986; 123:444-54. 10. Kirz DS, Dorchester W, Freeman RK. Advanced maternal age: the mature gravida. AM J 0BSTET GYNECOL 1985; 152:7-12.

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