- Sara Ellis Simonsen, CNM, MSPH, PhD
Sara Ellis Simonsen, CNM, MSPH, PhD
- Visiting Instructor, Department of Family and Preventive Medicine
- Division of Public Health
- University of Utah Health Sciences Center
- Michael W Varner, MD
Michael W Varner, MD
- Professor, Maternal-Fetal Medicine
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
A 1934 study suggested that increasing parity increased the risk of pregnancy complications, and first introduced the term "grand multipara" . The author concluded that grand multiparity was dangerous because, in his study, maternal mortality increased steadily from the 5th to the 10th pregnancy. This topic will discuss issues related to grand multiparity.
A reasonable definition of grand multiparity is ≥5 live births and stillbirths ≥20 weeks of gestation, with great grand multiparity defined as ≥10 live births and stillbirths ≥20 weeks of gestation . However, other definitions are also used. (See 'Variability in the definition of parity' below.)
Pregnancy losses under 20 weeks of gestation are considered abortions. Abortions are not counted toward parity, but are counted toward gravidity (ie, the number of times a woman has been pregnant, including her current pregnancy).
In the United States in 2011, nearly 190,000 women gave birth to a child that was at least their fifth birth, which represented about 4.8 percent of all births that year . Africa has the highest rate of grand multiparity .
FACTORS AFFECTING THE RELATIONSHIP BETWEEN PARITY AND PREGNANCY OUTCOME
The relationship between obstetric complications and parity has been studied extensively, with inconsistent findings. In addition to the usual limitations of observational data, there are several reasons for the discordancy:
- Solomons, B. The dangerous multipara. Lancet 1934; 2:8.
- Abu-Heija AT, Chalabi HE. Great grand multiparity: is it a risk? J Obstet Gynaecol 1998; 18:136.
- Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2011. Natl Vital Stat Rep 2013; 62:1.
- Opara EI, Zaidi J. The interpretation and clinical application of the word 'parity': a survey. BJOG 2007; 114:1295.
- Centers for Disease Control and Prevention. National Center for Health Statistics: NCHS Definitions. National Survey of Family Growth. June 18, 2004; December 4, 2004.
- Aliyu MH, Jolly PE, Ehiri JE, Salihu HM. High parity and adverse birth outcomes: exploring the maze. Birth 2005; 32:45.
- Bai J, Wong FW, Bauman A, Mohsin M. Parity and pregnancy outcomes. Am J Obstet Gynecol 2002; 186:274.
- Simonsen SM, Lyon JL, Alder SC, Varner MW. Effect of grand multiparity on intrapartum and newborn complications in young women. Obstet Gynecol 2005; 106:454.
- Lyrenäs S. Labor in the grand multipara. Gynecol Obstet Invest 2002; 53:6.
- Tanbo TG, Bungum L. The grand multipara--maternal and neonatal complications. Acta Obstet Gynecol Scand 1987; 66:53.
- Bugg GJ, Atwal GS, Maresh M. Grandmultiparae in a modern setting. BJOG 2002; 109:249.
- Roman H, Robillard PY, Verspyck E, et al. Obstetric and neonatal outcomes in grand multiparity. Obstet Gynecol 2004; 103:1294.
- Toohey JS, Keegan KA Jr, Morgan MA, et al. The "dangerous multipara": fact or fiction? Am J Obstet Gynecol 1995; 172:683.
- Babinszki A, Kerenyi T, Torok O, et al. Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors. Am J Obstet Gynecol 1999; 181:669.
- Brunner J, Melander E, Krook-Brandt M, Thomassen PA. Grand multiparity as an obstetric risk factor; a prospective case-control study. Eur J Obstet Gynecol Reprod Biol 1992; 47:201.
- Humphrey MD. Is grand multiparity an independent predictor of pregnancy risk? A retrospective observational study. Med J Aust 2003; 179:294.
- Samueloff A, Mor-Yosef S, Seidman DS, et al. Grand multiparity--a nationwide survey. Isr J Med Sci 1989; 25:625.
- Seidman DS, Armon Y, Roll D, et al. Grand multiparity: an obstetric or neonatal risk factor? Am J Obstet Gynecol 1988; 158:1034.
- Fuchs K, Peretz BA, Marcovici R, et al. The "grand multipara"--is it a problem? A review of 5785 cases. Int J Gynaecol Obstet 1985; 23:321.
- Chan BC, Lao TT. Effect of parity and advanced maternal age on obstetric outcome. Int J Gynaecol Obstet 2008; 102:237.
- Agrawal S, Agarwal A, Das V. Impact of grandmultiparity on obstetric outcome in low resource setting. J Obstet Gynaecol Res 2011; 37:1015.
- Geidam AD, Audu BM, Oummate Z. Pregnancy outcome among grand multiparous women at the University of Maiduguri Teaching Hospital: a case control study. J Obstet Gynaecol 2011; 31:404.
- Mgaya AH, Massawe SN, Kidanto HL, Mgaya HN. Grand multiparity: is it still a risk in pregnancy? BMC Pregnancy Childbirth 2013; 13:241.
- Shahida SM, Islam MA, Begum S, et al. Maternal outcome of grand multipara. Mymensingh Med J 2011; 20:381.
- Jacquemyn Y, Senten L, Vellinga S, et al. Does practice make perfect? An age-matched study on grand multiparity in Flanders, Belgium. J Perinat Med 2006; 34:28.
- Bobrowski RA, Bottoms SF. Underappreciated risks of the elderly multipara. Am J Obstet Gynecol 1995; 172:1764.
- Nassar AH, Fayyumy R, Saab W, et al. Grandmultiparas in modern obstetrics. Am J Perinatol 2006; 23:345.
- Al JF. Grandmultiparity: a potential risk factor for adverse pregnancy outcomes. J Reprod Med 2012; 57:53.
- Simmons D, Shaw J, McKenzie A, et al. Is grand multiparity associated with an increased risk of dysglycaemia? Diabetologia 2006; 49:1522.
- El-Toukhy T, Ramadan G, Maidman D, et al. Impact of parity on obstetric and neonatal outcome of external cephalic version. J Obstet Gynaecol 2007; 27:580.
- Shechter Y, Levy A, Wiznitzer A, et al. Obstetric complications in grand and great grand multiparous women. J Matern Fetal Neonatal Med 2010; 23:1211.
- Shah PS, Knowledge Synthesis Group on Determinants of LBW/PT births. Parity and low birth weight and preterm birth: a systematic review and meta-analyses. Acta Obstet Gynecol Scand 2010; 89:862.
- Hilder L, Sairam S, Thilaganathan B. Influence of parity on fetal mortality in prolonged pregnancy. Eur J Obstet Gynecol Reprod Biol 2007; 132:167.
- Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
- Hochler H, Yaffe H, Schwed P, Mankuta D. Safety of trial of labor after cesarean delivery in grandmultiparous women. Obstet Gynecol 2014; 123:304.
- Kugler E, Shoham-Vardi I, Burstien E, et al. The safety of a trial of labor after cesarean section in a grandmultiparous population. Arch Gynecol Obstet 2008; 277:339.
- Ali AM, Abu-Heija AT. Obstetric and perinatal outcome of women para > or = 5 including one lower segment cesarean section. J Obstet Gynaecol Res 2002; 28:163.
- Yamani Zamzami TY. Vaginal birth after cesarean section in grand multiparous women. Arch Gynecol Obstet 2004; 270:21.
- Dyack C, Hughes PF, Simbakalia JB. Vaginal delivery in the grand multipara following previous lower segment cesarian section. J Obstet Gynaecol Res 1997; 23:219.
- Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
- Sze EH, Sherard GB 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002; 100:981.
- Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579.
- Patel DA, Xu X, Thomason AD, et al. Childbirth and pelvic floor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery. Am J Obstet Gynecol 2006; 195:23.
- Moalli PA, Jones Ivy S, Meyn LA, Zyczynski HM. Risk factors associated with pelvic floor disorders in women undergoing surgical repair. Obstet Gynecol 2003; 101:869.
- Turan V. Grand-grand multiparity (more than 10 deliveries) does not convey a risk for osteoporosis. Acta Obstet Gynecol Scand 2011; 90:1440.
- Abrams B, Heggeseth B, Rehkopf D, Davis E. Parity and body mass index in US women: a prospective 25-year study. Obesity (Silver Spring) 2013; 21:1514.
- Araneta MR, Barrett-Connor E. Grand multiparity is associated with type 2 diabetes in Filipino American women, independent of visceral fat and adiponectin. Diabetes Care 2010; 33:385.
- La Vecchia C, Negri E, Franceschi S, Parazzini F. Long-term impact of reproductive factors on cancer risk. Int J Cancer 1993; 53:215.
- Högnäs E, Kauppila A, Pukkala E, Tapanainen JS. Cancer risk in women with 10 or more deliveries. Obstet Gynecol 2014; 123:811.
- Dossus L, Allen N, Kaaks R, et al. Reproductive risk factors and endometrial cancer: the European Prospective Investigation into Cancer and Nutrition. Int J Cancer 2010; 127:442.
- Hinkula M, Pukkala E, Kyyrönen P, Kauppila A. Grand multiparity and incidence of endometrial cancer: a population-based study in Finland. Int J Cancer 2002; 98:912.
- Hinkula M, Pukkala E, Kyyrönen P, Kauppila A. Incidence of ovarian cancer of grand multiparous women--a population-based study in Finland. Gynecol Oncol 2006; 103:207.
- Hinkula M, Pukkala E, Kyyrönen P, Kauppila A. Grand multiparity and the risk of breast cancer: population-based study in Finland. Cancer Causes Control 2001; 12:491.
- Clemons M, Goss P. Estrogen and the risk of breast cancer. N Engl J Med 2001; 344:276.
- FACTORS AFFECTING THE RELATIONSHIP BETWEEN PARITY AND PREGNANCY OUTCOME
- Variability in the definition of parity
- Variability in the definition of controls
- Nonlinear relationship between parity and pregnancy outcome
- Inadequate adjustment for maternal age
- Healthy person effect
- RISK OF PREGNANCY COMPLICATIONS
- Role of previous cesarean delivery
- LONG-TERM RISKS
- PATIENT COUNSELING
- PREGNANCY MANAGEMENT
- SUMMARY AND RECOMMENDATIONS