Direct obstetric causes account for nearly 75% of all maternal deaths. Controversy prevails in the effect of grand multiparity on adverse obstetric outcomes. This study thus aimed to determine and compare the obstetric outcomes in low multiparous (LM) and grand multiparous (GM) women in Public Hospitals of North Ethiopia.
Method
An institution-based comparative cross-sectional study was done among 540 (180 GM and 360 LM) participants from January 1 to March 30, 2021. The data was collected through face-to-face interviews and a review of clinical records and birth registries. Epi-Data version 4.6 was used for data entry and analysis was performed using SPSS version 25.0 statistical software. A p-value of ≤ 0.05 (2-tailed) was used to consider the significance of statistical tests.
Result
The prevalence of adverse obstetric outcomes was 32.6% (95% CI: 28.7–36.5). Antepartum hemorrhage, anemia, and postpartum hemorrhage were higher in grand multiparous women. Whereas, prolonged labor, induction/augmentation, prelabor rupture of membrane, episiotomy, and post-term pregnancy was higher in low multiparous women. Income (AOR (CI) = 3.15 (1.30–7.63), alcohol consumption (AOR (CI) = 3.15 (1.49–6.64), preterm delivery (AOR (CI) = 9.24 (2.28–27.3), cesarean delivery (AOR (CI) = 13.6 (6.18–30.1), and low birth weight (AOR (CI) = 3.46 (1.33–9.03) significant predictors of adverse obstetric outcomes. However, parity did not show a statistically significant difference in obstetric outcomes.
Conclusion
In the study area, obstetric complications were high compared to a systematic review and meta-analysis study done in the country (26.88%). Socio-economic status, alcohol consumption, gestational age at delivery, mode of delivery, and birth weight were significant associates of the obstetric outcome. There was no statistically significant difference in obstetric outcomes between GM and LM women. Socio-economic development, avoiding alcohol consumption, early identification and treatment of complications, and adequate nutrition and weight gain during pregnancy are needed regardless of parity.
Hinweise
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Abkürzungen
ANC
Antenatal care
APH
Antepartum Hemorrhage
DBU
Debre Berhan University
GM
Grand Multipara
IUFD
Intrauterine Fetal Death
LM
Low Multipara
PPH
Postpartum Hemorrhage
PROM
Prelabor rupture of membrane
Introduction
Globally, in 2017, an estimated 295,000 women died during pregnancy, delivery, and the postpartum period. Most (94%) of all deaths occurred in low and lower-middle-income countries such as Ethiopia. Sub-Saharan Africa accounted for nearly 66% of the global maternal deaths, while Southern Asia accounted for about 20% [1]. However, maternal deaths only tell part of the story. For every single woman who dies of pregnancy-related complications, between 20 and 30 more suffer short- and long-term disabilities, such as infections, hemorrhage, obstetric fistula, uterine rupture, or pelvic inflammatory disease [2]. In Ethiopia, more than 500,000 women and girls suffer from disabilities as a result of complications during pregnancy and childbirth each year [2]. According to a WHO report, pregnancy complications account for nearly 75% of all maternal deaths [1]. The top causes of maternal deaths in In Ethiopia are hemorrhage (29.9%), obstructed labor (22.3%), pregnancy-induced hypertension (16.9%), puerperal sepsis (14.68%), and unsafe abortion (8.6%) [3].
A prospective cohort study in Bangladesh reported a 25% magnitude of obstetric complications [4]. In Uganda, one-third of women reported an adverse pregnancy outcome [5]. Similarly, a comparative study in Southern Ethiopia determined the prevalence of adverse obstetric outcomes at 39%. The study further reported a higher prevalence of hypertensive disorders of pregnancy, antepartum hemorrhage (APH), and premature rupture of membrane (PROM) among grand multiparous women, while the higher risk of obstructed labor and cesarean delivery among low multiparous women [6]. Extreme ages and a history of stillbirth/miscarriage significantly increased the risks of obstetric complications [4]. History of medical illnesses, previous cesarean delivery, and high birth weight were also significant factors of adverse obstetric outcomes [6].
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Various studies have investigated the impact of grand multiparity on adverse obstetric and perinatal outcomes, and mixed findings were reported. Some studies showed an increased incidence of obstetric complications among grand multiparas, however, other studies explored a comparable risk of complications. A study in Saudi Arabia found that grand multiparous women have a comparable risk of maternal and neonatal complications compared to other parity groups [7]. Similarly, a comparative study in Southern Ethiopia found that parity did not show a statistically significant difference in obstetric outcomes [6]. However, grand multiparity was found to be a risk factor for PROM, stillbirth, and preterm delivery in Tanzania [8]. It was also associated with adverse maternal outcomes like cesarean delivery, fetal macrosomia, diabetes mellitus, and pregnancy-induced hypertension [9].
Sustainable development goal 3.1 sets a target for all global nations to decrease the maternal mortality ratio to less than 70 by 2030 [10]. Furthermore, the Global Strategy for Women’s, Children’s, and Adolescents’ Health planned to design programs aimed at maternal and child health globally [11]. Although older literature showed the effect of parity on maternal and perinatal outcomes, recent reports fail to support these findings. Hence, this study planned to determine and compare adverse obstetric outcomes in grand multiparous (GM) and low multiparous (LM) women and identify its associated factors in public hospitals of North Ethiopia.
Methods
Study design, setting, and period
An institution-based comparative cross-sectional study was done in North Shewa Zone public hospitals from January 1 to March 30, 2021. North Shewa is one of the 10 zones in the Amhara region of Ethiopia and is 130 km far from Addis Ababa, the capital of Ethiopia. Based on the 2007 national census, it has a total population of 1,837,490; 928,694 men and 908,796 women [12]. There are 12 Hospitals (2 private, 9 public, and 1 comprehensive specialized hospital). There are about 303 midwives, 766 Nurses, 120 Laboratory professionals, 130 Pharmacists, 150 General Practitioners, 15 Specialists, 25 integrated emergency surgical officers (IESO), and 54 Anesthesia professionals working in the zone.
Study population and inclusion and exclusion criteria
All multiparous women who gave birth in the study area were the source population. Randomly selected multiparous women in labor wards during the study period were the study population. Multiparous women with a single fetus/neonate at a gestational age of 28 weeks or above were included. Multiparous women with twin gestation/delivery, with known medical conditions like diabetes, HIV, and hypertension, referred from other health institutions, home delivery, and those who were unable to communicate or seriously ill were excluded from the study.
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Sample size calculation
The sample size was computed using Open-Epi version 3.03 statistical software. The following assumptions were made: the power of the study (1-β) to be 80%, 95% confidence interval (CI), the estimated ratio of unexposed (LM)-to exposed (GM) ratio is 2:1, and the percent of outcome among non-exposed group and odds ratio of previous studies were used as indicated in Table 1 below. Adding a 10% non-response rate, the largest sample size was 548 (183 GM and 365 LM).
Table 1
Sample size calculation for adverse obstetric outcomes in low multiparous and grand multiparous women who give birth in North Shewa Zone Hospitals, 2021
Simple random sampling was applied to select 5 hospitals. The average number of deliveries in these hospitals was estimated to be 639 per month. The sample size was proportionally allocated to each hospital based on their respective number of deliveries (Fig. 1). For each grand multiparous woman, two low multiparous women from the same hospital were selected consecutively as they were present.
Fig. 1
Sampling procedure for the assessment of adverse obstetric outcomes in low multiparous and grand multiparous women who give birth in North Shewa Zone Hospitals, 2021
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Data collection tool and quality control
A structured and pre-tested questionnaire was used to obtain information from demographic characteristics, antenatal and obstetric history, and obstetric complications. The data was collected through face-to-face interviews and a review of clinical records and birth registries. A standard questionnaire was first prepared in English, then translated to the local language Amharic and back to English by an independent translator to keep the consistency of the instrument. The questionnaire was adapted from published articles [6, 9, 15] and modified according to the local context.
Data quality was assured during collection, coding, entry, and analysis. Three diploma and two BSc midwives conducted interviews on daily basis using a standardized questionnaire for all women who deliver at the hospital within one to two hours of birth or immediately after recovery from a cesarean/complicated delivery. A training was given to the data collectors and supervisors regarding the objective, methods, tool, and data collection procedure to avoid any confusion and have a common understanding of the study. A pretest was done on 27 mothers (5% of the samples; 9 GM and 18 LM) in Arerti primary hospital and necessary amendments were considered following the result. The supervisors and principal investigators follow the daily activities of data collectors and checked the completeness, consistency, and clarity of the data.
Measurements
Low multiparity: a woman having two to four live births or stillbirths after 28 weeks of gestation [6, 15]. Grand multiparity: woman with five or more live births or stillbirths after 28 weeks of gestation [6, 15].
Obstetric outcomes: at least one obstetric complication before, during, and after delivery were considered, i.e., APH, PPH, anemia, PROM, preterm labor, cesarean section, uterine rupture, sepsis, pregnancy-induced hypertension, oligohydramnios, prolonged pregnancy, obstructed labor, induction/augmentation, and maternal death [6, 9].
Data processing and analysis
After data was collected and extracted from records, it was cleaned, coded, and checked for consistency and verification of missing values. Data was entered into Epi-Data version 4.6 and analysis was performed using SPSS version 25.0 statistical software. Descriptive statistics were summarized using frequency tables, percentages, and figures. Cross-tabulation and bivariable and multivariable analysis of variables were computed. Independent variables with a p-value of less than 0.25 in the bivariable analysis were exported into the multivariable logistic regression analysis. Multivariable analysis was used to control the possible confounders and identify important predictors of adverse obstetric outcomes. The adjusted odds ratio (AOR) with a 95% confidence interval was used to measure the strength of association. A p-value of ≤ 0.05 (2-tailed) was used to consider the significance of statistical tests. The model fitness was checked using Hosmer–Lemeshow goodness-of-fit (p = 0.688).
Result
Demographic characteristics
A total of 540 (180 LM and 360 GM) women were included in this analysis with a response rate of 98.9%. About 306 (85%) of LM and 70 (38.9%) of GM women were within the age range of 21 – 34 years (p = 0.000). Three-fourths, 266 (74%) of LM women reside in urban areas, while half 94 (52.2%) of GM women were rural residents (p = 0.000). Besides, 158 (44%) of LM and 42 (23.3%) of GM women had attended higher education (p = 0.000), and 58 (16.1%) of LM and 62 (34.4%) of GM women married before 18 years (p = 0.000). Further, 60 (16.7%) of LM and 32 (17.8%) of GM women have changed partners (Table 2).
Table 2
Distribution of socio-demographic data by parity among women who gave birth in North Shewa Zone Hospitals, 2021
Variables
Category
Parity, n (%)
LM (360)
GM (180)
p-value
Age of the mother
20 – 34 years
< 20 years
≥ 35 years
306 (85.0)
8 (2.2)
46 (12.8)
70 (38.9)
4 (2.2)
106 (58.9)
0.000*
Residence
Rural
Urban
94 (26.1)
266 (73.9)
94 (52.2)
86 (47.8)
0.000
Religion
Christian
Muslim
304 (84.4)
56 (15.6)
120 (66.7)
60 (33.3)
0.000
Mother’s education
No formal education
Primary
Secondary
Higher education
66 (18.3)
76 (21.1)
60 (16.7)
158 (43.9)
106 (58.9)
14 (7.8)
18 (10.0)
42 (23.3)
0.000
Mother’s Occupation
Housewife
Gov’t employee
Self-employed
164 (45.6)
112 (31.1)
84 (23.3)
108 (60.0)
26 (14.4)
46 (25.6)
0.000
Marital status
Married
Othersa
354 (98.3)
6 (1.7)
170 (94.4)
10 (5.6)
0.012
Husband education
No formal education
Primary
Secondary
Higher education
74 (20.9)
68 (19.2)
26 (7.3)
186 (52.5)
86 (50.6)
14 (8.2)
10 (5.9)
60 (35.3)
0.000
Husband occupation
Farmer
Gov’t employee
Self-employed
116 (32.8)
130 (36.7)
108 (30.5)
98 (57.6)
44 (25.9)
28 (16.5)
0.000
Age at marriage
< 18 years
≥ 18 years
58 (16.1)
302 (83.9)
62 (34.4)
118 (65.6)
0.000
Changing partner
Yes
No
60 (16.7)
300 (83.3)
32 (17.8)
148 (82.2)
0.746
Income (ETB)
Lower tertile
Middle tertile
Higher tertile
134 (37.2)
118 (32.8)
108 (30.0)
88 (48.9)
44 (24.4)
48 (26.7)
0.027
ETB Ethiopian Birr, GM Grand multiparous, LM Low multiparous
a Single, divorced, and widowed
* Fisher’s exact test
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Obstetric profile
The mean (± SD) gestational age was 39.17 ± 2.27 and 39.02 ± 2.09 weeks for low multiparous and grand multiparous women, respectively. About 342 (95.0%) of LM and 168 (93.3%) of GM women spaced a child for a minimum of two years. The majority of LM 348 (96.7%) and GM 156 (86.7%) women had antenatal care (ANC) follow-up. Abortion, neonatal mortality, and cesarean sections were the most frequently encountered obstetric complications previously. Additionally, 18 (5%) of LM mothers and 38 (21%) of GM mothers had previously given birth at home (Table 3).
Table 3
Obstetric characteristics of LM and GM women who gave birth in North Shewa Zone Hospitals, 2021
The prevalence of adverse obstetric outcomes was 32.6% (95% CI: 28.7–36.5). This was comparable in low multiparous and grand multiparous women (32.8% vs 32.2%). Antepartum hemorrhage, anemia, and postpartum hemorrhage were higher in grand multiparous women. Whereas, PROM, prolonged labor, induction/augmentation, episiotomy, and post-term pregnancy were higher in low multiparous women (Fig. 2).
Fig. 2
Adverse obstetric outcome in low multiparous and grand multiparous women in Public Hospitals of North Ethiopia, 2021
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Determinants of adverse obstetric outcome
Variables with a p-value of ≤ 0.25 in the bivariable logistic regression analysis were selected for the multivariable logistic regression analysis model. When adjusted for the socio-demographic and obstetric factors, parity did not show a statistically significant difference in obstetric outcomes [AOR (CI) = 1.42 (0.74–2.73)]. However, income, alcohol consumption, gestational age at delivery, previous mode of delivery, and birth weight showed a statistically significant association (Table 4).
Table 4
Determinants of adverse obstetric outcome in Public Hospitals of North Ethiopia, 2021
Variables
Adverse obstetric outcome
COR (95% CI)
AOR (95% CI)
Yes
No
Age
20 – 34 years
126 (71.6)
250 (68.70
1
1
< 20 years
8 (4.5)
4 (1.1)
3.97 (0.97–13.4)
3.44 (0.21–11.7)
≥ 35 years
42 (23.9)
110 (30.2)
0.76 (0.50–1.15)
0.67 (0.35–1.25)
Religion
Christian
129 (73.3)
295 (81.0)
1
1
Muslim
47 (26.7)
69 (19.0)
1.56 (1.02–2.38)
2.01 (0.99–4.06)
Mother’s education
No formal education
50 (28.4)
122 (33.5)
0.96 (0.61–1.49)
0.74 (0.29–1.87)
Primary
36 (20.5)
54 (14.8)
1.56 (0.93–2.61)
0.45 (0.17–1.21)
Secondary
30 (17.0)
48 (13.2)
1.46 (0.84–2.52)
0.82 (0.36–1.84)
Higher education
60 (34.1)
140 (38.5)
1
1
Age at marriage
< 18 years
46 (26.1)
74 (20.3)
1.39 (0.91–2.12)
0.79 (0.38–1.64)
≥ 18 years
130 (73.9)
290 (79.9)
1
1
Income (ETB)
Lower tertile
84 (47.7)
138 (37.9)
1.65 (1.06–2.58)
3.15 (1.30–7.63)*
Middle tertile
50 (28.4)
112 (30.8)
1.21 (0.75–1.97)
2.48 (1.22–5.06)*
Higher tertile
42 (23.9)
114 (31.3)
1
1
GA at first ANC visit
≤ 16 weeks
101 (62.3)
177 (51.8)
1
1
> 16 weeks
61 (37.7)
165 (48.2)
0.65 (0.44–0.95)
0.37 (0.21–1.66)
Previous obstetric complications
Yes
106 (60.2)
132 (36.3)
2.66 (1.84–3.85)
1.48 (0.88–2.49)
No
70 (39.8)
232 (63.7)
1
Mode of delivery (Previous birth)
Vaginal
128 (72.7)
352 (96.7)
1
1
Cesarean section
48 (27.3)
12 (3.3)
11.0 (5.66–21.4)
13.6 (6.18–30.1)*
Planned pregnancy
Yes
146 (83.0)
342 (94.0)
1
1
No
30 (17.0)
22 (6.0)
3.19 (1.78–5.72)
1.25 (0.47–3.29)
Alcohol consumption
Yes
24 (13.6)
28 (7.7)
1.89 (1.06–3.38)
3.15 (1.49–6.64)*
No
152 (86.4)
336 (92.3)
1
1
GA at delivery
Term
128 (72.7)
342 (94.0)
1
1
Preterm
26 (14.8)
10 (2.7)
6.95 (3.26–14.8)
9.24 (2.28–27.3)*
Post-term
22 (12.5)
12 (3.3)
4.89 (2.36–10.2)
4.82 (1.89–12.3)*
Newborn sex
Male
105 (59.7)
185 (50.8)
1.43 (0.99–2.06)
1.16 (0.71–1.92)
Female
71 (40.3)
179 (49.2)
1
1
Birth weight
Normal
130 (73.9)
312 (85.7)
1
1
Low birth weight
34 (19.3)
24 (6.6)
3.40 (1.94–5.96)
3.46 (1.33–9.03)*
Macrosomic
12 (6.8)
28 (7.7)
1.03 (0.51–2.09)
0.53 (0.19–1.42)
APGAR score
Low
24 (13.6)
16 (4.4)
3.43 (1.77–6.65)
1.51 (0.52–4.37)
Normal
152 (86.4)
348 (95.6)
1
1
Parity
Low multiparous
118 (67.0)
242 (66.5)
1
1
Grand multiparous
58 (33.0)
122 (33.5)
0.97 (0.67–1.43)
1.42 (0.74–2.73)
SVD Spontaneous vaginal delivery, GA Gestational age
*Statistically significant at p-value < 0.05
Mothers in the low-income tertile were three times more likely to develop obstetric complications compared to those in higher-income tertiles (AOR (CI) = 3.15 (1.30–7.63). The odds of adverse obstetric outcomes were higher among cesarean deliveries than the vaginal (AOR (CI) = 13.6 (6.18–30.1). Alcohol consumption increased the risk of adverse obstetric outcomes by threefold (AOR (CI) = 3.15 (1.49–6.64). Adverse obstetric outcomes were nine times more common in women with preterm deliveries (AOR (CI) = 9.24 (2.28–27.3). Further, mothers with low-birth-weight neonates were three times more likely to have adverse obstetric outcomes compared to normal birth weight (AOR (CI) = 3.46 (1.33–9.03) (Table 4).
Discussion
This study compared the adverse obstetric outcomes in low multiparous and grand multiparous women. APH, anemia, and PPH were higher in grand multiparous women. Whereas, PROM, prolonged labor, induction/augmentation, episiotomy, and post-term pregnancy were higher in low multiparous women. Income, alcohol consumption, gestational age at delivery, previous mode of delivery, and birth weight were significant predictors of adverse obstetric outcomes. However, parity showed an insignificant difference in obstetric outcomes.
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The current study found that parity was not significantly associated with composite adverse obstetric outcomes. However, APH, anemia, and PPH were higher in grand multiparous women. Whereas, PROM, prolonged labor, induction/augmentation, episiotomy, and post-term pregnancy were higher in low multiparous women. Similarly, a systematic review and meta-analysis finding showed that grand multiparity was not associated with an increased risk of pregnancy outcomes [16]. In Saudi, there is an insignificant increase in the maternal and neonatal risks in grand multiparas compared to the low multiparas. The study further concluded that grand multiparity could not be discouraged given that the women are provided with good perinatal care [7]. A comparative prospective cohort study in Uganda also reported that there was no difference in fetal outcome between grand multiparous and low multiparous women [17]. Further, grand multiparity was found to be an insignificant factor for adverse obstetric outcomes in South Ethiopia [6].
On the contrary, other studies found a statistically significant association between grand multiparity and adverse obstetric outcomes [9, 18, 19]. Grand multiparity was considered a risk pregnancy and increased the risk of obstetric complications in Tanzania [15]. These might be because of the variation in study design, setting, socio-economic status, and lack of account for possible confounders, i.e., interpregnancy interval, chronic disease, nutritional and psychosocial status. Besides, significant outcomes in the previous studies might be related to low health service utilization of grand multiparous women. Further, the differences in antenatal care access and quality may explain this disparity.
According to the current study, mothers in the low-income tertile were three times more likely to develop obstetric complications compared to those in higher-income tertiles. In Korea, the risk of obstetric complications, i.e., cesarean delivery, pre-eclampsia, gestational diabetes, obstetric hemorrhage, and preterm delivery were significantly higher in women with low-income levels [20]. Mothers with low-income levels also had higher risks of death [21]. This could be because women with low socioeconomic status tend to have low educational levels, inadequate prenatal visits, and poor medical service utilization. In addition, prolonged working hours/occupational fatigue and physical exertions likely affect obstetric outcomes.
It was found that the mode of delivery had a positive association with adverse obstetric outcomes. The odds of adverse obstetric outcomes were significantly higher among cesarean deliveries. A prospective cohort in Nepal found that the presence of severe obstetric complications significantly increased the likelihood of cesarean delivery [22]. Cesarean delivery appeared to meet the obstetric need to save the life of the mother and/or fetus and was performed following medical indications, particularly after the onset of labor. The most common obstetric indications of cesarean delivery were malpresentation, prolonged labor, non-reassuring fetal heart rate pattern, and obstructed labor.
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The current study identified alcohol consumption as a risk factor for adverse obstetric outcomes. Alcohol consumption increased the risk of adverse obstetric outcomes by threefold. This is comparable with a prospective cohort study in Japan that found alcohol consumption was associated with an increased risk of preterm birth [23]. In addition, women who drink alcohol had significantly higher odds of pregnancy-induced hypertension (PIH) [24]. The mechanism of this link might be due to alcohol induces endothelial dysfunction and insufficient spiral artery remodeling resulting in severe intravascular coagulation, decreased placental perfusion, placental dysfunction, and an imbalance of endogenous angiogenic factors, such as soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF). Alcohol could also increase the secretion of prostaglandins that increase cyclic 3ʹ,5ʹ-adenosine monophosphate activity and yield decreased cell division and increased uterine contractions [23, 24].
Gestational age at delivery was found to be an associated risk factor for obstetric complications. Women with preterm deliveries were nine times at higher risk of adverse obstetric outcomes. This finding was supported by a study done in Western Ethiopia, where mothers who developed anemia during pregnancy, PROM, and PIH were more likely to experience preterm birth [25]. Anemia may induce maternal and fetal stress and increase the risk of maternal infection stimulating the production of corticotropin-releasing hormone (CRH). Elevated CRH is a major risk factor for preterm labor, premature rupture of the membranes, and pregnancy-induced hypertension and eclampsia [26]. As amniotic fluid contains prostaglandin, PROM elevates fetal plasma interleukin-6 and induces uterine contraction. PIH may cause vascular damage to the placenta causing antenatal bleeding and preterm birth.
Moreover, mothers with low-birth-weight neonates were three times more likely to have adverse obstetric outcomes compared to normal birth weight neonates. Similarly, a cross-sectional study in Wolaita Sodo found that pregnancy-induced hypertension and anemia during pregnancy have independent effects in causing low birth weight [27]. Secondary data analysis in Zimbabwe also stated that the risk of low birth weight was significantly higher among women with PROM, eclampsia, anemia, APH, and preterm labor [28]. Low birth weight indicates the presence of some kind of obstetric complication that adversely affects the growth of the fetus. For example, hypertension in pregnancy may cause abruption placenta, which might result in reduced nutrient and oxygen supply to the growing fetus and may end up in low birth weight, growth restriction, or stillbirth [29]. This might be also due to poor socioeconomic status, inadequate maternal nutrition, and weight gain during pregnancy. This finding may also call attention to early identification and treatment of pregnancy complications and launch the 2016 WHO global recommendations for routine ANC visits.
Limitation
This finding study should be interpreted with the following drawbacks. Due to the insufficient count of cases, it was not possible to examine each specific adverse obstetric outcome separately with parity. There may be also a recall bias on previous obstetric profiles. Since it is a snapshot, it shares the limitation of a cross-sectional study that may not indicate a causal relationship. Finally, as the study was done in a hospital setting, the obstetric outcome of women who gave birth at home was not assessed.
Conclusion and recommendation
The adverse obstetric outcome was significantly associated with income, alcohol consumption, preterm delivery, cesarean delivery, and birth weight. Parity had no significant association with obstetric outcomes. Socio-economic development, avoiding alcohol consumption, early identification and treatment of complications, and adequate nutrition and weight gain during pregnancy are needed regardless of parity. Attention should be paid to both groups of women for their different obstetric complications. In addition, longitudinal studies are recommended to investigate the effect of parity on adverse obstetric outcomes.
Acknowledgements
The authors are grateful to Debre Berhan University (DBU) for the approval and financing of the study. We would also like to extend our appreciation to the study subjects, data collectors, and supervisors.
Declarations
Ethics approval and consent to participate
An ethical approval letter was obtained from the ethical review committee of Debre Berhan University, College of Medicine and Health science with protocol number P012. The committee has also approved thumb-printed consent from illiterate mothers. A further formal letter was written to the study hospitals. After the data collectors explained the objective, potential benefits, and risks of the study, written informed consent was obtained from the study subjects. Illiterate mothers were asked to thumbprint on the consent form. Confidentiality and anonymity were also assured. All methods were performed per the declaration of Helsinki ethical principles.
The Debre Berhan University, College of Medicine and Health science ethical review committee approved the procedure for thumb-printed consent from illiterate mothers.
Consent for publication
Not applicable.
Competing interests
The authors declare that there are no conflicts of interest.
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