The International Federation of Gynaecology and Obstetrics (FIGO) defined grand multipara as women who have delivered fifth to ninth fetuses, whereas women who have delivered ten or more times considered to be great-grandmul- tiparas [1] . Shaista et al. considered grand multipara to be women who gave birth in five or more previous pregnancies after the 28^th week of gestation [2] . Grand multipara in relation to obstetric performance is labelled high risk. High risk pregnancy is defined as one in which the mother, fetus or newborn are at increased risk of morbidity or mortality before, at or after birth [2] . It has been shown that the best obstetric outcome is often seen in women who are para 1, 2 and 3 [3] . The risk to the mother and child is relatively high in first pregnancy and then this risk declines during second, third and then slowly rises with increasing parity and by the sixth pregnancy, risks exceed those of first and after that rises steeply with each pregnancy [2] .

The incidence of grand multipara has decreased in most western countries since two generations due to better socioeconomic and educational status, better understanding of the limits of earth’s resources and therefore higher utilisation of better more available contraception [2] . Grand multiparity is a common problem in this part of the world and when added to low socioeconomic status; it significantly increases the risk to mother and fetus and limits the resources to feed, clothe and educate the children involved and indeed the resources available to all children in a country [1] . In developed countries, grand multiparity is becoming rare, with an incidence of 1% - 4% of all births while in developing countries like Nigeria, the incidence of grand-multiparity is between 5.1% and 18.1% [4] [5] [6] .

Grand multiparous pregnancies have been considered to be at higher risk of developing antenatal complications. These complications include hypertension in pregnancy, gestational diabetes mellitus, anemia, placental abruption, placenta previa, preterm labor, mal-presentation, mal-position and feto-pelvic disproportion [7] . Other complications include uterine inertia, dysfunctional labor, uterine rupture, intrauterine death, fetal macrosomia, postpartum hemorrhage and operative deliveries with its consequent risk of maternal morbidity and mortality [7] . Socioeconomic factors play a very important part; majority of these patients are poor with inadequate access to modern perinatal care coupled with increased maternal age [1] [5] . They tend to feed their numerous children at the expense of their own nutrition, thus are prone to malnutrition [8] . They are too busy to attend to their health and due to the rapid succession of pregnancies and periods of lactation; there are subsequent iron and calcium depletion [8] . These reported complications that occur to these groups of patients during pregnancy, delivery and puerperium underscores the need for special care during antepartum, intrapartum and postpartum period [2] . Although grand multiparity has long been considered to be associated with increased maternal and fetal complications, recent studies indicated that with proper perinatal care, women with high parity rates are no longer at high risk [2] . Some authors concluded that in a developed country with optimal health care conditions, grand multiparity should not be considered dangerous [9] [10] . So the controversy concerning the risk of grand multiparity can be resolved in this environment by this study because the interventions to reduce grand multiparity and its complications can only be applied when the magnitude of the condition is known. Thus the aim of this study was to determine the prevalence, obstetric outcome and complications of grand multiparity in UCTH, Calabar. This will help to increase awareness, scale-up care, suggest ways to reduce these conditions, improve maternal and fetal survival and quality of life. It will also help to reduce the morbidity, mortality and economic implications associated with grand multiparity and its complications.

This prospective case control study was carried out at the Obstetrics and Gynaecology Department of the University of Calabar Teaching Hospital, Calabar, Cross River state. Cross River state has a population of 2.8 million people with Calabar as the capital city. Calabar has a population of about 371,022 people comprising a heterogenous mix of diverse cultural, religious and ethnic groups [11] . UCTH serves as a referral center for both government and private hospitals within and outside the state. The study included 150 grand multiparous women (cases) and 150 of multiparous women (para 2 - 4) as controls matched for age that were booked in our hospital and admitted to the maternity unit for delivery during the same period. Exclusion criteria were primigravidae, primipara, unbooked women, previous caesarean section, previous myomectomy, those who refused to participate in the study and those with pre-existing medical conditions such as diabetes mellitus and chronic hypertension. The study protocol was approved by the hospital research and ethics committee.

The study was performed over 7 months’ period after the participants consented and met the inclusion criteria. During the period, all women who had previously given birth to five or more times (grandmultiparae) who met the inclusion criteria were recruited. The control group was selected to match each case for age. Each case was matched with a control woman, selected by identifying the first woman matched for age, delivering within the same period as the index case and had previously delivered two to four times (multiparae). The pattern was repeated until the desired sample was obtained. This was to reduce the reported effect of maternal age on the obstetric complications [12] .

On admission, patients’ histories were taken in details and the case file reviewed. A pretested questionnaire was used for the collection of biodata, obstetric history, socio-demographic data and antenatal complications of pregnancy by the researcher and also by trained residents attached to the labor ward. The data were obtained and filled by direct questioning, examination and follow up of the patients from admission till discharge from hospital. The maternal weight, blood pressure and fetal presentation were obtained and recorded. The fetal presentation was determined by abdominal palpation and when difficult, ultrasound was used to determine the fetal presentation. About 3 ml of venous blood was collected from each woman with application of tourniquet into Ethylene Diamine Tetra Acetic acid (EDTA) anticoagulated container for packed cell volume. Midstream urine was collected in a sterile container for urinalysis using the dipstick method in the hospital labor ward side laboratory. During labor, patients were managed according to unit’s protocol and partograph recording were used to evaluate the progress of labor. The intrapartum complications including prolonged labor, intrapartum hemorrhage, uterine rupture and mode of delivery were also recorded. After delivery, information on birth weight, Apgar scores and admission to neonatal intensive care unit (NICU) were obtained. Patients were monitored for 24 hours for primary postpartum hemorrhage. Also, data on maternal mortality, stillbirth and fetal malformation were obtained.

Anemia was defined as PCV of less than 30% as this is a more useful definition in the tropics [12] . Pre-eclampsia was defined as blood pressure of >140/90 mm Hg after 20 weeks of gestation with proteinuria on two or more occasions of 6 hours apart. Bleeding from genital tract after 28 weeks gestation and before delivery was taken as APH. Malpresentation was defined as presentation of the fetus other than vertex presentation in relation to maternal pelvis. Preterm delivery was defined as delivery before 37 completed weeks of gestation. Primary PPH was defined as blood loss estimation of 500 ml and above after normal vaginal delivery and 1000 ml after caesarean section or such that could compromise the cardiovascular system within 24 hours of delivery.

The mean age of the grand-multiparous women was 37.0 ± 2.8 years, and that of matched multiparous control group was 36.1 ± 3.0 years. Mean parity for the cases was 5.6 ± 0.9 while 3.0 ± 0.8 was for the control group.

Table 1 shows the socio-demographic characteristics of the study population. The grand multiparous women were significantly associated with educational levels (X² = 18.21, P-value = 0.000) and polygamous marriage (X² = 4.551, P-value = 0.033). Grand-multiparous pregnancy was significantly more among the muslims in case group (17.3%) than in the control group (6.7%) [X² = 8.081, P-value = 0.004].

The mean gestational age at delivery of the grand multiparous women was lower (38.40 ± 1.475 weeks) than the control (38.64 ± 1.338 weeks) though, the difference was not statistically significant (t-test = 1.476, P-value = 0.141) as shown in Table 2. The mean packed cell volume at delivery for the grand multiparous women was lower (33.59% ± 2.727%) than the control (35.21% ± 2.728%) and this was statistically significant (t-test = 5.143, P-value = 0.000).

Table 3 shows the antenatal complications of grand multiparous women and their controls. Pregnancy induced hypertension was significantly higher among grand multiparous women 8 (5.3%) than the control 1 (0.7%) (P = 0.018).

The packed cell volume of the participants decreases as the parity increases and showed a negative correlation with the parity as shown in Figure 1. The negative linear relationship between packed cell volume at delivery and parity was significant (Pearson correlation = −0.301; P-value = 0.000).

Table 4 shows the intrapartum complications. Fetal distress and caesarean section were higher among grand multiparous women than their controls,

PIH: Pregnancy induced hypertention; GDM: gestational diabetes mellitus; PROM: Premature rupture of membranes.