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.

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.

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.

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