|Year : 2021 | Volume
| Issue : 1 | Page : 31-34
Obstetric performance of women with advanced maternal age in Ahmadu Bello University Teaching Hospital, Zaria
Umma Suleiman Bawa, Abimbola Omolara D. Kolawole, Abdullahi Jibril Randawa
Department of Obstetrics and Gynaecology, ABUTH, Zaria, Nigeria
|Date of Submission||01-May-2020|
|Date of Decision||21-Jun-2020|
|Date of Acceptance||29-Oct-2020|
|Date of Web Publication||4-May-2021|
Dr. Umma Suleiman Bawa
Department of Obstetrics and Gynaecology, ABUTH, Zaria
Source of Support: None, Conflict of Interest: None
Context: Consequent upon changes in social norms over the years, there has been an increase in the age of marriage and childbirth in women. The older parturient poses a great challenge to the managing obstetrician and a greater challenge to attaining safe motherhood. Aim: To determine the obstetric performance and complications developed during pregnancy and delivery of women with advanced maternal age. Settings and Design: This was a retrospective (case–control) study. Setting: This study was conducted in an ANC and labour ward of ABUTH, Zaria, Nigeria. Materials and Methods: The antenatal and delivery records of women with advanced maternal age (≥35 years) and those within 20–25 years of age from 2002 to 2006 were reviewed. Records of 294 women with advanced maternal age, and 322 of those aged 20–25 years were used. Results: A total of 57% of women with advanced maternal age developed complications compared with 24% in those aged 20–25 years. A total of 13% had chronic hypertension, while 26.2% had pregnancy-induced hypertension. Labour was augmented in 12.2% of those who had spontaneous vertex delivery and 6.2% had EMLSC/S. Low birth weight babies occurred in 11.6% necessitating admission into the SCBU and 5.4% had stillborn. Conclusion: This shows the considerable risk in pregnancies of women with advanced maternal age. It is recommended that to minimise complications; preconception care, antenatal care and skilled attendant at delivery are paramount.
Keywords: Advanced maternal age, foetal outcome, obstetric performance
|How to cite this article:|
Bawa US, D. Kolawole AO, Randawa AJ. Obstetric performance of women with advanced maternal age in Ahmadu Bello University Teaching Hospital, Zaria. Niger J Basic Clin Sci 2021;18:31-4
|How to cite this URL:|
Bawa US, D. Kolawole AO, Randawa AJ. Obstetric performance of women with advanced maternal age in Ahmadu Bello University Teaching Hospital, Zaria. Niger J Basic Clin Sci [serial online] 2021 [cited 2021 Jun 23];18:31-4. Available from: https://www.njbcs.net/text.asp?2021/18/1/31/315414
| Introduction|| |
Consequent upon changes in social norms over the years, there has been an increase in the age of marriage and childbirth in women. This could be in order to achieve educational and career aspirations. The obstetric performance of women aged 35 years or more is widely considered to be less favourable than those of younger age.,,,,,, The mean age at first birth has risen sharply, especially in the developed world.,, In developing countries, the scenario is different. The women tend to become pregnant at advanced age due to concept of large family size, sometimes desire for male child and moreover due to lack of knowledge of availability of effective contraception.
The effect of advanced maternal age could negatively affect the outcome of pregnancy considering factors such as declining fertility, miscarriages, chromosomal abnormalities, hypertensive disorders and stillbirth. Advanced maternal age is associated with a range of adverse pregnancy outcomes. These risks are independent of parity and remain after adjusting for the ameliorating effects of higher socioeconomic status. Advanced paternal age which is frequently associated with advanced maternal age increases the risk of autosomal dominant disease such as achondroplasia, Marfan's syndrome, Huntington's chorea and von Willebrand's disease. This appears to result from new gene mutation.
In a study of women above 40 years, they were shown to have higher morbidity including antenatal and medical complications, higher caesarean section rate, placental abruption and placenta previa compared with younger patients., Another study demonstrated progressive thickening due to fibrosis of the muscular layer of the myometrial arteries as well as delay in maturation and differentiation of placental villi with advancement in maternal age. The β-cell functions of the pancreatic islets and their insulin sensitivity decline with age. Type II diabetes mellitus increases with age, and there is a much higher incidence of gestational as well as overt diabetes in older than in younger women.,, Abruptio placenta and placenta previa are also more frequently associated with older women. Abruptio is apparently related to the aging of the uterine vessels and is also associated with chronic hypertension, while placenta previa is related to higher parity, though other age-related factors may also be involved. Uterine leiomyoma, which is more common in these patients, is independently associated with placental abruption, dysfunctional labour and foetal malpresentations. Advanced maternal age was found to be significantly associated with severe maternal adverse outcomes, including maternal near miss, maternal death and severe maternal outcome. It was also found to be significantly associated with foetal and perinatal mortalities.,
The babies of older women have substantially increased morbidity and mortality.,, Adverse outcomes such as foetal anomaly, intrauterine growth retardation, preterm delivery and stillbirth all contribute to the increasing mortality and morbidity. Even when controlled for recognised coexisting conditions that contribute to foetal death, women aged 35 years or older continued to have a risk of foetal death that was twice as high as that amongst their younger counterparts. A study from Port Harcourt also reported a higher perinatal mortality. Older women were also shown in another study to have a longer interpregnancy interval. This correlated with higher perinatal mortality. Bearing in mind the cultural practices in the northern part of Nigeria and the common practice of continuing reproductive career in the late thirties and forties, it is important to document their obstetric performance.
This study was a retrospective case–control study done over a 5 year period from 1 January 2002 to 31 December 2006, which aimed to review the obstetric performance of the older woman and the outcome of their pregnancies at Ahmadu Bello University Teaching Hospital, Zaria.
| Materials and Methods|| |
This was a retrospective case–control study done over a 5-year period from 1 January 2002 to 31 December 2006. The antenatal and labour records of all women with advanced maternal age (≥35 years) and controls (20–25 years) within the said period were analysed. The unbooked patients and those who did not deliver in ABUTH were excluded from the study. The retrieval rate of the records was 90%. The information obtained included the biodata, complications during pregnancy and labour, foetal weight, maternal and foetal outcome.
The data collected were subjected to computer analysis using SPSS version 15 statistical software SPSS Inc. 233 South Wacker Drive, 11th Floor Chicago, Illinois, USA. P value for significance was set at ≤0.05.
| Results|| |
During this period, 6440 women were delivered in the labour ward of ABUTH, of which 294 (4.5%) were of advanced maternal age, 322 (5%) were aged 20–25 years of age and 5824 (90.4%) fell amongst the other age groups.
[Table 1] depicts the demographic characteristics of all the participants.
The majority of the women had secondary school education, 188 (30.5%), while 91 (14.8%) women had no form of education. A large number of women, 109 (17.7%), had tertiary education. As it is expected, the majority of the women were Hausa/Fulani, constituting 303 women (49.2%), while others from other parts of the country were 172 (27.9%). Most were Muslims, 400 (64.9%).
There was a comparison on the duration of pregnancy in both the cases and controls. For the purpose of this study, gestational age <38 weeks was taken as preterm and >42 weeks as post-term. The majority of both the cases and controls had normal duration of pregnancy 215 (73.1%) of the cases and 246 (76.4%) amongst the control group. Women with advanced maternal age had more cases of preterm labour 36 (12.6%) as opposed to 23 (7.1%) women in the control group (χ2 = 4.71, P = 0.09406), showing no significant relationship between maternal age and the duration of pregnancy.
There was a significant relationship between maternal age and the development of medical disorder (chronic hypertension) (P = 0.000003, OR = 5.16, confidence interval [CI]: 2.45–10.88). This is also true for pregnancy-induced hypertension (P = 0.00009, OR = 2.30, CI: 1.53–3.48), as depicted in [Table 2].
The great majority of both the cases and controls had a normal duration of labour: 215 (73.1%) in the cases and 272 (84.5%) in the control group. However, the women with advanced maternal age had more cases of precipitate labour 36 (12.3%) as against 6 (1.9%) in the controls. In this study, labour <3 h was termed precipitate while that which exceeded 12 h was prolonged. There was a significant relationship between maternal age and occurrence of precipitate labour (χ2 = 26.82, P = 0.0000014).
In terms of mode of delivery, the most common mode was spontaneous vaginal delivery: 242 (82.3%) in women with advanced maternal age and 289 (89.8%) in 20–25 years of age. Instrumental vaginal delivery was also higher in the cases 22 (7.5%) as opposed to 3 (0.9%) in the controls. They had similar rates for both elective and emergency caesarean section, and there was no record of destructive operation. This showed a significant relationship between maternal age and instrumental vaginal delivery (χ2 = 17.37, P = 0.0001697).
[Figure 1] summarises the complications women in both cases and controls had during labour and delivery.
|Figure 1: Percentage distribution of complications of labour and delivery|
Click here to view
[Table 3] considers the foetal outcomes, both morbidity and mortality. Most of the foetuses had a normal 1-min Apgar score.
There is a significant relationship between maternal age and APGAR at 1 min (χ2 = 19.31, P = 0.00006369), foetal birth weight (χ2 = 10.72, P = 0.004713), foetal morbidity (3χ2 = 28.51, P = 0.000000649) and foetal demise (4χ2 = 12.58, P = 0.00019550).
There was no record of maternal mortality in those categories of women in both the case and control groups.
| Discussion|| |
The proportion of women with advanced maternal age, that is, age ≥35 years, was 4.5%. This is as reported from the study conducted in Nepal where an incidence of 4.53% was recorded. It is common in this environment to commence deliveries at an early age but continue above the age of 40 years. It is a known fact that few women in our environment who get pregnant at advanced age do so not by their choice but due to various social reasons where pressure to have a male child remains one important cause.
As shown in this study, complications during pregnancy and delivery occurred more in women with advanced maternal age 57% as against 43% who had no complication. This is similar to findings from South Africa and Shagamu.,
Only one woman was recorded to have had spontaneous abortion (0.3%) which is lower than the report from Denmark but similar to the finding from Brazil. This could be because most of the women in this environment would not present to the hospital following an uncomplicated spontaneous abortion. Others would probably be managed in peripheral hospitals also equipped for post-abortion care. It could also be because gynaecology emergency records were not used.
Women with advanced maternal age had more medical complication, especially chronic hypertension that was present in 13% of those women. This is lower than reports from Brazil which showed an incidence of 22.1% and that from Nepal also showed that 26.6% had hypertensive disorders of pregnancy. The abdominal delivery rate for both emergency and elective was not significantly different between the advanced maternal age and those aged 20–25 years. This was unlike other reports which showed a significant difference between the two.,,,,
There was a significant difference in the instrumental vaginal delivery rate between women of advanced maternal age (>35 years) and those aged 20–25 years. This is similar to reports by Jolly et al. in the UK. This result was, however, different from the Nepal and Niger Delta studies that showed no difference in the instrumental delivery preterm births or twin gestation. The higher rate of medical complications could contribute to the difference in instrumental deliveries seen in the advanced maternal age.
In this study, the patients with advanced maternal age had a higher rate (7.1%) of delivering macrosomic infants, that is, birth weight ≥ 4 kg, as opposed to their younger counterparts where only 2.1% had foetal macrosomia. This is not in keeping with earlier reports where low birth weight was said to be higher in the advanced maternal age group but similar to that from Macedonia and Port Harcourt., This rate as earlier explained could be due to the presence of diabetes mellitus in the advanced maternal age. Some other reports have shown no difference in foetal weight in well-treated diabetics with advance maternal age.
The advanced maternal age was more likely to have special care baby unit admission, stillbirths and neonatal deaths, which is similar to earlier reports.,,,, The Apgar score at 1 min showed a difference between the two groups, with the cases having more babies with severe asphyxia. This is reported by others in similar studies.,
| Conclusion|| |
In spite of the limitations in this study, it is apparent that there is a considerable risk in pregnancies of those with advanced maternal age. This is because many of the disorders are identifiable and can be treated early with minimal complications. It is recommended that women should be counselled appropriately on the risks of delayed childbearing and complications should be anticipated. Parturients of advanced maternal age still constitute a high-risk group in our environment; efforts should be made to prevent delayed childbearing.
This is a retrospective study which limits any information obtained, and some confounders like parity were not explored. Data are from hospital records, limiting generalisation of findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kenny LC, Lavender T, McNamee R, O'Neill SM, Mills T, Khashan AS. Advanced maternal age and adverse pregnancy outcome: Evidence from a large contemporary cohort. PLoS One 2013;8:e56583.
Amarin V. Effect of maternal age on pregnancy outcome: A hospital based study. J Med R 2013;1:28-31
Giri A, Srivastav VR, Suwal A, Tuladhar AS. Advanced maternal age and obstetric outcome. Nepal Med Coll J 2013;15:87-90.
Hoque ME Advanced maternal age and outcomes of pregnancy: A retrospective study from South Africa. Biomed Res 2012; 23:281-5.
Koo YJ, Ryu HM, Yang JH, Lim JH, Lee JE, Kim MY, et al
. Pregnancy outcomes according to increasing maternal age. Taiwan J Obstet Gynecol 2012;51:60-5.
Jolly M, Sebire N, Harris J, Robinson S, Regan L. The risk associated with pregnancy in women aged 35 years or older. Hum Reprod 2000;15:2433-7.
Frederiksen LE, Ernst A, Brix N, Braskhøj Lauridsen LL, Roos L, Ramlau-Hansen CH, et al.
Risk of adverse pregnancy outcomes at advanced maternal age. Obstet Gynaecol 2018;131:457-63.
Ngowa JD, Ngassam AN, Dohbit JS, Nzedjom C, Kasia JM. Pregnancy outcome at advanced maternal age in a group of African women in two teaching Hospitals in Yaounde, Cameroon. Pan Afr Med J 2013;14:134.
Anuya AP, Manjiri PK, Jyothi U. Pregnancy in women aged 35 years and above: A prospective observational study. Obstet Gynaecol India 2015;65:93-6.
Heffner LJ. Advanced maternal age How old is too old? N Engl J Med 2004;351:1927-9.
Kahveci B, Melekoglu R, Evruke IC, Cetin C. The effect of advanced maternal age on perinatal outcomes in nulliparous singleton pregnancies. BMC Pregnancy Childbirth 2018;18:343. Available from: https://doi.org/100.1186/s12884-018-1984
. [Last accessed on 2019 Sep 08].
Laopaiboon M, Lumbiganon P, Intarut N, Mori R, Ganchimeg T, Vogel JP, et al
. Advanced maternal age and pregnancy outcomes: A multicountry assessment. BJOG 2014;121 Suppl 1:49-56.
Alves NC, Feitosa KM, Mendes ME, Caminha MF. Complications in preg-nancy in women aged 35 or older Rev Gaúcha Enferm 2017;38:e2017-0042.
Adefuye PO, Adefuye BO. Primigravida at advanced maternal age. Niger Med Pract 2013;63:5-6.
Radoń-Pokracka M, Adrianowicz B, Płonka M, Danił P, Nowak M, Huras H. Evaluation of pregnancy outcomes at advanced maternal age. Open Access Maced J Med Sci 2019;7:1951-6. Available from: http://dx.doi.org/10. 3889/oamjms. 2019.587
. [Last accessed on 2019 Jul 13].
Al Ghailani A, Gowri V, Al Hoqani FAS, Al Belushi AKM, Islam MM. Obstetrics complications and adverse outcome among elderly primigravidae of age 35 years and above in Oman. Clin Obstet Gynecol Reprod Med 2019;5. Available from: https//doi: org. 100.15761/COGRM.1000254
. [Last accessed on 2021 Jan 29].
Al-Dabbagh AS, Al-Taee WY. Risk Factor for Preterm Birth in Iraq: A Case Control Study. B M C Pregnancy and Childbirth; 2006. Available from: hpp//wwwbiomedcentral.com/1471-2393/6/13. [Last accessed on 2019 Jul 13].
Walker KF, Bugg GJ, Macpherson M, McCormick C, Grace N, Wildsmith C, et al
. Randomized trial of labor induction in women 35 years of age or older. N Engl J Med 2016;374:813-22.
Eugene MI, Alphonsus NO. Advanced maternal age at the first pregnancy and obstetric performance; a retrospective study. Pac J Med Sci 2014;13:21-31.
Ojule JD, Ibe VC, Fiebai PO. Pregnancy outcome in elderly primigravidae. Ann Afr Med 2011;10:204-8.
] [Full text]
[Table 1], [Table 2], [Table 3]