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Pregnancy outcome in elderly primigravidae at

the University of Maiduguri Teaching Hospital,
Maiduguri, Nigeria
ARTICLE in AFRICAN JOURNAL OF MEDICINE AND MEDICAL SCIENCES SEPTEMBER 2013

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International Journal of Medicine and Medical Sciences ISSN: 2167-0404 Vol. 3 (7), pp. 476-480, September,
2013. Available online at www.internationalscholarsjournals.org International Scholars Journals

Full Length Research Paper

Pregnancy outcome in elderly primigravidae at the

University of Maiduguri Teaching Hospital, Maiduguri,
Nigeria
Babagana Bako1 Inuwa Umaru1 Ado Danazumi Geidam1 Mohammed Ashiru Garba2
1

Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital P.M.B 1414, Maiduguri Borno
State, Nigeria.
2
Department of Paediatrics, University of Maiduguri Teaching Hospital P.M.B 1414, Maiduguri Borno State, Nigeria.
Accepted 26 June, 2013

Maternal age is an important determinant of pregnancy outcome and women aged 35 years and above
undergoing their first pregnancy are often classified as high risk obstetric patients. The objective of this
study was to determine the birth outcome in some women going through their first pregnancy at 35 years
and above compared with their younger counter parts aged 20-34 years. A ten year retrospective casecontrol study of the birth outcome of elderly primigravidae compared with younger primigravidae (20-34
years) managed at the University of Maiduguri teaching hospital, Maiduguri, Nigeria. During the study
period, there were 24,085 deliveries out of which 102 were elderly primigravidae giving the incidence of
0.42%. The elderly primigravidae are more prone to pregnancy induced hypertension and Preeclampsia
2
2
(x =9.41, p=0.002) and caesarean section (x =30.26, p=0.0001) compared to the younger mother. However,
the incidences of post date pregnancy and failed induction of labour (FIOL) were found to be much higher
in the control than the elderly primigravidae with p values of 0.001 and 0.024 respectively. There was no
statistically significant difference in the incidence of miscarriages, premature rupture of membranes
(PROM), placental abruption, preterm labour/contractions, instrumental vaginal deliveries and fetal
outcome in the two groups. Elderly primigravidae are at an increased risk of pregnancy induced
hypertension and Preeclampsia as well as caesarean delivery than the younger primigravidae. However the
fetal outcomes are comparable. We recommend modification of social habits to reduce the occurrence of
elderly primigravida.
Key words: Birth outcome, elderly primigravidae and pregnancy complications.

INTRODUCTION
In obstetric practice, maternal age is an important
determinant of the outcome of pregnancy and both
extremes are known to be associated with adverse
maternal and fetal outcomes (Sivalingam and Avalani,
1989; Cleary-Goldman et al., 2005).
In recent years, the pursuit of education and career has
made many women to defer child bearing until they are in
their late 30s. This trend has resulted in increase in the
number of women aged 35 years and above undergoing
their first pregnancies. Traditionally such women are
considered to be high risk obstetric patients because of

*Corresponding author. E-mail: babaganabako@yahoo.com

the complications associated with their pregnancies and

deliveries (Agboola, 2001; Heffner, 2004; ClearyGoldman et al., 2005).
Previous studies have suggested that they are more
prone to developing medical and obstetric complications
in pregnancy such as miscarriages, hypertensive
disorders
in
pregnancy,
gestational
diabetes,
malpresentation, preterm labour and antepartum
haemorrhage (Sivalingam and Avalani, 1989; Ziadeh,
2002). In labour, they are also at increased risk of
caesarean section and instrumental vaginal delivery
(Ilesanmi et al., 1998; Sizer et al., 2000; Cleary-Goldman
et al., 2005). The incidence of fetal distress and perinatal
morbidity and mortality were significantly higher among
the elderly primigravidae than their younger counterparts
(Ling et al., 2008; Ziadeh, 2002). However, with the impr-

Bako

et al.

476

vement in obstetric care, these risks have continued to be

a subject of controversy (Suwanrath et al., 1998). Some
authors reported that pregnancy and birth outcome are
poor (Berkomtz et al., 1990; Ales et al., 1990; Breart,
1997), while others reported no difference (Urguhart et
al., 1991, Ojule et al., 2011). This study was designed to
compare pregnancy and birth outcomes of elderly
primigravid mothers with younger primigravidae aged 2034 years.

MATERIALS AND METHODS

The labour ward register and case records were used
and all elderly primigravid women delivered at the
University of Maiduguri Teaching Hospital over a period
of 10 years from 1st January 2001- 31st December 2010
were identified. The case notes were retrieved and
studied retrospectively. For each elderly primigravida, the
next primigravida aged 20-34 years that delivered was
used as a control. Data regarding socio-demographic
characteristic such as age, level of education,
occupation, religion, booking status, pregnancy
complications, intra/postpartum complications, mode of
delivery and neonatal outcome were extracted from the
case notes. The information was coded and transferred
onto a profoma designed for the study. This was then
transferred onto SPSS version 16 statistical software and
analyzed. The socio-demographic characteristics,
pregnancy complications and birth outcomes are
presented as percentages on frequency tables. Chisquare test and student t test were used to analyze for
categorical
variables
and
continuous
variables
respectively. Multinomial logistic regression was used for
multivariate analysis to construct a model for maternal
characteristics, pregnancy complications and birth
outcome. The statistical significance was set at P< 0.05.
Elderly primigravidae are women aged 35 years and
above undergoing their first pregnancies as described by
Sivalingam and Avalani in 1989.

RESULT
During the study period there were 24,085 deliveries at
the UMTH, Maiduguri and 102 of these were elderly
primigravidae, giving an incidence of 0.42%. Out of the
102 patients, 94 case notes were retrieved making 92.2%
retrieval rate and these were analyzed in the study.
The mean age of the elderly primigravidae (cases) group
was 36.26 + 1.59 years, and 24.20 + 2.85 years for the
control group. Eighty two (87.23%) of the elderly
primigravidae had formal education compared to
44(46.81%) of the control. Abysmal 10(10.64%) of the
control were career civil servants compared to
54(57.45%) among the cases. Most of the elderly
primigravidae (58.51%) were Christians compared to

39(41.49%) among the control as shown in table 1. The

mean heights in meters and weights in kilogram of the 2
groups were similar; 162.45 + 4.68 versus 160.54 +
15.54 and 69.08 + 7.37 versus 63.23 + 9.47 respectively
with p values of 0.178 and p=0.075 respectively.
Table 2 compared the pregnancy complications and birth
outcomes in the two groups. Twenty one (22.34%)
women among the elderly primigravidae developed
pregnancy induced hypertension and/or preeclampsia
during antenatal period compared to 6 (6.38%) in the
control and the difference was statistically significant.
Similarly, 49(52.13%) of the elderly primigravidae had
caesarean delivery compared to 12(12.76%) of the
2
younger mothers, X =30.26, p<0.0001. However, the
incidences of post date pregnancy and failed induction of
labour (FIOL) were found to be much higher in the control
than the elderly primigravidae with p values of 0.001 and
0.024 respectively. There was no statistically significant
difference in the incidence of miscarriages, premature
rupture of membranes (PROM), placental abruption,
preterm
labour/contractions,
instrumental
vaginal
deliveries and fetal outcome in the two groups as shown
in the table. There were 3 babies delivered with
congenital anomalies in the studied population. A baby
each in both the cases and control group with spina bifida
occulta and another in the case with hypospediasis.
However, there was no statistically significant difference
in the occurrence of these anomalies between the two
groups as shown in table 1.
Even after logistic regression analysis we found that the
elderly primigravidae were more likely to be educated
with OR=15.87, CI: 6.84-36.82. In the same vain
pregnancy induced hypertension/preeclampsia and
caesarean delivery were significantly higher among the
elderly primigravidae with OR=3.58, CI: 1.85-10.68 and
CI=7.16, CI: 2.99-16.99 respectively.
Table 3 showed the indications for Caesarean section in
the patients studied.
The indications for caesarean section in the 2 groups
varied widely, most of the elderly primigravidae (58.6%0)
were offered caesarean delivery on the account of being
elderly primigravidae or on maternal request. While
42.11% of the controls had caesarean delivery because
of cephalopelvic disproportion or obstructed labour and
the difference were statistically significant as shown in
table 3. Most of the caesarean deliveries are elective
among the elderly primigravidae 41/49 (83.67%)
compared to 3/12 (25.0%) in the control.

DISCUSSION
The incidence of elderly primigravidae of 0.42% in this
study is higher than 0.07% reported by Ilesanmi (1998) in
Ibadan, Nigeria but lower than 1.4% reported by Ojule et
al (2011) in Port-Harcourt, Nigeria and 0.65% reported by
Sivalingam and Avalani (1989) in Malaysia.

477

Int. J. Med.Med.Sci.

Table 1. Sociodemographic characteristic of the patients.

S/NO
1.

2.

3.

4.

Characteristic
Educational status
No formal education
Formal education
Total
Occupation
House wives
Student
Business
Civil servant
Total
Religion
Christians
Muslims
Total
Booking status
Booked
Unbooked
Total

Cases (%)

Control (%)

P value

12(12.76)
82(87.23)
94(100)

50(53.19)
44(46.81)
94(100)

34.75

0.000

19(20.21)
9(9.57)
12(12.77)
54(57.45)
94(100)

71(75.53)
12(12.76)
1(1.06)
10(10.64)
94(100)

57.64

0.000

55(58.51)
39(41.49)
94(100)

32(34.04)
62(65.96)
94(100)

11.32

0.001

82(87.23)
12(12.77)
94(100.)

73(77.66)
21(22.34)
94(100.)

2.97

0.080

Table 2. Pregnancy complications and birth outcome.

Complications
Threatened miscarriage
PROM
Preterm delivery
PIH/Preeclampsia
Placental Abruption
Post date
Obstructed labour
Fetal distress
FIOL
PPH
Assisted Vaginal delivery
Caesarean section
LBW
IUGR
5th minutes Apgar score
Congenital Malformation
Stillbirth

Cases(%)
9(9.57)
9(9.57)
8(8.51)
21(22.34)
3(3.19)
0(0.00)
2(2.12)
4(4.26)
0(0.00)
5(5.32)
9(9.57)
49(52.13)
19(20.13)
9(9.57)
3(3.19)
2(2.12)
2(2.12)

Control(%)
8(8.51)
5(5.32)
4(4.36)
6(6.38)
2(2.12)
10(10.64)
3(3.19)
2(2.12)
5(5.31)
2(2.12)
7(7.45)
12(12.76)
17(17.09)
6(6.38)
1(1.06)
1(1.06)
0(0.00)

X
0.064
1.215
1.405
9.41
0.204
10.44
0.204
0.684
5.108
1.325
0.268
30.26
0.269
0.613
2.01
0.345
2.017

P value
0.801
0.271
0.236
0.002
0.651
0.001
0.651
0.408
0.024
0.250
0.605
0.000
0.874
0.965
0.365
0.206
0.156

Key:
PROM: Premature rupture of membranes
PIH: Pregnancy induced hypertension

The lower incidence in this study is because women in

this part of the world venture into marriage at an earlier
age and therefore start child bearing before they are 35
years. This may not be unconnected to the culture and
religion of the people of Borno state who are
predominantly Muslims. However, the recent National
Demographic Health Survey in 2008 showed that the age

at first birth is rising slowly and the average age at first

birth in the North-eastern Nigeria is 18.2 years.
Our study showed a preponderance of formal education
among the elderly primigravidae with more than half of
them have attended formal education and majority are
gainfully employed. The pursuit for higher education and
career perhaps contributed to the delay in starting child-

Bako

et al.

478

Table 3. Multinomial logistic regression analysis model of maternal characteristics and pregnancy complications in elderly
primigravidae.

Educational status
Elderly primigravidae
Controls
Booked patients
Elderly primigravidae
Controls
PIH/Preeclampsia
Elderly primigravidae
Controls
Caesarean section
Elderly primigravidae
Controls

Odd Ratio

95% Confidence Interval

P value

15.87
-

6.84 - 36.82

0.00

2.83
-

1.05 - 5.45

0.01

3.58
-

1.85 - 10.68

0.04

7.17
-

2.99 - 16.99

0.00

Table 4. Indications for caesarean section.

S/No
1.
2.
3.
4.
5.
6.
7.

Indication
Elderly primigravida
Maternal request
PIH/Preeclampsia
CPD/Obstructed labour
Fetal distress
Placental abruption
FIOL
Total*

Cases
18(31.03)
16(27.59)
11(19.97)
7(12.07)
4(6.89)
2(3.45)
0(0.00)
58

Controls
0(0.00)
1(5.26)
2(10.53)
8(42.11)
2(10.53)
1(5.26)
5(26.32)
19

X
6.060
2.949
0.249
8.232
0.0000
0.000
13.856

P value
0.014
0.086
0.617
0.004
0.985
1.000
0.000

*The total is higher than for the caesarean section because of multiple
indications in some patients.
PIH: Pregnancy induced hypertension
CDP: Cephalopelvic disproportion
FIOL: Failed induction of labour

bearing among the elderly primigravid mothers. This

finding is similar to the findings reported from other
centres (Sivalingam and Avalani, 1989; Bell JS et al.,
2001; Ziadeh, 2002).
Similar to the findings by Joseph et al., (2005) and Oboro
and Dare, (2006) we found an increase occurrence of
pregnancy induced hypertension (PIH) and Preeclampsia
in the older mothers. The elderly primigravidae are at
least 3 times more likely to develop pregnancy induced
hypertension/peeclampsia than the younger mothers.
This may not be unconnected to the fact that advancing
maternal age is known to increase the risk of other
chronic diseases particularly diabetes mellitus and
hypertension. Our finding however contrasts with the
finding of Ojule et al., (2011), who reported no increase
occurrence of PIH/Preeclampsia amongst the older
mothers.
Post date pregnancies were found to be higher among
the control group, this may be because the care givers

are more comfortable allowing the younger mothers to go

post date before inducing them. Additionally, higher rate
of the elective caesarean section for the elderly
primigravidae shown in the study will result in lower
occurrence of post date among them. More so that most
elective caesarean sections are done at 38-39 weeks in
our centre.
The incidence of caesarean section among the elderly
primigravidae was higher than among the younger group.
This is similar to the series reported from other centres
(Bell JS et al., 2001; Cleary-Goldman et al., 2005; .
Jirattigalachote and Prechapanich, 2008). Concerns
about the maternal age as a cause of increase maternal
and perinatal morbidity and mortality has made the
routine recommendation of elective caesarean section for
these women in the past and this tradition has been
maintained by many doctors as seen in our study with
many of the caesarean sections been done based on this
presumption. In some cases, the mothers are so appreh-

479

ensive that they request for caesarean section, and in

this study maternal request was the second commonest
indication for caesarean delivery. The high rate of
maternal request among the study group may be
explained the fact that the elderly primigravidae often
consider their pregnancies as precious and are less
willing to take risks with vaginal delivery. The higher
concern for safety amongst the elderly primigravidae has
been reported earlier by windrigde et al (1999) and many
of the elderly primigravidae may feel that elective c/s is
safer than vaginal delivery for their babies. However
there is no firm evidence to substantiate this claim (Idama
and Lindow, 1999).
Both maternal and obstetrician's concerns are
responsible for the undue intervention especially the
caesarean delivery in the elderly primigravidae. The
implication of this increased intervention is that it will lead
to increased medical demand on the scarce resources
particularly in a low resource setting like ours. Until a firm
evidence of the benefit of such intervention is
established, elderly primigravidae should have adequate
counseling and allowed to make informed choice on their
mode of delivery and also be supported to try vaginal
delivery where feasible.
The fetal outcome among the older primigravid women is
generally controversial, some reported increased in
perinatal mortality (Fretts and Usher, 1997; Astolfi et al.,
2005; Ling et al., 2008) while others did not (Oboro and
Dare, 2006; Ojule et al., 2011). Our study revealed no
significant difference in terms of
fetal outcome,
congenital malformations, stillbirth, neonatal death, and
APGAR scores between the two groups.
Anthropometric measures may play a significant role in
obstetric performance especially those at high risk of
developing cephalopelvic disproportion and medical
conditions in pregnancy. However, in this study there
were no statistically significant difference in the maternal
height and weight at booking between the two groups.
Hence, this might not have influenced the birth outcome
in this study. There was no maternal mortality during the
period of the study in the two groups.

CONCLUSION
Elderly primigravidae are at an increased risk of
pregnancy induced hypertension/Preeclampsia and
caesarean delivery than the younger primigravidae.
However there is no difference in the fetal outcome in the
two groups.

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