Induction of labour with vaginal prostaglandin tablet vs gel.

The objective of this study was to compare outcomes in women whose labour was induced with vaginal prostaglandin E2 tablets with those induced with prostaglandin gel. We compared outcomes of induction during two audits conducted in 2005 (PGE2 gel) and 2009 (PGE2 tablets). We found that there was no difference in induction rates; 21% in 2005 and 24% in 2009. The recommended dose of prostaglandin E2 was exceeded in 6% and 17% of women induced with gel and tablets, respectively (p=0.007). There was a difference in use of syntocinon to augment uterine contractions, 39% vs 58% for women induced with gel and tablets, respectively (p=0.001). There was no difference in overall operative delivery, 37% in gel and 38% in tablets. There was no difference in the proportion of women who had vaginal birth within 24 h; 50% vs 42% for gel and tablet, respectively (p=0.187). We conclude that compared to prostaglandin gel, women who received prostaglandin tablets were more likely to require syntocinon to augment contractions.

National survey of obstetricians in Wales regarding induction of labour in women with a previous caesarean section.

We conducted a national survey of consultants in Wales to elicit the opinions on induction of labour in women with a previous caesarean section. A total of 65 of the 87 consultants returned the postal questionnaire (75% response rate) and 54 of them were practising obstetricians. All but one obstetrician (53/54) would consider induction and for post-term indication, 47/53 would offer induction to a woman with a previous section; 40/53 (75%) of obstetricians would consider the prostaglandin method. The majority (36/40) would use prostaglandin tablets/gel; 80% (29/36) would use up to 2 doses (maximum recommended) and two-thirds (36/54) would consider syntocinon for augmentation of labour. A total of 34/54 (63%) consultants felt that Bishop's score would influence their decision to offer induction of labour (IOL) in a woman with one previous section and some 88% (47/53) of obstetricians always mentioned the increased risk of caesarean section and uterine rupture to these women during counselling before offer of induction. In conclusion, our survey reveals the variation in approach to management of postdates in women with previous caesarean section. We recommend a national audit of induction of labour in women with previous caesarean section.

Impact of Calman system and recent reforms on surgical training in gynaecology.

Specialist training in the UK has been affected by changes in recent years aimed at a reduction in junior doctors' working hours to comply with employment regulations and the introduction of structured training with specified duration. The Calman reforms implemented in 1996 introduced a focussed system with defined competencies and a shorter training period. The previous system was based on experience gained in an apprentice-type setting with no defined duration of training. The European Working Time Directive (EWTD) regulates the number of working hours for junior doctors and aims for a 48-h working week by 2009. In the surgical disciplines a reduction in working hours and shorter duration of training could adversely affect the acquisition of operative skills. The concern among trainees and their trainers was that surgical exposure has been reduced and therefore trainees have limited surgical experience by the time they complete training. We conducted this study in a teaching district hospital to determine the effect of recent changes on gynaecological surgical training. We found that there was a 27% reduction in surgical activity between 1995 and 2005 from 3,789 to 2,781, whereas the number of trainees had increased by 67% from 6 to 10. The proportion of operative procedures performed by trainees decreased from 55% (2,078/3,789) in 1995 to 34% (951/2,781) in 2005 (p < 0.001). The average number of procedures performed by each trainee in 2005 was 95 compared with 346 in 1995, a 73% reduction (p < 0.001). Innovative approaches to surgical training in gynaecology are required to produce a competent surgeon in a shorter time, or the risk of future consultants having limited surgical experience will increase.

Randomised controlled trial of two antenatal care models in rural Zimbabwe.

OBJECTIVE: To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe. DESIGN: Cluster randomised controlled trial with the clinic as the randomisation unit. SETTING: Primary care setting in a developing country where care was provided by nurse-midwives. POPULATION: Women booking for ANC in the clinics were eligible. MAIN OUTCOME MEASURES: Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes. METHODS: Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care. RESULTS: We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model. CONCLUSION: In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.

Best practices for antenatal care in Zimbabwe.

Evidence based recommendations, taken from systematic reviews of available literature form the basis for best practices. The manpower and resources available at health institutions in Zimbabwe have been taken into account in developing these antenatal protocols. Good quality is achieved when all the six visits are undertaken at the recommended times, and the activities are carried out competently by providers displaying a good attitude towards the patients. The providers should assess the quality of antenatal care periodically using indicators of access and the correct performance of procedures.

Occurrence of diabetogenic changes in pregnancy among black women in an urban setting.

OBJECTIVE: To find out if pregnancy in black Zimbabwean women is a diabetogenic state using basal blood levels of cortisol, insulin, C-peptide and glucose. METHODS: 111 women (28 non-pregnant, 29 first trimester, 26 second trimester and 28 third trimester) aged between 18 and 35 years were recruited for the study. Fasting plasma cortisol, insulin, C-peptide and glucose were determined by standard methods. The glucose/insulin ratio was used as an index of insulin sensitivity and the C-peptide/glucose ratio as well as the homeostasis assessment model (HOMA) as an index of insulin resistance. RESULTS: The means of fasting plasma cortisol levels were significantly elevated, p < 0.0001 among the four groups (non-pregnant, first, second and third trimester women). Fasting plasma insulin levels peaked during the third trimester and significant differences were noted among all women, p < 0.05. Similar data was obtained for C-peptide levels (a better indicator of beta-cell insulin secretory activity) among the groups, p < 0.01. The means of fasting plasma glucose levels were significantly decreased with advancing gestation, p < 0.0001. Significantly lower glucose/insulin ratios, a measure of insulin sensitivity and elevated C-peptide/glucose ratios, an index of insulin resistance, were demonstrated among the women, (p < 0.05 and < 0.01 respectively). CONCLUSION: The basal data presented in this paper clearly demonstrates that the diabetogenic effects of pregnancy are also expressed by Zimbabwean black women, especially in late gestation.

Does maternity care improve pregnancy outcomes in women with previous complications? A study from Zimbabwe.

To determine the utilization of maternal health care services and pregnancy outcomes for women with a history of complications in previous pregnancy, we analysed the pregnancy records of multiparous women (parity > or =1) who booked and completed follow-up in Gutu district, Zimbabwe between January 1995 and June 1998. Women with previous uncomplicated pregnancies (n = 6140) were classified as low risk, whereas those with complications of previous pregnancy (n = 1077) were classified high risk. At enrolment, there was no difference in maternal age and parity between low- and high-risk women. A higher proportion of high-risk women had more than five antenatal visits (32% versus 21%; P<0.001) and gave birth in hospital (47% versus 18%; P<0.001). The risk of antenatal (relative risk [RR] 1.57; 95% confidence interval [CI] 1.32-1.88), labour/delivery (RR 1.98; 95% CI 1.75-2.25) and neonatal (RR 1.83; 95% CI 1.44-2.34) complications was elevated in high-risk women. There was increased risk for perinatal death in high-risk women, but this did not reach statistical significance (RR 1.56; 95% CI 0.98-2.49). The recurrence ratio for most complications was low and the sensitivity of historical risk markers in predicting women likely to develop further complicated pregnancies was only 23%. Most women with previous pregnancy complications can safely give birth in the rural health centre. We concluded that high-risk women had an elevated risk of complications in the index pregnancy and that better utilization of maternal health care, especially for delivery, reduced adverse perinatal outcomes.

Labor induction with vaginal misoprostol and extra-amniotic prostaglandin F2alpha gel.

OBJECTIVE: To compare the effectiveness of vaginally administered misoprostol with extra-amniotic prostaglandin F2alpha (PGF2alpha) gel for induction of labor. METHOD: A randomized controlled trial, with women allocated to receive either misoprostol 50 microg intra-vaginally or extra-amniotic PGF2alpha gel 5 mg, was conducted in Harare Maternity Hospital. A total of 152 women were admitted for induction of labor with a term singleton, pregnancy and cephalic presentation were recruited. The main outcome was duration of induction. RESULTS: There were no differences in the characteristics of women in the two groups at recruitment. In the misoprostol group there was a significantly reduced need for augmentation of labor with oxytocin (OR=0.36; 95% C.I. 0.17-0.73) and delivery by cesarean section for failure to progress (OR=0.11; 95% C.I. 0.00-0.88). The risk for duration of induction to vaginal delivery exceeding 12, 18 or 24 h was reduced by 18%, 38% and 68%, respectively, but only the risk for duration >24 h was significantly reduced (OR=0.32; 95%C.I. 0.11-0.91). The mean duration of induction was shorter in the misoprostol group, 15.2 vs. 23.6 h (P=0.02). There were no differences in fetal outcome. CONCLUSION: Misoprostol 50 microg was associated with less use of oxytocin in labor, a shorter induction to delivery interval and fewer cesarean sections for failure to progress when compared with extra-amniotic PGF2alpha gel.

Misoprostol versus oxytocin in the third stage of labor.

OBJECTIVES: A double blind randomized controlled trial was performed at the tertiary hospital in Harare, Zimbabwe to compare oral misoprostol with intramuscular oxytocin in the management of third stage of labor. METHODS: A total of 499 women were randomized to receive either 400 microg misoprostol orally or 10 IU oxytocin intramuscularly. The incidences of postpartum hemorrhage and side effects were examined. RESULTS: The demographic and labor characteristics were comparable. Postpartum hemorrhage occurred in 15.2% of women given misoprostol and in 13.3% of those given oxytocin (P=0.534). Measured blood loss of more than 1000 ml occurred in 3.7% of the misoprostol group compared with 2% in the oxytocin group (P=0.237). There was no significant difference in the need for additional oxytocic drugs or blood transfusion in women given misoprostol (P values 0.137 and 0.600, respectively). Significant side effects of misoprostol were shivering [RR=1.32 (95% CI 1.11-1.58); P=0.002) and a rise in temperature [RR=2.02 (95% CI 1.75-2.33); P<0.001]. CONCLUSIONS: Oral misoprostol is as effective as intramuscular oxytocin in the prevention of PPH. Shivering and transient pyrexia were specific side effects of misoprostol. Misoprostol has potential in reducing the high incidence of PPH in developing countries.

Prophylactic augmentin in prelabor preterm rupture of the membranes.

OBJECTIVE: To determine whether the use of prophylactic Augmentin in PPROM prolongs gestation and reduces neonatal and maternal morbidity due to sepsis. METHOD: Study setting was Harare Maternity Hospital, Zimbabwe. Women with PPROM between 26 and 36 weeks' gestation were randomly allocated either to a group given a course of prophylactic oral Augmentin or another receiving no prophylactic antibiotic treatment. The calculated sample size was 72 women per group. Data were analyzed using the EPI INFO program. RESULTS: A total of 171 women were recruited into the study, 84 in the Augmentin group and 87 in the No Treatment group. The group receiving prophylactic Augmentin had a significantly longer latency period between rupture of membranes and delivery. There was a trend towards increased neonatal and maternal morbidity due to sepsis in the No Treatment group although no statistical significance was reached. CONCLUSION: The use of prophylactic Augmentin in PPROM significantly prolongs gestation. It appears to decrease neonatal and maternal morbidity due to sepsis.

Effectiveness and safety of high dose oxytocin for augmentation of labour in nulliparous women.

OBJECTIVE: To compare high and low starting dose of oxytocin infusion for effectiveness and safety in augmentation of labour in nulliparous women. DESIGN: An open randomised controlled clinical trial. SETTING: Harare Maternity Hospital, Zimbabwe. SUBJECTS: 258 nulliparous women, with spontaneous onset of labour, who required augmentation. MAIN OUTCOMES MEASURES: Duration of augmentation, mode of delivery, maternal and neonatal complications. INTERVENTIONS: Women were randomly allocated to either low dose (starting at 4 mIU/minute) or high dose (starting at 10 mIU/minute) oxytocin group. RESULTS: Of the 258 women enrolled, 133 were randomized to the low and 125 to the high starting oxytocin dose groups. The groups were comparable for maternal and gestational age. There was no difference in mean cervical dilatation before augmentation of labour; six cm in both groups (p = 0.167). The mean augmentation to delivery interval was shorter in the high dose group, 218 versus 326 minutes (p < 0.001). There was no difference in the mode of delivery and fetal outcome in terms of birthweight, five minute Apgar score, admission to neonatal unit and perinatal death. CONCLUSION: A high starting dose of oxytocin infusion is as safe but more effective for augmentation of labour in nulliparous women, compared to a low starting dose.

Health workers' participation in voluntary counselling and testing in three districts of Mashonaland East Province, Zimbabwe.

OBJECTIVES: To determine the proportion of health workers who had undergone VCT for HIV in three districts of Mashonaland East Province and to further explore reasons for non-participation in those who had not been tested. SETTINGS: The study was conducted in the rural Districts of Murewa, Mutoko and Mudzi in Mashonaland East province. DESIGN: The study was a descriptive cross sectional survey. SUBJECTS: All categories of health workers in Murewa, Mutoko and Mudzi. MAIN OUTCOME MEASURES: Participation in VCT, and reason for non-participation. RESULTS: Out of 200 questionnaires sent out 183 (91.5%) were completed and returned. The majority of the respondents were nurses 142 (77.6%), female 113 (61.7%), married 135 (73.8%). The median age was 33 (Q1; 28: Q3; 38) and they had attained a high school education 137 (74.9%). Of the respondents 160 (87.4%) had not gone for VCT; 141 (77%) did not want to have an HIV test. The reasons for not being willing to have an HIV test included not being ready to go for VCT 154 (84.2%); could not cope with the results, 143 (78.1%), do not have the courage to go 133 (72.7%); no need for testing as there is no cure for HIV/AIDS 106 (57.9%). One hundred and twenty six (69%) indicated that they needed counselling for them to be able to go for VCT. CONCLUSION: HIV/AIDS programmes have been directed at the community at large neglecting the health worker. This study, therefore, recommends programmes specifically tailor-made for health workers. These programmes should have a strong counselling component and should focus on self-efficacy so that health workers can finally be ready, be able to cope with HIV results and have the courage to participate in VCT.

Maternal outcome in eclampsia at Harare Maternity Hospital.

OBJECTIVES: To study the presentation, management and determinants of maternal outcome in eclampsia at Harare Maternity Hospital (HMH) in order to design interventions for reduction of maternal mortality. DESIGN: Cross sectional descriptive study. SETTING: Harare Maternity Hospital, Harare, Zimbabwe. SUBJECTS: All women with diagnosis of eclampsia treated at HMH during an 18 month period. MAIN OUTCOME MEASURES: The study variables included age, parity, booking status, gestational age, location at time of first seizure, number of fits, seizure to delivery interval, maternal complications and the clinical management. RESULTS: There were 151 women with eclampsia from 25,425 deliveries in HMH (5.9 per 1,000 deliveries). The case fatality was 26.5%. The majority of fits (67.5%) occurred antepartum. The mothers who died were significantly older than the survivors, mean age 25.8 versus 22.3 (p = 0.007), and had a higher proportion of multiple seizures, 0.67 versus 0.39 (p = 0.009). In 38% of cases the first seizure occurred at home. The proportion of complications was higher among those who died. Deficiencies in clinical management were more common in the women who died, 39.5% versus 20.9% for survivors (OR 2.55; 95% CI 1.09 to 5.99) and they included delays in achieving delivery, inadequate clinical assessment and poor monitoring. CONCLUSION: Eclampsia remains a significant cause of maternal mortality in HMH with a high case fatality rate. Advanced maternal age, antepartum onset of convulsions and multiple fits were associated with increased risk of maternal death. There were deficiencies in the clinical management of a high proportion of cases.

Trends in maternal mortality for the Greater Harare Maternity Unit: 1976 to 1997.

OBJECTIVE: To determine the magnitude, trends and the main causes of maternal death for Harare Maternity Hospital (HMH) and thereby identify potential areas for interventions. DESIGN: A descriptive retrospective analysis of maternal mortality data from the institution included in publications and recent annual reports. SETTING: Department of Obstetrics and Gynaecology Greater Harare Maternity Unit, Zimbabwe. MAIN OUTCOME MEASURES: The trends in maternal mortality ratios (MMR) and the relative importance of different causes of death between 1976 and 1997. RESULTS: There was a decline in MMR between 1976 and the early 1980s but there has been a steady increase in MMR for Harare residents from 50/100,000 in 1988 to 224/100,000 in 1997. Sepsis has remained the leading cause of maternal death. There has been a significant increase in indirect deaths due to meningitis, tuberculosis and pneumonia where HIV infection is an underlying factor. Avoidable factors were identified at patient/community, local health facility and at the tertiary hospital. There has been a decline in the quality of care in recent years. CONCLUSION: Maternal mortality for HMH is unacceptably high and could still be rising. HIV infection has contributed to the worsening picture. Interventions to improve access and quality of care at all levels could lead to significant reduction in maternal deaths.

Vaginal misoprostol for induction of labour: a more effective agent than prostaglandin F2 alpha gel and prostaglandin E2 pessary.

OBJECTIVES: To compare labour outcome in women who had labour induced with PGF2 alpha gel, PGE2 vaginal pessary or misoprostol administered intravaginally or orally. STUDY DESIGN: Unmasked randomised controlled trial. SETTING: Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare. SUBJECTS: Women with a singleton foetus in cephalic presentation after 37 weeks gestation admitted for induction of labour who were randomised to prostaglandin F2 alpha gel (n = 76), prostaglandin E2 pessary (n = 75) and misoprostol administered either intra-vaginally (n = 128) or orally (n = 127). MAIN OUTCOME MEASURES: Primary outcome was induction to delivery interval. Secondary outcomes included use of oxytocin during labour, mode of delivery, duration of labour, neonatal condition at delivery and maternal complications. METHODS: Four hundred and six women admitted for induction of labour with a singleton foetus in cephalic presentation after 37 weeks gestation were enrolled. To estimate the risk with induction using other agents the odds ratio and 95% confidence interval was calculated using the group that received prostaglandin F2 alpha gel as referents. RESULTS: The women were comparable for baseline characteristics. Compared to prostaglandin F2 alpha gel, the need for augmentation with oxytocin in labour was significantly reduced in women induced with prostaglandin E2 pessary (OR 0.46; 95%CI 0.23 to 0.93), vaginal misoprostol (OR 0.34; 95%CI 0.18 to 0.63) and oral misoprostol (OR 0.42; 95%CI 0.22 to 0.78). There was no difference in mode of delivery. There was a significantly reduced risk (OR 0.20; 95%CI 0.04 to 0.86) of Caesarean section (CS) for failure to progress in the vaginal misoprostol group. Labour induced with misoprostol and prostaglandin E2 pessary was significantly shorter than in prostaglandin F2 alpha gel. Vaginal misoprostol significantly shortened the induction to delivery interval. There were more admissions to the neonatal unit in the misoprostol groups. CONCLUSION: Compared to prostaglandin F2 alpha gel, misoprostol and prostaglandin E2 pessary had reduced need for oxytocin and a shorter duration of labour. Effects of misoprostol on the foetus need further investigation before it is used as a routine agent for induction of labour.

Liver and kidney function tests in normal and pre-eclamptic gestation--a comparison with non-gestational reference values.

OBJECTIVE: To compare liver and kidney function tests in pre-eclampsia and in uncomplicated pregnancy and to relate the results to physiological reference values. DESIGN: Prospective cross sectional study. SETTING: Antenatal clinic and antenatal labour wards, Harare Hospital, Zimbabwe. SUBJECTS: 38 pre-eclamptic and 72 normal women of similar parity, gravida and gestational age. MAIN OUTCOME MEASURES: Serum albumin, total bilirubin, alkaline phosphatase (ALP), aspartate transaminase (AST), alanine transaminase (ALT) and gamma-glutamyl transaminase (GGT) were used as indices of hepatic function. Serum creatinine, urea and uric acid were used to assess renal function. RESULTS: Albumin, bilirubin and ALT did not show any differences between the pre-eclamptic and normotensive pregnant women. The activities of the following enzymes, ALP (p < 0.001), AST (p = 0.001) and GGT (p < 0.01) were significantly elevated in pre-eclamptic women. The renal indices, creatinine, urea and uric acid were significantly raised in pre-eclampsia (p < 0.001). No significant differences were observed in the haematological parameters, haemoglobin (Hb), white blood cell count (WBC), red blood cell count (RBC), mean corpuscular volume (MCV) and platelet count. Almost all the biochemical and haematological parameters were lower in normal pregnancy compared to the physiological reference values used in our maternity unit. CONCLUSION: Liver and kidney function is modified by normal pregnancy. However, the majority of the liver and kidney function tests between pre-eclamptic and normal pregnancy exhibited significant differences. The physiological reference values that are currently in use are different from those of women with uncomplicated pregnancies and may not be entirely suitable for management of pre-eclampsia which has hepatic and renal involvement.

Field efficiency of syphilis screening in antenatal care: lessons from Gutu District in Zimbabwe.

OBJECTIVES: To determine coverage for antenatal syphilis screening in a rural area and evaluate the accuracy of on-site Rapid Plasma Reagin (RPR) tests performed by nurse-midwives. DESIGN: Descriptive cross sectional. SETTING: Rural Health Centres (n = 23) in the Gutu District of Zimbabwe. SUBJECTS: Women booking for antenatal care in the district were used to determine coverage of screening. Results from women who had an RPR test performed during a nine week period were used in assessing the accuracy of tests performed by nurse-midwives. INTERVENTION: On-site antenatal screening for syphilis using an RPR kit with immediate results and treatment for women who tested positive. MAIN OUTCOME MEASURES: Prevalence of syphilis (positive RPR) at booking and the level of agreement between three observers (RHC nurse-midwife, medical practitioner under field conditions and medical laboratory technologist). RESULTS: Eighty five percent of women were screened for syphilis at the first antenatal visit and 11% had a positive RPR. Almost all (97.3%) women with a positive RPR test result were treated. The accuracy of tests performed by RHC staff was poor with a sensitivity of 40% (95% CI 21.8 to 61.1) when compared to those done by the medical practitioner and 8.7% (95% CI 1.5 to 29.5) when compared to those done in a laboratory. The predictive value of a positive test was 22.7% and that of a negative test was 94.9%. CONCLUSION: The coverage of screening for syphilis in pregnant women in Gutu District was good but the results were unreliable. There is need for nurse-midwives, who perform the majority of RPR tests in the RHC, to receive adequate training to ensure competence in testing and to strengthen quality control procedures.

Relation of parity to pregnancy outcome in a rural community in Zimbabwe.

This population-based cohort study was conducted to compare pregnancy complications and outcome among nulliparous, low (1-5) and high (> or = 6) parity women. Women who registered for antenatal care and gave birth in Guru District, Zimbabwe, between January 1995 and June 1998 were classified into groups by parity. The women were compared for baseline characteristics, utilisation of health facilities and occurrence of pregnancy complications such as hypertensive disorders of pregnancy, haemorrhage, pre-term delivery, operative delivery, low birth weight and perinatal death. In estimating risk, primiparous (parity = 1) women were used as referents. Pregnancy records for 10,569 women were analysed. Mean ages of nulliparous and high parity (> or = 6) women were 20.1 and 37.7 years respectively (p < 0.001). Prevalence of anaemia at booking (haemoglobin < or =10.5 g/dl) was reduced in nulliparous compared to multiparous women (11.7% vs 16.8%; p > or = 0.001). Nulliparous women were likely to book early (< or = 20 weeks) for antenatal care, have a higher number of visits (> or = 6) and fewer home births. Nulliparous women had higher risk for low birth weight (RR 1.70; 95% CI 1.36 - 2.13). Compared to low parity women, nulliparous and high parity women had an elevated risk of hypertensive complications RR 1.62 (95% CI 1.37-1.92) and RR 1.64 (95% CI 1.29 - 2.07) respectively. The risk of developing any pregnancy complications was highest in nulliparous women (RR 1.48; 95% 1.31- 1.67). In conclusion, nulliparous women had an increased risk of pregnancy complications. High parity women with no previous complicated pregnancy were at low risk of complications.