Key findings:
The key findings of the study reveal a low incidence of elderly pregnancy, with most subjects being booked, literate, residing in rural areas, and primarily housewives. Multiparity was significantly higher in the elderly gravid group compared to the control group, while primiparity was predominant in the control group.

What is known and what is new?
The abstract presents a study aiming to identify socio-demographic factors associated with elderly gravida. Known trends of delayed pregnancy are confirmed, with novel insights into the prevalence of elderly pregnancy in a specific setting. The study reveals distinct socio-demographic characteristics between elderly and younger pregnant women, shedding light on potential management strategies.

What is the implication, and what should change now?
The study highlights a low incidence of elderly pregnancy and socio-demographic factors among participants. It underscores the need for tailored management strategies for elderly gravidas. Future research should focus on addressing barriers to prenatal care access and enhancing support for multiparous elderly women, particularly in rural areas.
 

Elderly gravida refers to women having pregnancy at or above the age of 35 years. In India, such women constitute 19% of the total pregnant population. Data suggests that about 40% of all women develop some complications related to pregnancy. One such risk factor is elderly pregnancy that leads to many complications during pregnancy, labor and also to the baby [1]. The trend of delaying pregnancy is present worldwide, in both low and high income countries [1].

There are two groups of elderly primigravida. One with high fecundity- women married late but conceived soon after marriage and second with low fecundity- women married early but conceived long after marriage [2].

With the advent of better obstetric care, women over 35 years of age have safer pregnancies than in the past although pregnancy complications for this age group are higher than younger women [3].

Fertility reduces with increasing maternal age as there is low ovarian oocyte reserve and quality, with an increasing number of ovulatory cycles [4]. Poor oocyte quality is associated with an increased risk of aneuploidy, chromosomal abnormalities like Down syndrome, ectopic pregnancy, spontaneous abortions and metabolic disorders.[5,6]

The purpose of this study was to determine the socio-demographic factors associated with elderly gravida which would help us subsequently, in delineating the management of elderly gravida.
 

• To assess the socio-demographic factors in elderly gravida in tertiary care hospitals.

   

• To compare the socio-demographic factors of elderly gravid with the control group.
   

This prospective study was carried out in the department of Obstetrics and Gynecology at Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla for a one year period from 1st July 2018 to 30th June 2019.

Selection of Patients
All participants were divided into two groups

Group1 (Study Group)- 
All pregnant women aged 35 years or more.
Patient admitted in labor room. 
Women consenting for participation in the study.

Group2 (Control Group)- 
Every pregnant woman with age ≥20 to ˂35 years, who gets enrolled in the labor room admission register next to a case, was taken as a control.
 

Written consent was taken and counseling about the study was done of the women willing to participate in the study. Confirmation of pregnancy was done. Demographic information like age, socioeconomic status, ethnicity, educational status, antenatal care, and their weight and height were taken. The socioeconomic status was computed using the modified Kuppuswamy scale. Baseline socio-clinical profile including booked/ unbooked case, rural/ urban background was taken. Booked patient was one who has at least one visit in the first and second trimester and two visits after 28 weeks onwards. Comparative data of the two groups was subjected to statistical analysis. 
 

A prospective study was conducted in the department of Obstetrics and Gynecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College , Shimla, to study the pregnancy outcome at maternal age 35 years and older. Group 1 consisted of 415 subjects >35 years of age and Group 2 consisted of 415 subjects 20-34 years of age delivering in this hospital during a one year period from 1st July 2018 to 30th June 2019.

There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older.It was observed that out of 415 subjects in the study group, 349(84.10%) were in the age group of 35-39 years and 66(15.90%) were in the age group of 40 years and above. The oldest patient was 44 years old. Mean age was 37.80+1.83 years. In the control group subjects were in the age group of 20-34 years of age. It was observed that out of 415 subjects in the control group, 117(42.65%) were in the age group of 20-24 years, 148(35.66%) were in the age group of 25- 29 years and 90 (21.69%) were in the age group of 30- 34 years. (Table-1)

Table 1: Age Distribution in Study and Control Group.

It was observed that out of 415 subjects in both the study and control group 303(73.01%) and 316(76.14%) belonged to rural areas respectively. It was not significant statistically. 112(26.99%) belonged to the urban area in the study group and 99(23.86%) in the control group.

It was observed that out of 415 subjects in both the study and control group 378 (91.08%) and 361 (86.99%) were housewives respectively. In the study and control group 37(8.9%) and 54(13%) subjects respectively were employed. It was observed that 6 (1.45%) were professionals in the study group while there were no professionals in the control group. 16(3.86%) subjects were employed in the government or private sector in study and 42(10.12%) in the control group. It was observed that 6(1.45%) subjects were laborers in the study group and 12(2.89%) in the control group. Maximum subjects in both the groups were housewives and it was comparable. (Table-2)

Table- 2: Distribution of Socio-Demographic Factors in Study and Control Group

It was observed out of 415 subjects in both the study and control group 6(1.45%) were illiterate in both the groups. 39(9.40%) subjects had studied up to primary school in the study group and 12(2.89%) in the control group. 150(36.14%) subjects had studied up to middle school in the study group and 63(15.18%) in the control group. 200(48.19%) and 310(74.70%) subjects had studied up to high and higher secondary school in the study and control group respectively. 20(4.82%) subjects were graduates or post graduates in the study group and 24 (5.78%) in the control group. Most of the subjects in both the groups had studied up to high or higher secondary school. Higher education can be one of the reasons for delay in pregnancy in the study group.

Socio economic status was classified according to the modified Kuppuswamy scale. It was observed that out of 415 subjects in both the study and control group, 27(6.51%) subjects belonged to class II in the study group and 9(2.17%) in the control group. 100(24.10%) subjects belonged to class III in the study and 180(43.37%) in the control group respectively. It was observed that 279(67.23%) subjects belonged to class IV in the study group and 214(51.57%) subjects in the control group. 9(2.17%) subjects belonged to class V in the study and 12(2.89%) in the control group respectively. (Table-2) 

Table-3: Parity and Booking Status in Study and Control Group

It was observed that out of 415 subjects in both study and control group 36(8.67%) and 284(68.43%) were primiparous respectively with statistically significant p value(0.00001). 172(41.45%) were second paras in the study group and 110(26.51%) in the control group. 138(33.25%) and 18(4.34%) subjects were third paras in the study and control group respectively. 69(16.63%) and 3(0.72%) were grand multiparas in the study and control group respectively. The number of grand multiparas were more in the study group (16.63%) and primiparas were more in the control group (68.43%).

A booked subject is defined as a subject who has at least 4 visits, first as early as possible, second in between 24-28 weeks, third visit at 32 weeks and fourth visit at 36 weeks. It was observed that out of 415 subjects in both the study and control group 319(76.87%) and 385(92.77%) were booked respectively with p value of 0.00001 which was statistically significant. 96(23.13%) and 30(7.23%) were unbooked in the study and control group respectively. (Table-3)

A prospective controlled study was conducted in the department of obstetrics and gynecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College , Shimla, to study the pregnancy outcome at maternal age 35 years and older. Study group consisted of 415 subjects >35 years of age and the control group consisted of 415 subjects 20-34 years of age delivering in this hospital during a one year period from 1st July 2018 to 30th June 2019. There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older.

In the present study the percentage of pregnant women aged > 35 years was 6.00% In the studies conducted by Giri A et al [7] and Pawde A et al [8], the percentage was 4.53% and 9.63% respectively .The present study was conducted in Himachal Pradesh. Most of the women complete their family by the age of 24-25 years.

In the present study, 76.87% subjects were booked in the study group. In the study conducted by Beydoun H et al [9] the incidence was higher (99.00%) as the women who had visited the healthcare provider even once during their pregnancy were also included. Incidence was less in our study than in the study conducted by Luke B et al [10] (86.7%) as this study was conducted in the USA which is a developed country and people were more aware of the importance of regular antenatal visits. It was observed that a lesser proportion of elderly women received the antenatal care compared to the control group.

In the present study, 26.99% and 73.01% subjects belonged to urban areas respectively in the study and control group. The p value was 0.30 which was not statistically significant. In the study conducted by Lisonkova S et al [11] 76.36% elderly belonged to urban areas .This study was conducted in British Columbia which is a developed country and the criteria for rural area was taken as 10000 residents. The present study was conducted at Kamla Nehru State Hospital, Shimla which is a tertiary institute receiving referrals from all the rural areas. Moreover most of the population in Himachal Pradesh is still residing in rural areas. So, the maximum number of subjects belonged to rural areas.

In the present study 5.30% and 10.12% subjects were professionals and employed in the study and control group respectively. The p value was 0.00 which was significant. This was lower than the study conducted by Loke A Y et al [12] (63.8%).This study was conducted in Hong Kong which is a developed country and is socioeconomically developed. The numbers of working women are more in developed countries and these women tend to delay their marriage in pursuit of their careers. Also the literacy rate and socio-economic status is lower in Himachal Pradesh.

In the present study 98.55% subjects were literate in the study and control group respectively with 4.82% subject’s graduates or post graduates in the study group and 5.78% in the control group. This was comparable to the study conducted by Loke A Y et a1 [12] (99.00%). Women tend to delay their pregnancy in pursuit of higher education.

It was observed that out of 415 subjects the study group 36(8.67%) were primiparous. Which was less than in the study done by Ramachandran N et al [13] and Pratibha V Dixit et al [1]. There were 379(91.33%) multiparous subjects in the study group. There is a smaller number of elderly primigravida. Elderly gravida are mostly multigravida The number of grand multiparas were more in the study group (16.63%). The cause for more multigravida is ignorance, lesser knowledge of contraceptive measures and desire for a male child. The sample size of the studies conducted by Ramachandran N [13] and Pratibha V Dixit [1] was too small as compared to present study.
 

The incidence elderly pregnancy was low in the present study. Maximum numbers of subjects were booked, literate, from rural areas and were housewives. Multiparity was more in the study group as compared to the control group. While managing an elderly pregnancy, an obstetrician should be vigilant so as to detect any complication earlier and manage accordingly. Patients should be counseled about the potential risks and complications. Close supervision during antenatal, intrapartum and postpartum period contributes to good maternal and perinatal outcomes.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College.
 

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