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High parity (\u2265\u20095 previous births) is an underemphasized biological vulnerability linked to poverty and affecting a sizeable proportion of SSA births. Despite increased risk, high parity women rarely use hospitals for childbirth. We assessed whether emergency referral during childbirth was associated with adverse events in high parity women in hospitals in Benin, Malawi, Tanzania and Uganda. We used e-registry data collected in 16 hospitals included in the Action Leveraging Evidence to Reduce perinatal morbidity and morTality (ALERT) trial. Main outcomes were severe maternal outcomes and in-facility peripartum death (fresh stillbirth or very early neonatal death). Main exposure was parity; emergency (in-labour) referral was included as effect modifier with potential confounders. We used multivariable logistic regression including parity\/referral interaction and post-regression margins analysis. Among 80,663 births, 4,742 (5.9%) were to high parity women. One third reached hospital following emergency referral. Severe maternal outcomes and peripartum mortality were over 2.5-fold higher in high parity women with emergency referral compared to the lowest risk group. To avert these adverse events, emergency referral must be avoided by ensuring high parity women give birth in hospitals.\u00a0<\/jats:p>\n          <jats:p>\n            <jats:bold>Trial registration<\/jats:bold>\u00a0Pan African Clinical Trial Registry (<jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/www.pactr.org\" ext-link-type=\"uri\">www.pactr.org<\/jats:ext-link>): PACTR202006793783148. Registered on 17th June 2020.<\/jats:p>","DOI":"10.1186\/s12939-025-02379-5","type":"journal-article","created":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T08:16:58Z","timestamp":1737361018000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Mixed vulnerabilities: the biological risk of high parity is aggravated by emergency referral in Benin, Malawi, Tanzania and Uganda"],"prefix":"10.1186","volume":"24","author":[{"given":"Manuela","family":"Straneo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lenka","family":"Be\u0148ov\u00e1","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"van den Akker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muzdalifat S.","family":"Abeid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Ayebare","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Paul","family":"Dossou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Greta","family":"Handing","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bianca","family":"Kandeya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea B.","family":"Pembe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Hanson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,1,20]]},"reference":[{"key":"2379_CR1","unstructured":"UNICEF. 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Trop Med Int Health. 2017;22(1):63\u201373.","journal-title":"Trop Med Int Health"}],"container-title":["International Journal for Equity in Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12939-025-02379-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12939-025-02379-5\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12939-025-02379-5.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T08:17:12Z","timestamp":1737361032000},"score":1,"resource":{"primary":{"URL":"https:\/\/equityhealthj.biomedcentral.com\/articles\/10.1186\/s12939-025-02379-5"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,20]]},"references-count":48,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["2379"],"URL":"https:\/\/doi.org\/10.1186\/s12939-025-02379-5","relation":{},"ISSN":["1475-9276"],"issn-type":[{"value":"1475-9276","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,20]]},"assertion":[{"value":"28 September 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"6 January 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 January 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Ethical approval for ALERT was obtained from institutional review boards in Benin, Malawi, Tanzania, Uganda, Sweden, and Belgium, as follows:Ethics approval from all countries exempted the study from informed individual consent from women, as data would be de-identified before incorporation into the e-registry. All study procedures were in accordance with national ethical standards on human experimentation and with the Helsinki Declaration.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"TvdA is part of the editorial board of BMC Pregnancy and Childbirth. There are no other competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"19"}}