This is the one of the first study reporting the baseline data of pregnancy complications among Palestinian pregnant women. It establishes that more than 20% of Palestinian pregnant women have at least one complication with PTL being most frequent and GDM and PIH, equally, being second most frequent. Among fetal complications, LGA and SGA were the most commonly recorded complications during pregnancy.
Studies conducted in Palestine neighboring countries reported similar results in the past. A Turkish study reported 23.9% of women experiencing complications during their pregnancies . Among the complications, PIH and GDM were the most commonly reported. Similarly, a retrospective study from Dubai also reported PIH and GDM as the most identified complications . Apart from that, PTL was the most commonly observed complication in a Jordan . Results from the current study indicate that participants in our group depicted sort of similar complications that are prevalent in the region.
Among fetal pregnancy complications, the current study identified SGA and LGA as the most common fetal complications during pregnancy (Table 2). This finding was consistent with previous studies identifying these complications as the most prevalent ones affecting fetuses during the pregnancy [31–34]. Moreover, the incidence rates for SGA and LGA in the current cohort of participants were similar to the rate of 16-20% of pregnant women reported previously [35, 36].
Regarding risk factors of pregnancy complications, we found that both nulliparity and low parity (previous 1 to 3 live births) women had higher risk of having complications during pregnancy when compared to high parity (>6) women. This means, both naulliparity and low parity were risk factor of complications during pregnancy. Parity has an inconclusive effect on pregnancy complications. Some studies showed different results and somewhat discrepancies regarding parity and pregnancy complications. Parities of three and above are considered a risk factor for GDM (37), while PTL was reported in some studies among high multiparity (≥5) women [18, 38]. On the other hand, nulliparous women are also reported to be at a greater risk of having pregnancy complications than women with other parities [31, 38, 39, 40]. A significant association between different parity levels and pregnancy complications (including GDM, PIH, and PTL) was also reported by Bai et al study . The study showed that the risk of any obstetric complications was higher among nulliparous women compared to parity one women. However, the study also revealed that multiparous women (>4) were also at a higher risk of pregnancy complication as compared to women with parity one. A recent meta-analysis of the Asian population identified only multiparity as a risk factor of GDM . Moreover, Shechter-Maor et al (2020) reported that primiparous women (having 1 previous live birth) were at higher risk of having pregnancy complications than multiparous women . The conflicting results of parity in different studies pointed to the complexity of the association between possible risk factors of pregnancy complications. This means, there may be a possible influence of further factors that contribute to a higher risk of these complications, such as ethnicity, socio-economic status, family history, and previous history of these complications.
An interesting result from the current study was gravida not having any adverse association with pregnancy complications. Instead, it depicted a statistically significant negative effect against pregnancy complications (O.R =0.11). The results identified pregnant women, mainly of gravida 4, being at lower risk of having pregnancy complications than higher gravida women. The degree of gravida or gravida status is rarely reported in previous studies as a risk factor or protective factor of pregnancy complications. In this context, Heaman and colleagues reported that being a primigravida is a risk factor of PTL . However, the said study also showed that being a multigravida woman with a previous history of PTL was a common risk factor for PTL and eclampsia as well. Additionally, primigravid women are previously highlighted by another researcher from Australia as well in a way that primigravid women have much higher rates of maternal complications . However, a recent study from South India showed that gravidity was not associated with high-risk pregnancy and included complications such as anemia, PIH and GDM .
The current study revealed that pregnant women living in camps had greater risk of having pregnancy complications (O.R=2.35) as compared to women living in cities. The possible explanation might be due to lagging pregnant women living in camps in getting health care services regularly due to social, educational and economic conditions which are known to be much lower in Palestinian camps than cities and towns.
Regression analysis of current study results missed the age as a common risk factor for having complications during pregnancy. It was contrary to the Jordanian study that identified older women (age > 40) to be at high risk of such adverse pregnancy complications . Similarly, many other international studies have also reported that advancing age (women ≥40 years) is a potent risk factor of pregnancy complications [45–48]. Advanced age was also identified to be a risk factor for having specific complications during pregnancy such as GDM [49, 50], pre-eclampsia , and PIH . However, the current study did not find age as a risk factor for maternal pregnancy complications; this might be due to the small number of pregnant women with advanced age in our study sample.
Contrarily, the regression model for fetal pregnancy complications from current data managed to identify younger age (17-40 years) as a protective factor of fetal complications during pregnancy. This indicated that these complications were more common to be seen among mothers with older age (>41 years). This has previously been reported by some studies where fetuses of older-age women (≥40 years) are prone to endure complications such as IUFD  IUGR [48, 53], LGA , and SGA . Yet, some other studies reported age of 35 years and above as the cut-off for increased risk of complications such as LGA, but this cut-off point did not found age as a risk for SGA fetal complications .
However, both LGA and SGA have indecisive trend across the studies. As an example, LGA was more commonly reported among women aged 40 years old and more when compared to younger pregnant women aged 30-34 . However, the result was insignificant when comparing women aged women 35-39 years with the reference group pregnant women (30-34 years). Moreover, other showed women age 30 to 34 years old had lower rates of SGA compared with women age 20 to 29 . This phenomenon was also established when SGA was more frequently reported among women age 35 to 40 years old compared with women aged between 20 to 24 . Yet another angle of the relationship between age and fetal complications is that young age women (<19 years) had a lower risk of having fetal complications such as LGA . Nonetheless, current results indicate that advanced age women are at higher risk of having fetal complications during pregnancy (Table 4) as reported earlier [48, 52, 53, 56, 58].
The results of the current study showed a relationship between parity status and fetal complications; fetal complications were more commonly seen among mothers with nulliparity, low multi-parity (1-3 previous live births) and high multi-parity (4-6 previous live births) compared to the reference group (Table 4), indicating women with high parities had a lower risk of fetal complications in our sample. Some studies reported that nulliparous women had significant associations with adverse fetal complications compared with multiparous women [31, 60] where nulliparous women depict significant adverse association with SGA . Additionally, the increased risk of fetal complications such as SGA [32, 62] and IUGR  is also reported to be higher among primiparous mothers than multiparous mothers. Contrarily, there has been a study indicating LGA as more common to see among very high parity women (10-14 parities), but a lower risk of SGA was reported among this group . However, since the study did not include nulliparous women in the analysis, it is difficult to compare our results with it. Moreover, a meta-analysis concluded that women who were both multiparous (≥3) and had their age ranging between 18-34 years had some protective effect against SGA . Similarly, another study showed that only nulliparous women aged ≥ 30 years but not multiparous women were at higher risk of having SGA when compared with nulliparous women age 20 to 29 . This may indicate that not only the level of parity may affect fetal complications, but the explanation of this could also be due to the existence of other influencing factors such as maternal age or the existing relationship between specific parity levels with specific fetal complications.
The current study revealed that the continuation of smoking during pregnancy is quite common among Palestinian pregnant women. The high prevalence of smoking could be attributed to the increase in the Shish smoking practice among all Arab countries which itself is becoming an acceptable attitude among both men and women. Regression analysis showed that smoking women were at a higher risk of having fetal complications during pregnancy than non-smokers. This result confirmed previous findings whereby smoking in pregnancy is an established risk factor for fetal complications such as SGA [17, 25, 44, 62, 63, 64] and IUGR [65, 66] in plenty of previous studies as a risk factor. It is well known that cigarette smoking during pregnancy decreases the carrying capacity of oxygen for both fetal and maternal blood, which in turn diminishes the oxygen available to the fetus at the tissue level and further effect fetal oxy-hemoglobin dissociation . Hence, the current study, once again, confirms the importance of smoking as a major risk factor for fetal complications during pregnancy.
Strengths and Limitations
This being one of the first studies to report baseline data regarding maternal and fetal pregnancy complications among Palestinian pregnant women, also has some limitations need to be addressed. There was no information collected about the history of previous pregnancy complications such as previous pre-eclampsia, abortion, PIH or GDM. Moreover, pregnant women who had pre-existing medical problems such as hypertension, diabetes, and epilepsy were not included in the study; this can underestimate the prevalence of complications during pregnancy. However, despite these limitations, we believe this study contributes to the literature related to the identification and evaluation of complications and risk factors of complications occurring during pregnancy.