Advanced Maternal Age: Pregnancy Over 35

According to recent statistics, more than 18% of pregnant and recently postpartum people are 35 years of age or older, or of Advanced Maternal Age. That’s a lot! For first babies, that number is more than 10%. These numbers are big increases that have been steadily rising since the mid-1970’s. It’s an interesting thing to think about, but also can have big implications for health care.

What is Advanced Maternal Age (AMA)?

This is the medical label that people get when they are 35 years of age or older when they give birth. This term might not feel right for everyone, but at least it’s an improvement over the previous labels of “Geriatric Pregnancy” or “Elderly Primigravida (pregnant for the first time)”! This label can mean a lot.

It can definitely impact the way you feel about yourself during your pregnancy, and how you feel about your birth. You might really internalize this label and start to feel more nervous about your condition and about your body’s abilities. I hope this article serves to reassure you that you have a VERY high chance of having a healthy pregnancy, birth and baby. Even if your risks are highER, they are likely not truly high, and not just because of your age.

Why Are More People Having Babies After 35?

It can be hard to know for sure, but there are many factors that could be contributing to the increase in age for pregnancy and birth. Some of the suspected reasons are shown here:

1. Assisted Reproductive Technology (ART) – Even when people want to have a baby, sometimes they can’t do it the old-fashioned way. We now have improved ways to help people get pregnant. ART can include using donor sperm, donor eggs, AI (artificial insemination where the sperm is placed in the vagina near the cervix AKA turkey baster method), IUI (intrauterine insemination where the sperm is placed directly into the uterus using a catheter), medications, IVF (in vitro fertilization where the egg and sperm are removed and combined outside the body, then implanted into the uterus), and other procedures that can be done to make the body better able to get pregnant or hold on to a pregnancy. Because fertility declines some by age 30 and significantly around age 35, fewer people achieve pregnancy on their own. So, when people choose to start trying to conceive later, they might then have trouble. Also, sometimes people start trying early, but because of infertility issues that might not be caused by age, it can take years to achieve a viable pregnancy and they are of AMA by the time they finally become pregnant. The improvement in and increased use of ARTs can be partly responsible for the increase in age for first time parents.
2. People are choosing not to start a family until later for a lot of reasons, such as:

a. More time spent on education.
b. An increase of women in higher earning, traditionally male-dominated jobs and fields. Many women choose to wait to get pregnant until they feel well-established in their careers.
c. Lack of childcare is a factor, whether that’s due to the fact that many people live further away from their extended families, or because of the increased cost of childcare.
d. Economic reasons cause some people to wait longer. They may not feel that they earn enough to pay for childcare or to reduce their household income significantly.
e. Workplace policies that are unsupportive of new families. That might mean insignificant parental leave, or policies that make it difficult for parents to work and have the flexibility to care for their children when they’re sick or have other needs.

How Advanced Maternal Age Affects Your Health Care

These labels can also make a difference in the health care you receive. Providers might make different recommendations for people after age 34. This can be so tricky though! Is there really that much difference between someone who is 34 and someone who is 35? Not necessarily. There is a lot of grey area, but 35 is a general target. It really should be treated on a case-by-case basis though. For example, are you going to just turn 35 when your baby is born, did you conceive on your own, have you had a complication free pregnancy, are you a generally healthy person at a generally healthy weight, do you eat well, sleep well, and exercise? If all of those things are true, your risks really might not be much higher than a younger person’s.

If the opposite are true for some or all of these questions, you really might be in a higher risk category. But what does that mean? It’s good to have a conversation with your provider about this before you start to worry too much. Most of the time, they will look at your complete history and health picture before deciding that you should be treated as a high risk patient.

I also encourage you to ask about your Absolute Risks if that information hasn’t been offered. You might be offered care options based on your age that you are perfectly comfortable with, or others that you aren’t. It’s always important to have open communication with your provider. Tell them if something makes you uncomfortable, and they’ll most likely talk about alternatives with you.

Some people believe that midwifery care is no longer an option at a certain age. This can sometimes be true, but it’s usually more nuanced than that. Midwives are well-trained in managing many types of pregnancies, even in some that might be categorized as high risk. Many midwives can very competently and comfortably care for a person who is classified as AMA. If you are 35-39, and otherwise low risk, this is usually easier and you may not need any additional care.

Your midwife might also recommend that you be seen by a Maternal Fetal Medicine Specialist (MFM). This is an obstetrician who goes on to further specialize in high risk maternity care. If you’re under OB care, they might also recommend that you see an MFM. That can often mean just having a few appointments with the MFM at recommended checkpoints to be sure your pregnancy is progressing normally, but you continue regular care with your OB or midwife and plan to give birth with their support. If you are 40+, it might get more difficult to find a midwife care provider, but it can also depend on other factors.

Like Lauren mentions in the interview, this is not her first baby. She’s an experienced mother, became pregnant without ART, is in very good health, has no other risk factors, and has had a long relationship with her midwife. Because of their long history, her midwife understands that she is a very healthy and responsible pregnant person who had five uncomplicated pregnancies and births before this one. However, the fact that she is 45 years old means that she can still be under the midwife’s care, but also that they both feel more comfortable that she is also seeking care from an MFM.

Lauren’s experience with her MFM mirrors that of many others. They are there to provide their specialized expertise and very close monitoring, but they also have the perspective of working with the most high risk cases. That means they likely see your age as a relatively small risk factor, and recognize that most people do go on to have a healthy pregnancy and birth. That added perspective has helped Lauren feel very confident about her pregnancy.

Pregnancy Risks Associated with Advanced Maternal Age

While it’s true that a person experiences a very significant decline in fertility after age 35, it does not necessarily mean there is an equal decline in a person’s ability to have a healthy pregnancy or birth after age 35. The risks that are most often associated with Advanced Maternal Age can (but do not always) include the following:

• Babies with genetic conditions: This risk increases with the age of the fertilized egg. The most common of these is Down Syndrome. At age 35, the risk of having an embryo with this condition is almost triple that of a person at age 25. That’s a lot. However, that’s still just 1 in 240. ACOG recommends screening and counseling based on a person’s history, risk, and preference.
• Miscarriage: Miscarriage is a pregnancy loss that occurs before 20 weeks of gestation. Chances for miscarriage do go up with age. The lowest risk of miscarriage is for people who are 25-29 years old at 10%. They go up just a little bit to 11% until age 35. Then the risk goes up to 17% until age 40 when it goes up to 33% and 57% after age 45.
• Stillbirth: This is the risk that worries people the most, and with good reason. No one wants to consider this possibility. A stillbirth is a pregnancy loss that occurs after 20 weeks of pregnancy. First, it’s important to note that these rates are different if the AMA pregnancy is NOT the first child. In fact, people who are having a baby at the age of 40 or older and have given birth before, actually have a lower stillbirth risk than those giving birth for the first time who are under the age of 35. So, for people giving birth FOR THE FIRST TIME, the absolute risk of stillbirth at ages 35-39 is about 0.641%. For people over 40, this risk goes up to 0.865%. People under the age of 35 have a 0.372% risk of stillbirth. You can see that the relative risk of stillbirth goes up a lot after age 35, but the absolute risk is still pretty low at just 0.641-0.865%. So you can feel assured that stillbirth is very unlikely for you, regardless of your age. Also, these numbers show risk for ALL people in that age category. Some people have other risk factors besides age, others do not. You might feel even more reassured that your risk is lower if you do not have any other risk factors for stillbirth.
• Pregnancy conditions: After age 35, a person’s chances of having other complications during pregnancy go up. For example, your risk for gestational diabetes more than doubles. It goes from a 1% chance to a 2.85% chance. That’s still not very high, but it is an increased risk.
• Birth complications: People over age 35 also have an increased risk for having birth complications such as a low birth weight baby or postpartum hemorrhage. Again, these risks are increased, but still not HIGH.
  Interventions: This one can be hard to tease out. Sometimes people get more interventions BECAUSE they have a condition or situation that requires it. Other times, people are offered interventions, even without an apparent need, just because of their age and increased risk. For example, a person over age 35 is more likely to be offered an early induction because of their increased risk for stillbirth. Does this mean that the person needed the induction because their baby would have been stillborn without it? No. That’s very unlikely. It’s important to weigh the risks and benefits and your preferences, when making these decisions. You might be very happy to opt for an induction because the increased risk for stillbirth is enough to make that decision for you. Someone else might decide that they have other options that they would prefer, and that their risk is still so low that it doesn’t factor into their decision-making. One example where using an intervention for fear of possible complications related to maternal age is elective cesareans. ACOG does not recommend elective cesareans for people based on age.

Benefits to Being of Advanced Maternal Age

Even though your risks may increase after age 35, it does not mean you will have a bad outcome. Again, a drop in fertility is the most dramatic change that comes with increased age. The other risks do increase some, but the risks are still very low. Most of the time, people have very normal births and postpartum recoveries.
It’s not all negative. AND there are actually some positive outcomes that result from being older when you decide to have a child.

• Many people take better care of themselves during pregnancy when they’re older, as Lauren is doing. This is wisdom that often comes from age and experience, and can help you keep your risks low.
• Many people are more financially stable. This can be helpful during pregnancy so that you can participate in more classes and appointments that might not have been affordable at a younger age. Lauren is taking more classes and getting prenatal massages this time! These kinds of things can definitely contribute to feeling better and better outcomes.
• More mindfulness is something that can also come with age. Often, people who are pregnant at an older age have been wanting children for longer. This might make you better able to appreciate all of the milestones and look forward to your birth and meeting your baby even more. You may have also learned that time starts moving quickly as you age, and you want to make the most of it.
• You might have better job stability and maternity benefits as an older adult. This can make it easier to take the time you need during and after your pregnancy.
• You may have had more time to learn important life skills such as patience and good communication. This is helpful during your prenatal care, but also with parenting and relationships!
• Breastfeeding rates get higher with age. Your ability to breastfeed is not really affected by your age, and you might be even more aware of the benefits of providing breastmilk. You might be better able to access care and support for breastfeeding. Whatever the reasons behind it, the fact is that older mothers tend to be more successful and breastfeed for longer!

References:

Evidence on: Pregnancy at Age 35 and Older