Getting pregnant after 35 is also known as advanced maternal age. In this post, we’re going to talk about the known risks of pregnancy after age 35, comment on some of ACOGs practice guidelines for advanced maternal age pregnancy, and the actual statistics to best navigate your pregnancy and birth experience if you’re having a baby after 35 years old.
Trigger warning: This article discusses miscarriage and stillbirth.
Why is Getting Pregnant After 35 an Important Topic?
This is crucial to discuss, because research has shown slight differences in complication rates across the spectrum of maternal age as an independent risk factor for perinatal outcomes.
But, what are the exact risks in real numbers for women over 35 compared to those under 35 getting pregnant?
Are the risks high enough to rightfully pressure more fear, interventions, and testing to these pregnant women? Let’s find out.
More and More Women Are Getting Pregnant After 35
For decades now, there has been a steady rise in the number of women giving birth at age 35 and older.
In 2018, 18% of women were 35 and older, up from 15% in 2013, 11% in 2002, and 8% in 1990 [1, 2, 4, 5].
There has also been an increase in the number of first babies born to people in the U.S. who are 35 or older, from 7.4% in 2000 to 9.1% in 2014 and 10.8% in 2018 [3, 5].
The average age at first birth is now 26 years of age, which is a record high for the U.S.!
The average age at first birth has increased for all races and Hispanic groups as well as all states and the District of Columbia (D.C.) from 2000 to 2014.
Why is this happening?
Birth control is actually not the reason for this change, as birth rates in younger women have also gone down in countries that do not use birth control.
Reasons people are delaying becoming parents include:
- Women are reaching higher educational levels (Mills et al. 2011)
- More women work in male-dominated fields that are not as understanding or supportive of motherhood (Mills et al. 2011)
- Cultural and value shifts have led towards more people not feeling “ready” to have a child yet (Cooke et al. 2010)
- Lack of childcare, low benefit levels, and workplace policies that signal to people that you cannot be both a wage earner and a mother (Mills et al. 2011)
- Economic or housing uncertainty, unemployment, temporary work, or unstable labor markets (Mills et al. 2011)
- Medical reasons (Molina-García et al. 2019)
- Divorce, not knowing the right person to have a child with, and living together before marriage leads some people to delay parenthood (Mills et al. 2011; Molina-García et al. 2019)
What is Pregnancy After 35 Called?
The scientifically accurate term for a pregnancy after 35 is called ‘advanced maternal age.’
If you have a practitioner who calls it a ‘geriatric pregnancy,’ I would walk away from this midwife or obstetrician and find a new one, as this is an old and degrading term. Especially for mothers of age and health to conceive a baby.
Can You Get Pregnant After 35?
Fertility is the chance you will get pregnant or can get your partner pregnant.
Age humans age our fertility declines.
For women, this decline begins slowly in the early thirties and speeds up in the late thirties and forties.
For men, their fertility starts to decline when they’re in their late 40s, with up to a 23% decline in fertility each year beginning at age 39 [6].
Chances of getting pregnant with each menstrual cycle by age [7]:
- 25% for a healthy couple in their 20s-early 30s
- 20% by age 30
- 5-10% by age 40
You can maximize your chances of getting pregnant with natural family planning. This is a way to know when you’re ovulating each month by looking at things like:
- Cervical mucus
- Basal body temperature
- Cervical positioning
Complications in Pregnancy After 35
The areas of concern addressed in this article include: genetic conditions, miscarriage, stillbirth, inductions and cesareans, and outcomes with the midwifery model of care in home births and birth centers.
Genetic Conditions
Certain genetic conditions are more common in pregnancies of older people.
The following are the age-related rates of an embryo having Down syndrome at 10 weeks of pregnancy [8]:
- 1 in 1,064 at age 25 (0.09%)
- 1 in 686 at age 30 (0.15%)
- 1 in 240 at age 35 (0.42%)
- 1 in 53 at age 40 (1.89%)
- 1 in 19 at age 45 (5.26%)
These are the live birth rates of having a baby with Down syndrome at term [8]:
- 1 in 1,340 at age 25 (0.07%)
- 1 in 939 at age 30 (0.11%)
- 1 in 353 at age 35 (0.28%)
- 1 in 85 at age 40 (1.18%)
- 1 in 35 at age 45 (2.86%)
The rates of having a baby with Down syndrome at term are not as high as the chances at 10 weeks, mostly because these pregnancies have higher rates of miscarriage and stillbirth. Therefore, not all will reach the term period.
In the U.S., ACOG recommends that screening and diagnostic testing for chromosomal conditions be discussed and offered to everyone early in pregnancy regardless of their age or risk factors. However, they say that people should be counseled regarding their specific risks based on their age and their genetic family history [9].
Conversely, I say that if genetic testing is going to change the course of something you want or will decide throughout your pregnancy, then this is a good thing to do.
But if genetic testing is not going to change how you would move forward or manage your pregnancy, and only make you more stressed and worried, that is a valid reason to decline genetic testing even if you’re advanced maternal age.
This is the same logic I recommend for considering cervical exams in labor.
Risk of Miscarriage
The rate of spontaneous miscarriage (pregnancy loss before 20 weeks) increases with age (CDC, 2020). The increased risk of miscarriage with advanced maternal age (and parental age) is related to both egg quality and an increase in preexisting medical conditions such as diabetes, hypertension, obesity, etc.
A large Norwegian study recently found that the rate of miscarriage was [10]:
- 17% at <20 years
- 11% at 20-24 years
- 10% at 25-29 years
- 11% at 30-34 years
- 17% at 35-39 years
- 33% at 40-44 years
- 57% at >45 years
What is the Risk of Stillbirth?
In the U.S., stillbirths are commonly defined as pregnancy losses that take place at or after 20 weeks of pregnancy [11].
One study looked at the medical records of 358,120 women who gave birth at 18 hospitals in the U.K. between the years 1988 and 1997 [12].
The researchers in the United Kingdom found:
- Women aged 18 to 34 had a stillbirth rate of 4.7 per 1,000, or (0.47%)
- Women between 35 and 40 years old had a stillbirth rate of 6.1 per 1,000, or (0.61%)
- And, women 40 and older had a stillbirth rate of 8.1 per 1,000, or (0.81%)
A larger and more recent study from the Netherlands included over 1.6 million people who gave birth to a single baby at term from 1999-2010 [13].
This study excluded women with prenatal complications including congenital anomalies, hypertensive disorders, and diabetes.
The researchers examined many adverse pregnancy outcomes by maternal age, including stillbirth (occurring between 37 weeks + 0 days to 42 weeks + 6 days).
The researchers in the Netherlands found:
- Women aged 18 to 34 had a stillbirth rate of 1.7 per 1,000, or (0.17%)
- Women between 35 and 39 years old had a stillbirth rate of 2.2 per 1,000, or (0.22%)
- And, women 40 and older had a stillbirth rate of 3.0 per 1,000, or (0.30%)
These stillbirth rates are lower than those in the U.K. study, most likely because they excluded higher-risk pregnancies and late preterm losses.
does it matter if you’re a first-time mother, or if you had a baby before?
An observational study used birth certificate data from 2001-2002 to look at maternal age, stillbirth rates, and whether the risk was higher for women having their first baby. This study included 5.5 million pregnancies in which women were pregnant with a single baby without birth defects.
This study defined stillbirth as a fetal death occurring at 20 or more weeks of pregnancy [14].
The table below shows that pregnancy at age 35 or older is linked to an increased risk of stillbirth in both first-time mothers and mothers who have given birth before.
However, the rates of stillbirth are higher for those who are having their first baby compared to subsequent babies.
Interestingly, you can see that women who are having a baby at the age of 40 or older and have given birth before, actually have a lower risk of stillbirth than those who are giving birth for the first time under 35 years old.
Furthermore, no matter where you wall on this table, the risk of having a stillbirth is still below 1%.
what if someone is healthy and over the age of 35? Do they still have a higher risk of stillbirth?
The study above also looked at this question using 5.5 million U.S. birth certificates.
When researchers compared healthy women (no diabetes, no high blood pressure, no kidney/heart/lung disease) to the overall sample, they found that healthy women did have a lower risk of stillbirth, but the risks still increased with age.
In other words, being healthy does lower your risk of stillbirth. Still, being 35 or older seems to carry a higher risk when compared to a healthy younger woman. Again, the risks across the board regarding stillbirth are still under 1%.
How Many Pregnant Women 35 or Older Are Induced or Have Cesareans?
Induction rates do not seem to increase with age when you look at U.S. birth certificate data [15].
The overall induction rates from 2018 are: 27.5% (age 25 to 29), 25.6% (age 30 to 34), 25.0% (age 35 to 39), and 27.1% (age 40 to 54).
However, cesarean rates climb steadily with age. Cesarean rates are 30.0% (age 25 to 29), 33.9% (age 30 to 34), 40.1% (age 35 to 39), and 48.0% (age 40 to 54).
Check out: The Dangerous Truth About Our Climbing Cesarean Rates
Almost every women giving birth in the medical-industrial complex in high-income countries are recommended or offered an elective induction at 39 weeks. The 2019 UpToDate recommendation for pregnant people aged 40 and older is to give birth at 39 weeks. This recommendation is based on Grade 2C evidence.
UpToDate states that Grade 2C is essentially an expert opinion; a weak recommendation based on low-quality evidence.
Check out: Induced Labor 101: What You Need to Know
elective cesareans
The ACOG Committee Opinion about cesarean on maternal request estimates that 2.5% of all births in the U.S. are Cesareans on maternal request [16].
The Committee Opinion states, “In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended.” They do not list advanced maternal age as a medical indication for a cesarean.
Maternal request for cesarean increases with advancing maternal age. Pregnant women aged 35 and older are about two times more likely to have a cesarean upon maternal request compared to younger pregnant women [17].
This is concerning because planned Cesarean significantly increases the risk of severe complications in healthy pregnant people aged 35 and older.
A large U.S. study evaluated maternal outcomes in over 442,000 healthy women aged 35 and older who gave birth from 2003 to 2012 [17]. About 8% of women in the cohort planned elective cesareans.
When compared to the women who planned vaginal births, those who planned cesareans had a significantly higher death rate (2.6 per 10,000 versus 0.4 per 10,000).
People who had elective Cesareans also experienced more complications, including hysterectomy, cardiac arrest, acute kidney failure, and sepsis. The authors concluded, “When possible, planned cesarean deliveries should be avoided in this population.”
Check out: The Truth About Elective Cesarean Birth Safety
Advanced Maternal Age in Midwifery-Led Settings
The Birthplace in England study was a large study looking at the birth outcomes of nearly 80,000 people who were at least 37 weeks along, planned a vaginal birth, and received care from a midwife during labor during the years 2008 to 2010 [18].
The researchers broke down that group further to compare outcomes for women who were advanced maternal age and giving birth outside of a hospital setting.
For this analysis, researchers looked at about 63,000 women who were “low-risk” and between 37 weeks 0 days and 42 weeks and 0 days.
Out of these, there were 12,078 women who were 35 or older, of whom 4,581 planned a birth at home, 1,923 planned a birth in a freestanding birth center, and 2,506 planned a birth in an “alongside midwifery unit” (midwifery birth center located in the hospital but separate from labor and delivery).
The rest planned a birth in a traditional hospital labor and delivery unit.
Researchers found that women 35 years or older had similar newborn outcomes whether they gave birth in a midwifery-led setting or inside a hospital labor and delivery unit.
While those who giving birth in a midwifery-led setting had fewer interventions such as augmentation, vacuum/forceps, and fewer adverse outcomes requiring an obstetrician’s intervention, such as unplanned cesareans and 3rd or 4th degree tears.
For example, 42% of first-time mothers age 35 to 39 had Pitocin® augmentation in a planned hospital birth, while only 23% of first-time mothers the same age had Pitocin® in a planned midwifery-led setting.
Similarly, only 5% of women 40 or older had a 3rd or 4th degree tear in a midwifery-led setting, compared to 11% of similarly aged women on a labor and delivery/obstetric unit.
More positive outcomes in home and birth center settings:
Another study that used data from the Midwives Alliance of North America Statistics Project (MANA Stats) examined outcomes from nearly 50,000 midwife-attended, planned community births in the home or freestanding birth center setting [19]. Pregnant women aged 35 and older made up 19% of participants in the dataset.
The researchers found that older pregnant women who planned community birth and did not have additional risk factors were not at higher risk for childbirth complications.
There was no evidence of increased risks of perinatal death or postpartum hemorrhage with older maternal age.
For most outcomes, older pregnant people had absolute risks only a percentage point or two higher than younger people. (These findings are consistent with the data discussed above).
The authors concluded that community birth with advanced maternal age, in the absence of other risk factors, is not as risky as previously assumed. It actually holds less risk since the rate of stillbirth is the same, yet in labor and delivery units the rate of interventions are higher including unplanned cesareans and 3rd and 4th degree tears.
Check out: The Dangerous Truth About Our Climbing Cesarean Rates
Additionally, Is Home Birth Safe? The Pros and Cons
Key Points on Advanced Maternal Age
- Delaying pregnancy can lead to more difficulties getting pregnant. Fertility decline begins slowly in the early thirties and speeds up in the late thirties and forties.
- Certain genetic conditions are more common in pregnancies of older women, and there is a greater chance of miscarriage.
- There is a higher risk of stillbirth in women who are 35 or older, but that risk has gotten lower over the past few decades, and it is also lower among people who are healthy and/or have given birth before.
- Women having a baby at the age of 40 or older and have given birth before, actually have a lower risk of stillbirth than those who are giving birth for the first time under 35 years old.
- Across the spectrum of age and if the woman has given birth before, the risk of stillbirth is below 1%.
- In England and in the U.S., midwifery-led care for home births and birth centers had lower rates of interventions with no increased risk to the baby when compared to care provided in the hospital on a labor and delivery unit.
- Planned elective cesarean significantly increases the risk of severe complications in healthy pregnant women aged 35 and older compared to planned vaginal birth.
Conclusion on Advanced Maternal Age
Just because a woman is 35 years or older does not make her high risk.
Regardless of pregnancy, the risk of things like diabetes and hypertension increase with age. But with a healthy woman 35 year or older who does not have these conditions, she should be treated the same as any other healthy pregnant woman.
Additionally, by working with midwives who provide longer appointments (60-90 minutes compared to the average 5-7 in the medical model), a woman can receive more preventative counseling on nutrition, exercise, and lifestyle to better prevent the manifestation of diabetes, preeclampsia, etc.
Of course, if that route doesn’t work out, moving to an obstetrician and managing with pharmaceuticals is always a back-up option.
Also, consider utilizing kick counting starting at about 20 weeks of pregnancy to have an idea how your baby is doing. If their kicks fall below their normal, this can signal to have your midwife or obstetrician check on you and assess if you might want to have a non-stress test (NST) or biophysical profile (BPP) on your baby.
Questions or Comments on “The Truth About Getting Pregnant After 35”
If you have any questions or comments, please leave them below👇🏻
Talk soon, mama!
– Katelyn Lauren
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References:
[1] Martin, J. A., Hamilton, B. E., Sutton, P. D., et al. (2003). “Births: Final data for 2002.” Natl Vital Stat Rep. 2003 Dec 17;52(10):1-113. Click here.
[2] Martin, J. A., Hamilton, B.E., Osterman, M. J., et al. (2015). “Births: final data for 2013.” Natl Vital Stat Rep. 2015 Jan 15;64(1):1-65. Click here.
[3] Martin, J. A., Hamilton, B. E., Osterman, M. H. S., et al. (2019). Births: Final Data for 2018. Natl Vital Stat Rep. 2019 Nov;68(13):1-47. Click here.
[4] Mathews, T. J. and Hamilton, B. E. (2014). “First births to older women continue to rise.” NCHS Data Brief. 2014 May;(152):1-8. Click here.
[5] Mathews, T. J. and Hamilton, B. E. (2016). Mean Age of Mothers is on the Rise: United States, 2000-2014. NCHS Data Brief. 2016 Jan;(232):1-8. Click here.
[6] Matorras R, Matorras R, Expósito A. Decline in Human Fertility Rates with Male Age: A Consequence of a Decrease in Male Fecundity with Aging?. Gynecologic and Obstetric Investigation. 2011;71:229-235
[7] The American Society for Reproductive Medicine. Female Fertility Journey. https://www.reproductivefacts.org/patient-journeys/female-fertility-journey/
[8] Haddow, J. E., G. E. Palomaki, J. A. Canick and G. J. Knight (2009). Prenatal screening for open neural tube defects and down’s syndrome. Fetal Medicine. C. H. Rodeck, M. J. Whittle and J. Queenan, Elsevier.
[9] ACOG. Pregnancy at Age 35 Years or Older.
[10] Magnus M C, Wilcox A J, Morken N, et al. (2019). Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study BMJ 2019; 364:l869. Click here.
more references:
[11] Centers for Disease Control and Prevention (2020). What is Stillbirth? National Center on Birth Defects and Developmental Disabilities. Accessed February 18, 2021. Click here.
[12] Jolly, M., N. Sebire, J. Harris, S. Robinson and L. Regan (2000). “The risks associated with pregnancy in women aged 35 years or older.” Hum Reprod 15(11): 2433-2437. Click here.
[13] Kortekaas, J. C., Kazemier, B. M., Keulen, J. K. J., et al. (2020). Risk of adverse pregnancy outcomes of late- and postterm pregnancies in advanced maternal age: A national cohort study. Acta Obstet Gynecol Scand. 2020 Aug;99(8):1022-1030. Click here.
[14] Reddy, U. M., C. W. Ko and M. Willinger (2006). “Maternal age and the risk of stillbirth throughout pregnancy in the United States.” Am J Obstet Gynecol 195(3): 764-770. Click here.
[15] CDCs National Vital Statistics Reports 2018.
[16] American College of Obstetricians and Gynecologists (2019). Committee Opinion No. 761: Cesarean Delivery on Maternal Request. Obstet Gynecol. 2019 Jan;133(1):e73-e77. Click here.
more references:
[17] Lavecchia, M., Sabbah, M., and Abenhaim, H. A. (2016). Effect of Planned Mode of Delivery in Women with Advanced Maternal Age. Matern Child Health J. 2016 Nov;20(11):2318-2327. Click here.
[18] Li, Y., Townend, J., Rowe, R., Knight, M., Brocklehurst, P., & Hollowell, J. (2014). “The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study.” BMJ Open, 4(1), e004026. Click here.
[19] Bovbjerg, M. L., Cheyney, M., Brown, J., et al. (2017). Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States. Birth. 2017 Sep;44(3):209-221. Click here.
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