Episode 124 - Pregnant over 35 years old

Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. Today I'm talking about a topic that I've been avoiding. I don't want to talk about it because it's so big but the requests, the number of requests that I've been getting for this episode has outweighed my intention to never address it and so here I am. I'm going to attempt a crack at the topic of what the system calls advanced maternal age or some people will even have the audacity to call it a geriatric pregnancy. You're having a geriatric pregnancy, get this. If you are pregnant and over 35 years old, look it depends on the hospital and the clinician as to what you would be defined as if you were 35 or older. Sometimes they say you're of advanced maternal age and I'm using speech marks. The definitions are a bit vague and gray depending on who you're talking to and certainly the Australian College of Midwives guidelines, which is the guidelines that I'm required to follow as a private midwife, they would say that over 40 is considered advanced maternal age but some hospitals and some medical people have the age of 35 in their mind as that number. Now I haven't wanted to address this because it's so big and convoluted and has so many elements so of course there's going to be areas that I miss and skip over and it's not done completely and because this is such a big topic and not everybody is going to have all of their questions answered in this single episode, of course you are welcome to ask me questions and go into more detail about this but that privilege is reserved for the premium podcast hub members who have access to me to ask more detailed questions so I'm more than happy to cover this in the premium hub. If you want to join the premium hub you can see the details in the show notes below and that is where we get into more detail about everything. So here's what I'm going to talk about today. Firstly, what are the perceived problems with being pregnant over the age of 35 and I'll also cover things that you can be aware of if you're pregnant over 35 so that you can help mitigate some of the potential complicating factors but essentially I want to make you aware of what the research says about being pregnant over the age of 35 and then it's up to you to make some decisions about your individual risk profile and what you're going to do about that. If you are coming to this episode as a woman who's over 35 and pregnant firstly I want to say congratulations and also I want to celebrate this time because what might happen to you in the system is you might really be looked down upon as a ticking time bomb and so I want to help cushion you from that through this episode and also let you know that if your care provider has set you to this episode that it's quite possible that you are in safe evidence-based woman-centered hands because this information is counterintuitive to what you might hear in a mainstream service. So I'm going to start with research papers here to give you an overall idea of what the research world understands about pregnancy as we get older and I realise that there's more to decision making than understanding a vague risk profile but this is where most care providers are going to be stuck and they'll be talking to you about your possible unique risks based mostly on your age. So having this in your mind will help protect you from being manipulated into decisions based on your clinician's assessment of your risk level which could only be considering the one single element of you being over 35 years of age. So let's start by looking at a few studies in detail and this first one is from Denmark and it's called Risk of Adverse Pregnancy Outcomes at Advanced Maternal Age by Lion Fredrickson and it was released in 2018 and just so you know if you're listening to this and you want to get access to all the papers that I'm going to talk about today if you're on the mailing list for this podcast you'll get access to every research paper that I've used to make any of the episodes. So just have a look down in the show notes you'll see how to get onto the mailing list and then you'll get access to the research papers and you can have a look for yourself. You can take my word for it if you want to but if you want to solidify things and understand things in your own way feel free to go and have a look at these papers. So this study 2018 it was a nationwide cohort of 369,000 singleton pregnancies in Denmark so one baby 369,000 pregnancies and they collected up the information from the whole area of Denmark for women who are having pregnancies from 11 weeks until they gave birth and in this study pregnant women were divided into two maternal age groups so 35 to 39 year olds and then 40 year olds and older and they compared their outcomes with pregnant women who were aged between 20 and 34 years so here we go 369,000 women all divided up into their age groups and they were looking at some particular pregnancy outcomes which were chromosomal abnormalities so differencing chromosomes, congenital malformations so chromosomally normal but there was still a malformation as the baby developed, miscarriage, stillbirth and birth before 34 weeks of gestation so they're looking at preterm births. So whenever you're looking at any study they'll usually tell you what particular things they're looking for not every study looks at every single element of their topic and so here they looked at these five things chromosomal abnormalities, congenital malformations, miscarriage, stillbirth and preterm birth before 34 weeks. I'll do a very brief breakdown of the stats and then we'll look at them in a bit more detail so among the pregnant women who were aged 40 years or older 10.8% of them experienced one or more of those things on the list that I just explained compared with 5.46% of women who were aged 20 to 34 so that means that if you're over 40 there's an 89% chance that you won't have one of the outcomes that were studied in this research so 89% chance that you won't experience chromosomal abnormalities in your baby congenital malformations, miscarriage, stillbirth or preterm birth and from this study if you're between the ages of 35 to 39 we can understand that you have a 93% chance that none of these things will happen to you and this study found that if you're aged between 20 and 34 94.5% of the time none of these things will happen to you so yes we can see that here just crudely from that very basic summary there's an increase in the chance for complexity for women having their baby over 40 and potentially over 35 and I'm not denying that in this episode it does appear that women over 35 and over 40 do experience an increase in undesirable circumstances but let's pull it apart to fully understand what this increase looks like and if it warrants interfering with pregnancy or even worse denying women of adequate care with midwives because of their age and this is what happens women who are older are indiscriminately labeled as high risk because of their age and the system doesn't look at them as an individual and when you're labeled high risk that sometimes means that you lose access to midwifery models of care and midwifery care and you get allocated to being looked after by obstetricians or to standard care or what I call substandard care through a fragmented maternity system and this is a problem and it's so ridiculously stupid because we know that continuity of carer or continuity of care with either a midwife or your known and trusted obstetrician has the best outcomes for women at any risk level so instead we choose to deny the women who would most benefit from access to midwives and midwifery care and continuity of carer access to those things it's backward and insane and anyone who tells you that you can't have access to midwifery models of care because of your perceived risk level does not understand the role or the skill of midwives or the research about outcomes that you will get from being in midwifery care models and I'm going to talk to you about the mango trial in a minute to make this point and to point you to a super cringy video that is on my YouTube channel I made it about six years ago and it covered the the crux the bones of the mango trial you can go and have a look at if you want I've got a YouTube channel Melanie the midwife it's going to get some attention but it's been sitting there for a while but anyway back to this study let's break these stats down smaller so you can see the individual percentage risk and what they translated into so just to summarize if you are 20 to 34 years old then there is a 94.5% chance that none of these things chromosomal abnormalities congenital malformations miscarried stillbirth and pre-term birth will happen to you if you're between the age of 35 and 39 it's a 93% chance that it won't happen and if you're over 40 there's an 89% chance that none of those things will happen to you based on what we know from this study so let's have a look at the details so before we look at the detailed stats just to let you know that in this study stillbirth was defined as any baby who died in utero after 22 weeks of gestation so stillbirth doesn't relate to having been in labor with a live baby and then giving birth to a baby that has really sadly passed away this definition is any baby who dies in utero after 22 weeks of pregnancy and a miscarriage is any baby who's lost before 22 weeks of pregnancy now let's have a look at the details of these stats and there's a table in this paper and it breaks down the prevalence so how common the adverse pregnancy outcomes were by age and it breaks it down into little details so you'll see here when your care provider tells you that there's an increased risk of things as you get older that's not untrue but what they don't tell you is the stats and how much the increase is so that's what i'm going to tell you now so chromosomal abnormalities if you're between again this is based on this study from denmark chromosomal abnormalities for the age group of 20 to 34 was 0.56 percent if you're between 35 and 39 it's 1.32 percent so at least a double rate and if you're over 40 it's 3.83 percent now just remembering not all chromosomal abnormalities are not compatible with life they're not all so serious and also a lot of chromosomal abnormalities can be screened for early so there's the nipped test what we call the harmony test here in Australia and early screening tests that are often offered to women who are older in acknowledgement of this increased risk in order to screen for and check for chromosomal abnormalities and so this isn't a kind of a consideration in the early part of your pregnancy it doesn't depend on who your care provider is a midwife or an obstetrician or the place where you're going to for care can offer you screening options to check for chromosomal abnormalities in acknowledgement that there seems to be an increased risk of this and this is what they say is owing to the age of the eggs as we get older our genetic material ages which is one possible reason for this increase in chromosomal abnormalities 0.56 percent 1.32 percent and 3.83 percent consecutively in those age groups so let's look at congenital malformations these seem to be not so different so if you're in the age range of under 35 it's 3.32 percent if you're over 35 but younger than 40 3.49 percent and if you're four you're older 3.93 so not too dissimilar for congenital malformations where there's a formation problem with the baby so miscarriage and this is a pregnancy loss before 22 weeks if you're under 35 it's 0.42 percent if you're 35 to 39 0.96 percent so just under 1 percent and if you're over 40 it's 1.68 percent okay now let's look at stillbirth because this stillbirth stat is what most care providers will be basing their recommendations off and I'll talk to you about the recommendations for women who are having pregnancies when they're older for birth this stillbirth rate is what sticks in care providers minds so based on this study if you are 20 to 34 years old there's a 0.28 percent chance that your baby will be still born from 22 weeks onwards 0.28 if you're over 35 but under 40 it's 0.35 percent if you are 40 and over your risk of stillbirth from 22 weeks onwards is 0.43 percent it hasn't reached even half a percent and it's less than double from if you were aged 20 to 34 so 0.28 percent 0.35 percent 0.43 percent that's the stillbirth stats now this is what encourages care providers this increases stillbirth rate is what inspires care providers to offer you early induction so these stats are an interesting number to look at when you are deciding on your own level of risk and if you're interested in accepting that induction in the interest of preventing stillbirth and they pair that decision making with the knowledge that every week that you're pregnant beyond 37 weeks the natural risk of stillbirth increases anyway so from 41 weeks it's approximately six in 10,000 babies will be stillborn and it goes up to approximately 11 in 10,000 by 42 weeks and this is a steady increase from 37 weeks and there was a research paper called the arrive trial which recommended induction of labor at approximately 39 weeks for any woman anyway there's this paper has massive gaps and issues with its methods so don't take it as gospel what I'm saying is is your care provider is likely to have in their mind that induction of labor is an appropriate management strategy full stop and then when you start to include the increased risk of stillbirth for women who are older over 35 or over 40 then it starts to make a lot more sense in their clinical mind to be recommending induction at 39 weeks and pre-term birth before 34 weeks again if you're 20 to 34 years old 1.21 percent you're 35 but younger than 40 1.3 percent and if you're 40 or older the chance of a pre-term birth is 2 percent and now if they they did this composite outcome so basically they put all of those stats together and that's the big summary that I gave you at the beginning if you're between 20 and 34 years old there's a 5.46 percent chance that any of those things will happen to you if you're 35 to 39 there's a 6.99 percent chance that any of those things will happen to you and if you're 40 or older there's an a 10.82 percent that any of those things will happen to you and that's what we learn from this study however what the researchers also explained is that if you are a smoker during your pregnancy if it's your first pregnancy if you've conceived through reproductive technology and you're overweight or obese then you sit at the higher risk end of these things happening so when any of those things are not there then your risk is lower despite your age so we're talking about women over 35 in this research and how their thoughts have poor outcomes but this is cloudy because as we age our bodies do change and behave differently partly because of the natural aging process but that's also dependent on how well we've looked after them some women over 35 are fit and healthy and consciously care for their bodies and their minds and others are incredibly unhealthy so yes an unhealthy woman over 35 is more likely to have complications in her pregnancy than an unhealthy 25 year old but is a healthy fit and consciously healthy woman over 35 going to have more chance of complications than an unhealthy 25 year old and that is the question that I don't believe research can answer for us and so if you're over 35 and pregnant consider looking at your individual health profile are you consciously and honestly eating our full complete and nutritious diet do you sit within a healthy weight range have you got complicating factors already in your life that mean you're dealing with health issues and so consider are you a healthy woman over 35 or are you already an unhealthy and have complicated health factors over the age of 35 because I think these two things are different when we're looking at pregnancy just in the same way as they would be different if you are under 35 and so let's not discount all of the elements of good health and lifestyle choices and also we will see in the next articles that I'm going to talk about education level also makes a difference so there's all these compounding factors your age is not one single isolated element now let's have a look at another study which broke this down even further and it looked at older women having their first second third fourth or subsequent babies and it wanted to see if this affected the outcomes and what you'll see here is that the chances of complexity or not can also be dependent on if you're having your first baby over 35 or if it's a subsequent baby because this study indicated that that having had a baby before is actually protective against some of the complicating factors of pregnancy as you get older so this study was done in Sweden and it was designed to investigate the association between advanced maternal age in inverted commas and still birth risk in first second third and fourth babies all more so again they looked at the whole population and they looked at all women aged 25 years and older with a single baby so no twins were included who later went on to give birth in Sweden and there was 1.8 million pregnancies involved or 1.8 million women involved in this study and they broke it down into ages 30 to 34 35 to 39 and 40 years and older and compared that with women who were between the ages of 25 and 29 they also adjusted for other factors that I was just speaking about sociodemographic factors so income and education levels if women smoked or not body mass index I know that's not a great measure but that's what they used if the women had a history of stillbirth and how long it had been since their last baby they also broke it down even further and they looked at two low risk groups and they looked at women who had a high level of education and women who didn't smoke who were of normal weight they wanted to see these things made a difference and I'll give you a summary of the results here so stillbirth rates increased by maternal age yes we already knew that from the previous study in this study women who were between 25 and 29 had a stillbirth risk of 0.27 percent if you were 30 to 34 it was 0.31 percent so that's a 0.04 percent increase if you were between 35 and 39 in this study it was 0.4 percent and if you were 40 years or older it was 0.53 percent so stillbirth increased by maternal age in the first births but it only increased in the second third and fourth births for women with low to the to middle level education but not women with high education so what they were saying is women in the higher education group didn't experience an increase in stillbirth rates by maternal age so while they identified that being older is an independent risk factor for stillbirth in women having their first baby this age related risk is reduced or eliminated in women who have had subsequent babies especially if they're in a category of being highly educated and also they believe that there's a physiological change that happens in our bodies during our first pregnancies that naturally protect our following babies and this is something I hadn't heard before so one of the complicating factors of being pregnant when you're older is some of the research suggests that you've got an increased chance of things like preeclampsia and high blood pressure and gestational diabetes issues with placental blood flow to the baby that can lead to small for gestational age babies or growth restriction and this paper actually sought to explain the physiological mechanism behind that but also to explain that if you've had a baby before it's like your uterine blood vessels and your body is kind of primed to protect you against poor blood flow through the placenta and these researchers explained that the the physiologic mechanism explaining the association between advanced paternal age and stillbirth have mainly focused on placental aging and placental insufficiency so they're basically looking at the possibility that if a woman's older that her placenta as she goes on through her pregnancy also might not function as well as it gets older and they've identified sclerotic legions which increase by age which means kind of like areas of the placenta that just stop working in me become sort of hard and rocky and they think that because these increase by maternal age and then also age of the placenta that could be one factor that causes under perfusion so lower blood flow and an impaired flux of nutrients to the baby which eventually can lead to stillbirth so where the baby is depleted of oxygen and nourishment and sadly die but they mentioned that neonatal birth weight generally increases each baby you have we know that every baby you have they generally get a bit bigger and the greatest increases between that first and second birth and one theory is that the first pregnancy paves the way for sustainable and more extensive endovascular trophoblast invasion in women who've had babies before let me explain that so when your placenta is implanting in your uterus they essentially the cells invade your uterine tissue in order to access the blood vessels there and what they're saying is is that after your first pregnancy the the way is paved for more extensive vascularization of your placenta because this invasion into your uterus by the placenta is more effective because there's an increase amount of tissue in the uterine spiral arteries and these spiral arteries is what deliver blood and nourishment to your baby and what they're saying is that this ultimately leads to a decrease in vascular resistance and increase blood flow in the placental arteries in the next pregnancy and they've said that this theory or interpretation of this finding is supported by ultrasound studies so they call them Doppler studies of uterine arteries and they show that there's actually physically more notches and a higher resistance against effective blood flow in women who have had one baby compared to women who have had more than one baby and so what they found when they looked at the stats for these 1.8 million births was that pregnancies of for women having their first births the second third and fourth births when they analyze them separately they found different things and potentially this is because of the change in anatomy that happens in subsequent babies and what these researchers are suggesting is we can't bundle older mothers having their first baby in with older mothers who have had babies before because the outcomes are likely to be different and so this paper which was published in 2015 it's called Advanced Maternal Age and Still Birth Risk in Nulley Paris and Paris Women so that just means women who haven't had babies before compared to women who have had babies before again this is in the resource folder you can have a look at it and when we have a look at the Still Birth stats which is the main outcome that they were looking for in this study they broke it up into low or medium level of education stats so depending on who you are as a woman you can categorize yourself but I assume that they've used you know worldly standards of education with regards to how far through school you were you went and if you've had higher research or higher degrees at universities or colleges so let's look at the stats for women who are over 35 with a low to medium level of education and there was nearly a million women in this category and if it was your first baby the risk of Still Birth was 0.5% if you were between 35 and 39 0.5% if you were 40 or older with a low to medium level of education having your first baby over 40 the Still Birth risk was 0.71 and that goes down for your second birth and then it slightly elevates for third and fourth births and then what they found for women of high level education there was nearly 800,000 women in this category that compared to women of lower education who were 40 or older had a Still Birth risk of 0.7% if you were highly educated that slightly reduced to 0.67 the major change that we see here though is for women having their second births if you're 40 or older with a low to medium level of education your Still Birth risk was 0.55% if you had a high level of education that nearly halved to 0.28% which is actually lower than the Still Birth rate for women between the ages of 29 and 25 and 29 having their first baby and so education level seems to make a significant difference to Still Birth rates in the 40 or older group in fact they were better than in the 25 to 29 age group for first babies for women of low or medium level of education now there's these charts keep going with stats and if I just rattle off stats to you they're going to be fairly meaningless that's just going to be a number soup I wish I could show you this graph the point that this paper makes is that your age is one single factor but there are multiple protective factors that put you in a lower risk category for Still Birth than some younger mothers having their first babies one of those things is a high level of education the other thing that seemed to be protective is women who were non smokers and of normal weight and so this study concludes that advanced maternal age is an independent risk factor for Still Birth in women having their first babies but this age related risk is reduced or eliminated in women having subsequent babies partly as a result of the physiologic adaptions that occur during the first pregnancy but also in relation to their education levels weight and and lifestyle choices such as smoking now I covered these papers in particular partly to give some statistics on the overall chances of complications occurring if you're pregnant over 35 but also to help you realize that this one size fits all risk profiling is foolish and it's poor clinical reasoning when we know that there are multiple factors that impact upon the health of a pregnancy age is just one of them so the single recommended strategy of early induction of labour at 39 weeks for older women is insane and it doesn't recognize the nuance of this circumstance and that's what many of you will be up against because of your age many of you will be offered an induction of labour around 39 weeks and I'm not being dramatic about that you'll see that in actual policy wording I've got in the resource folder examples of hospital policies I've got access to multiple hospital policies in that resource folder as an example of what your care provider might be following just when they hear that you are of advanced maternal age again speech marks but if you're a pregnant woman over 35 you can ask your care provider to print the advanced maternal age policy at their hospital off and they can give that to you so that you know what you'll be guided towards what to expect from that facility that you're giving birth in unless of course you're having a home birth it'll be completely different and again if you have an obstetrician who's caring for you they might not have a specific policy so it's worth having this conversation about what their expectations are and see if they match yours okay let's have a look at one more paper here as we build this discussion and this one includes women of very advanced maternal age so this is women over 42 years old and fortunately for this one there is a full text article available in the resource folder so you can have a look at the graph that shows the findings which actually might make it easier to imagine for the visual learners among us so I'll speak these stats out but hopefully it will be more meaningful to some of you if you can see it visually so this paper is a 2019 paper from Canada and it's called adverse maternal and neonatal outcomes among singleton pregnancies in women of very advanced maternal age and they included a total of 421,000 women in this study 83,900 of which were between the ages of 35 and 42 and 3,266 were over 42 so pretty big numbers the 303,266 amount of women who were over 42 having babies it would capture some of the more common occurrences but not the rarer ones there aren't enough numbers to make conclusions about rare outcomes with only 3,266 women but something that this study did do differently to the previous two studies that we've already mentioned in the podcast it sought to assess whether or not the use of reproductive technologies in order to get pregnant changed the risk profile or chances of something going wrong in pregnancies of these women who were over 35 you thought so it's no surprise to learn that as women get older our fertility reduces and so typically more of older women will be seeking the assistance of reproductive technologies to help get pregnant as they age and certainly in this study about 20 percent of the women over 42 were using reproductive technologies and around 12 percent of those who are over 35 and we know that IVF or ART can impact on the outcomes and health of a pregnancy and so this research wanted to check if the use of reproductive technologies compounded the risk of being older and pregnant so did those risks layer upon each other to create more risk or not and the other things that increase with age are the rates of women that already have pre-existing conditions so including diabetes or prediabetes endocrine issues high blood pressure and heart disease so not only are we looking at a population where one in five are using reproductive technologies they're also more likely to have pre-existing health conditions that would complicate their pregnancy at any age independent of their age however older women particularly in this study are also more educated and have higher income which are both factors which we saw in the last study that were protective against the development of complications in pregnancy so the question is you know do all of these factors combine and cancel each other out or do their layer upon layer increase the risk for older women so this study looked at a few things and the primary outcome so the first thing that they were looking for is they put together a group of issues which they call ischemic placental diseases and under this umbrella they combined the stats for preeclampsia intrauterine growth restriction so where the baby doesn't grow as big as it should IUGR placental abruption where the placenta comes away from the side of the uterus and stillbirth and this was what they call a composite outcome so together combined they look at the stats of this that was the first thing they were looking for and you'll remember from one of the previous studies I was talking about how the placenta implants in the uterus and how it invades the uterus with these trophoblastic cells and so what is thought to happen is that women who are older could be more likely to have impaired trophoblastic invasions so the placental tissue has less capacity to invade the uterine tissue and create shallow spiral artery conversions what they call it so this reduces the amount of blood flow that they can get through to the placenta and through to the baby and these this situation is what's thought to be the cause of some preeclampsia it can then result in intrauterine growth restriction where the baby's not getting enough blood flow to deliver enough nutrients and oxygen and it can be a factor in placental abruption and therefore stillbirth and so they combine these things all together and assess them together they also broke it apart but that was the primary outcome the primary thing they wanted to check and then there was some secondary outcomes including preterm birth gestational diabetes placental previa postpartum hemorrhage if the mother required admission to intensive care unit and outcomes for the baby including small for gestational age babies if any babies died if there were any congenital abnormalities if the baby needed to be admitted to special care and if any of them were born with a low apgar score so basically if any were born in poor condition so let's have a look at this quite beautifully explained graph in this paper and again I encourage you to go into the resource folders you can get on the mailing list if you want access to that we can see what the outcomes were now this time I'm just going to read the outcomes for women over 35 to 42 years old and the ones who are over 43 that might help me to be able to communicate these stats in a meaningful way instead of comparing all the different ages because I guess if you're over 35 you don't really care what the stats are for a 20 to 34 year old you're probably just interested in what it means for you and similarly if you're over 43 years old let's have a look at the age group from 35 to 42 years old let's see what this study found and so this was an assessment of 83,900 women in this study were between 35 and 42 so let's see what happened to them so the composite outcome of preeclampsia intrauterine growth restriction placental abruption and stillbirth they put them all together and approximately 10% of women between 35 and 42 years experienced those composite issues now when you break that up preeclampsia 0.83% intrauterine growth restriction was 8.72% placental abruption was 0.59% stillbirth was 0.35% which was a little bit lower than previous studies that we talked about so this is the reason why they induce women who are advanced maternal age they are worried about stillbirth the percentage rate in this study of women between 35 and 42 years old of approximately 83,000 women was 0.35% preterm birth 7% of the number of women who got gestational diabetes it was 8.8% that's about double in the lower age group placenta previa where the placenta is low lying 1.1% postpartum hemorrhage was 2.19% actually lower chance of having a postpartum hemorrhage if you are over 35 and over 43 compared to if you are younger so that's kind of cool protective small for gestational age babies 4.1% the number of babies who died was 0.14% and that was the exact same stat than for the younger group the 20 to 34 year olds so no increase in neonatal death in this group there was a slight increase in congenital abnormalities and very similar neonatal admission rates and low up gas scores so about 12% of babies needed admission to neonatal intensive care and that was very similar 11.7% in the 20 to 34 year old group so that is the 35 to 42 year olds all right now let's have a look at women who are over 43 what their outcomes were in this study so there was about three and a half thousand women in the over 43 year group so the composite outcome of all of those placental issues including stillbirth was 13.35% remembering that it was 10.09 if you were between 35 and 42 years old interestingly which actually I'm just looking at the graph now and just noticed if you're between 20 and 34 years your composite risk of having preeclampsia growth restriction in your baby placental abruption and stillbirth if you're 20 to 34 years was 10.41 if you're in this study if you're 35 to 42 years it's 10.09 actually goes down there you go I only saw that very good all right and then it goes up to 13.5 if so up about 3% on the 20 to 34 year olders now the risk of preeclampsia roughly doubles if you're over 43 years old to 1.59% it's the risk of intrauterine growth restriction is 1% higher than if you were younger and that is 10.96% placental abruption approximately doubles to 0.92% stillbirth again approximate doubling on the if you were between the ages of 20 to 34 years if you're over 43 years old the stillbirth rate is 0.67% preterm birth slightly increased less than double at 9.64% gestational diabetes is about three times higher if you're over 43 and that was 13.96% of women over 43 in this study had gestational diabetes percent of previa again it increases to 1.68% just remembering though these women also have increased use of reproductive technologies which can make you more likely to have a placental previa postpartum hemorrhage is lower chance of postpartum hemorrhage if you're over 43 years old than if you were between 20 and 34 years there's a 2.33% chance of a postpartum hemorrhage and that's lower than if you were 20 to 34 years old now those are the raw stats and these authors concluded a few things of note and they said when further analysis was performed with stratification by the method of conception so whether or not it was a spontaneous conception or whether or not they use reproductive technologies the authors say that we found that artificial reproductive technologies did not synergistically enhance the effect of very advanced maternal age on adverse pregnancy outcomes which means that the risk factors didn't layer upon layer and increase the risk of things going on it all it didn't seem to have an impact at all so it didn't enhance the effect of being an older mother and women who were of advanced maternal age who can see through reproductive technologies were noted to have a higher economic socioeconomic status than compared to those who can see spontaneously and this may mitigate the adverse effect of being of very advanced maternal age and impact on the pregnancy outcomes which we already found out from the other study so the point I'm trying to get across here is that if you are an older woman having a baby you're significantly more likely than not to have a complication-free pregnancy but more likely to have a pregnancy complication than a younger woman unless of course you compare a highly educated older woman to a younger woman of low education in which case the risk profile changes completely again now it's clear to see that age alone is a poor predictor of which women will have a complication relating to their age or not because there are mediating factors including their weight smoking status whether or not they use reproductive technologies do they have pre-existing health conditions is this their first baby or have they had babies before what are their education levels and no doubt there are more modulating factors that I haven't listed here I want to say to all women over 40 who are listening to this confident that they've cared for their bodies well that they're active and they move their bodies if you don't have pre-existing health conditions you've had a baby before you're well-married and well rested well educated it's highly likely that the research papers and risk risk percentages that I've listed today don't relate to you because presented risks are so generalized and so bundled and how many different people they put together their generalizability and relatability to your individual circumstance almost becomes irrelevant so we saw from the first paper that we discussed today that not discriminating between the number of babies women have already had gives a different outcome so when you separate out women who have had babies before we see a different outcome to women who are having their first babies when they're older we also can't conclude what the risk profile is of an older woman who's pregnant with twins who used reproductive technologies we can't do that from these studies because these studies were all on singleton pregnancies so maternity care is traditionally very poor at risk calculation and perceive every circumstance to be risky and as a result of being so bad at being able to know which women will have a complication and which won't they intervene in every birth in order to make up for the fact that they can't predict which women and which baby will be okay and which won't so unless you want to go with the flow and accept an induction then you've got some personal reflections and research and decisions to make for yourself because it's highly unlikely that your care provider is going to consider all your individual risk factors when making the recommendation for you to have an induction because it's quite likely that they will only just see the fact that you're a woman over 35 or over 40 years old and the other and final thing that I want to say is that the most evidence-based way to access adequate and attentive care is to engage with the care of a midwife if you're a woman with possible complicating factors including that of stillbirth and preterm birth. Midwives have been shown time and time again to be essential care providers in a strategy to reduce the number of stillbirths and preterm births. At the very least we know that midwifery care can do this but what's more and what we learned from the mango trial is that women of all risk levels have at least the same outcomes as women cared for by doctors if they're cared for by midwives except that the women who receive midwifery care are more satisfied with their care and it's also more cost effective for society, for government, for hospitals if they give every high risk woman the care of a midwife they save somewhere in the vicinity of five to six hundred dollars per woman without increasing adverse outcomes this is women with risk factors. So the take home message for women out there who are pregnant over 35 is that yes statistically speaking on the whole and in general you're at more risk of complications for yourself and your baby however this is incredibly nuanced depending on your personal circumstances you've got to assess your own personal risks no one can accurately predict your personal risk. So let's do our best with this and step one do what you can to access midwifery care and even better if it's a known midwife who will be able to be with you for your pregnancy birth and afterwards that is a recipe regardless of your circumstances for best possible outcomes. Secondly I encourage you to assess your own personal risk factors and health and go on a journey to do what you can to personally mitigate risk factors that you identify. I can't tell you what to do that because each one of you will have different needs some of you might be grappling with blood sugar management some of you might have high blood pressure some of you might be so beautifully healthy others might want to lose a little bit of weight before they conceive your own personal journey is your knowledge. So assess that and understand your own risks and then go on the journey for how you might mitigate those risks. So even if you've identified that there's a risk factor that doesn't mean you are definitely going to have a complication you can identify a risk factor apply some strategies to mitigate or reduce the impact of that risk factor so it doesn't become an actual complication and that's work for you to do. Thirdly get access to the policies that govern your pregnancy at the facility that you'll be giving birth at so ask them for their advanced maternal age policy so that you know what to expect from them and you don't get surprises throughout your pregnancy and then finally fourthly assess for yourself if an induction of labor is really what you need based on your circumstances at the time rather than making a decision for induction that's based on your age. Now what I haven't done here in this episode is spoken about all the possible screening tools that can be used through your pregnancy to help screen for and estimate your risk of issues through the pregnancy. This is a whole other episode and probably more but you know for example we know that as women age there's more chance that their baby will have a congenital abnormality or malformation. There are early pregnancy screening tools and tools that can be used through the pregnancy to determine if this is happening for you and so this is a possible strategy for risk mitigation is if you're having a pregnancy and you're over 35 then there's a whole raft of tests and screening that you could opt for to help you determine what things you're at risk of and what things you don't need to be considering in this pregnancy. Now if you do want to continue this conversation about pregnancy after 35 years old please do consider joining the premium podcast hub for a tiny $9 a month and you'll see all the details in the show notes in there there's the option to ask me a question to get free access to all the research that you use to create each podcast episode you can join the mailing list at MelanieTheMidwife.com or you can join our members hub and financially support the work of this podcast. In the hub you can ask me questions and premium members get access to a monthly Q&A episode where I answer listener questions you'll also get episode transcripts and additional resources for each podcast episode all the details are in the show notes