A former school friend of mine, who had her first child this year, told me about her anger when an obstetrician referred to her pregnancy as ‘geriatric’. Inappropriate though this term may seem (indeed, it has largely dropped out of use in health care), my erstwhile classmates and I must face the fact that we have now crossed the line into what is known as ‘advanced maternal age’. Having been born in August, I was always the youngest person in my year at school and spent the first two decades of my life constantly being told I was too young for this, that or the other—so it's almost refreshing to find out I'm supposedly too old for something. But how seriously should we heed the warnings that come with our advancing years, and how can midwives best support pregnant women in their 30s and 40s?
Advanced maternal age is associated with a higher risk of complications in pregnancy and childbirth, including Down syndrome, preterm birth, poor fetal growth, gestational diabetes, pre-eclampsia and miscarriage (Cavazos-Rehg et al, 2015). Of course, to face such risks one must be able to conceive in the first place—something we are told is increasingly unlikely. In 2015, a lead consultant for reproductive medicine hit the headlines when she warned of a ‘fertility time bomb’ ticking away for women who do not have a baby before the age of 30 (Walton, 2015). Statistics, meanwhile, tell a different story: in my lifetime, the fertility rate for women aged 40 and over has more than trebled (Office for National Statistics, 2016).
A recent study published in BJOG (Fitzpatrick et al, 2016) focused on pregnancy at ‘very advanced maternal age’ (VAMA); in the case of this study, this refers to women aged 48 or over. Predictably, the researchers found that women in this age group were more likely than the comparison group (women aged 16–46) to experience a range of complications. However, they also pointed out that older women were more likely to have assisted conception and, therefore, had a higher rate of multiple pregnancy. When the results were adjusted for these factors, most of the effects of VAMA were diluted; only gestational diabetes, caesarean birth and admission to intensive care remained significantly associated with VAMA. While this study confirms that pregnancy-related risks increase with maternal age, it is interesting to note that it is not necessarily age itself that is the crucial factor.
Midwives and other health professionals have a responsibility to educate women about risk factors associated with pregnancy and birth, enabling them to make informed choices. But it is essential that these risks are not exaggerated or misunderstood. To build a strong, trusting relationship with the women in their care, midwives must provide up-do-date, evidence-based information, and then support the decisions that women make. While advanced maternal age does present some higher risks, there are numerous cases of women in their 30s and 40s having healthy, uncomplicated pregnancies. Individualised care is key to achieving the best possible outcomes for women and infants. Women face huge societal pressure regarding whether and when to conceive, how to behave while pregnant, and how to be a good mother. Midwives have the potential to offer a safe haven from this barrage of ‘advice’, by advocating for individuals and being with women, not against them.