Rebecca Dekker, PhD of Evidence Based Birth released a new article today – “The Evidence for Advanced Maternal Age” which examines and summarizes the current research available on the topic of pregnancy and birth at the age of 35 years old or beyond. The age at which people are having their first child continues to increase for a variety of reasons and more families are faced with navigating maternity care options with the label of “advanced maternal age” attached to their medical records. What are the current recommendations for these patients? What are the best practices? Unnecessary worries or legitimate concerns? Experiencing pregnancy and birth as an older pregnant person can be a bit more complicated and this new report can help families navigate the information with increased confidence. I am delighted to have an opportunity to interview Rebecca Dekker about this new AMA report and ask some questions on behalf of Science & Sensibility readers.
Sharon Muza: Why did you choose to address this topic? Why now? Was this a result of reader requests, new information that has come to light or something else?
Rebecca Dekker: Every topic I choose has been requested by Evidence Based Birth® readers! Many of my readers are birth and health care professionals who work with lots of clients who are having babies at age 35 and beyond. Only about 10% of women giving birth in the U.S. are 35 and older, but among doulas, childbirth educators, and midwives, I believe they have much higher rates of clients in this age group. And there’s not a lot of good, consolidated info out there that they can turn to. Of course, there are lots of individual research studies, but for the public there did not seem to be a single article explaining the research. So I think this article meets a true need of my audience.
SM: We know that infertility and miscarriage increase as a woman ages, do you think that people who are pregnant at an older age, particularly those who are having their first child, desire, prefer and find comfort in a more conservative approach with increased surveillance and “special handling” or is this additional scrutiny unwelcome generally speaking?
RD: It’s very possible that both are true– it probably depends on the individual family’s values, goals, and preferences for their care. Some may prefer to “protect the pregnancy at all costs” and some may be frustrated with the increased surveillance. I talk about this more in a lecture I give on this topic, but I’ve seen people name this phenomenon as the “precious child.” The “precious child” term seems like a misnomer, because isn’t every child precious? But even in the UpToDate article about advanced maternal age, they state that because women are not guaranteed to be able to carry a subsequent pregnancy to term, their clinicians recommend “delivery” at 39 weeks– in order to minimize the risk of stillbirth by any means possible. So I think this fact is very much on the mind of clinicians. I don’t think any research has looked at this phenomenon among families themselves, to assess their perception of the “precious child” factor and whether or not this influences their decision-making towards the end of pregnancy.
SM: With improvements in screening and more accurate diagnoses for genetic anomalies in the fetus, do you feel that women are more comfortable in waiting to have children, knowing they have increased resources available to them to identify potential concerns?
RD: The research that I’ve looked at has found that on average, families who choose to delay childbearing are not making completely informed decisions. There is evidence that they understand the increased risk of infertility with increasing age, but most people are not aware of the increased rates of stillbirth, Cesarean, and other childbearing difficulties. I have not seen research showing that women are delaying childbearing because of the increased accuracy with early prenatal testing. Research on that particular topic (delaying childbearing because of genetic testing) may be out there, but I have not seen it.
SM: Some facilities, health care practices or even state regulations consider people older than 35 to be high risk maternity patients and limit or prohibit them from receiving care with out of hospital providers or even hospital based midwives. Do you believe these recommendations are warranted given the facts discussed in your article?
RD: The only evidence we have on this comes from the Birthplace in England study, which shows that otherwise low-risk women who are 35 and older actually had better outcomes in midwifery-led settings that included home birth, freestanding birth centers, and true birthing centers inside of hospitals. Women who birthed in traditional labor and delivery units had much higher rates of Cesareans and interventions (on average there was about a doubling in the rate) with no increased benefit to the baby. This research evidence may or may not be applicable to some areas of the U.S., but it looks like the midwifery-led model of care (where midwives are leading the health care team, not working under physicians) is very beneficial to healthy childbearing women who are 35 and older. You might even be able to say, “If you’re planning a pregnancy, you might want to try and have your babies before your late 30s. But if you do decide to have babies in your late 30s and 40s, hire a midwife!”
SM: What do you believe people can do to help themselves to have the healthiest pregnancy and birth possible, if they are labeled “advanced maternal age”, both before pregnancy and during?
RD: I think the same teachings that childbirth educators and health professionals teach to younger women (to help them stay low risk) also apply to older women. To help improve your chances that you will remain “low risk,” try to avoid modifiable risk factors for gestational diabetes, preeclampsia, and preterm birth before and during pregnancy. For example, exercise and good nutrition are very important ways you can boost your chances of avoiding these complications, although of course they are not fool-proof. And then, like I just said in my previous paragraph, consider the midwifery-led model of care if your values and preferences tend to lean towards avoiding interventions unless they’re medically necessary. Talk with your care provider about the pros and cons of fetal testing/monitoring at the end of pregnancy and timing of induction, should you need one. There is so little evidence for both of these things (fetal testing and timing of induction) in women 35 and older, so a lot of the information for decision-making comes down to your individual care provider’s opinion. Clinical opinion is a form of medical evidence, and right now for some of these decisions, it’s the best form of evidence that we have!
SM: What do you suggest AMA consumers do if they are confronted with or offered information or care that does not align with the evidence that supports a safe pregnancy and healthy baby for those over the age of 35?
RD: Get a second opinion! You always have the right to a second opinion. In any other field of medicine, people do not hesitate to get second or third opinions. I think that is totally appropriate for pregnant women who are 35 and older, as well.
SM: Why do you think this topic is so stagnant amongst medical professionals? Why is it so difficult to shift our thinking around this issue when good research seems suggest that the risk of problems or concerns is significantly lower than it has been in past years?
RD: At the REACHE conference I attended a few weeks ago, one of the attendees said the reason she thinks professionals don’t know about the evidence is because they only read abstracts (the summaries of the papers). I thought that was a very good guess, and probably has a lot of truth in it! However, we do have research evidence that with medicine in general, reasons providers do not follow evidence-based guidelines include not being aware of the evidence, not believing the evidence, and not wanting to change the status quo. In obstetrics, we also have the added barrier of fears related to liability. And with “advanced maternal age,” there are scarcely any clinical guidelines out there (ACOG and ACNM are completely silent on the issue), and the guidelines that we do have make recommendations based on clinical opinion only.
SM: If readers were to take away only one important message from your post on advanced maternal age, what do you want it to be?
RD: I have two points. First, if you are considering delayed childbearing, have a preconception visit with a care provider. Talk about what’s involved with a) getting pregnant, b) carrying a pregnancy, and c) having a baby at age 35 and older, so that you and your partner can make informed decisions about timing your pregnancies.
If you do find yourself pregnant at age 35 and older, don’t panic! The vast majority of women who are 35 and older and reach term will have a healthy baby. Stillbirth rates for women of “advanced maternal age” have declined significantly over the past few decades. Researchers aren’t sure why this is happening; some have suggested it’s due to the increased use of biophysical profiles, other fetal monitoring, and inductions at the end of pregnancy. Regardless of the cause of the decline in stillbirth rates, I think that information is reassuring.
SM: What is next for you and Evidence Based Birth®? What exciting things should we be on the lookout for?
RD: There is a lot going on… I am going to be updating several articles this summer with new evidence! I’d like to publish an article on the Hepatitis B shot for newborns later in 2016. I’m continuing to release CEU classes at Evidence Based Birth®, and I’m planning an inter-professional Evidence Based Birth® retreat for May 2017.