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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Women's Health
January 17 , 2001

News this month
Postponing motherhood: the risk of waiting

Increasing numbers of women in the U.S. and abroad are choosing to have families later in life. Many are focused on finishing school, pursuing careers and establishing solid relationships before beginning their families, but a new study indicates women over age 35 face more pregnancy-related risks than their younger counterparts. The study, conducted by researchers at the Danish Epidemiology Science Center in Copenhagen, found the risk of unsuccessful pregnancy rises dramatically to 20 percent and higher after a woman reaches age 35.

A new study indicates women over age 35 face more pregnancy-related risks than their younger counterparts.

"We found the risk of miscarriage increases with maternal age–irrespective of a woman’s reproductive history," said lead author Dr. Anne-Marie Nybo Anderson, professor of epidemiology. The report, published in the British Medical Journal, provides some sobering statistics:

  • by age 35, one in five of all pregnancies ends in miscarriage, stillbirth or ectopic pregnancy (a dangerous condition in which the fertilized egg implants outside the uterus);
  • by age 42, the failure rate rises to more than half; and
  • after age 45, nearly three out of four pregnancy results are not successful.

By contrast, women in their early to mid-20s experience only a 9 percent failure rate.

Study, one of largest to date
The researchers looked at more than 1.2 million pregnancy outcomes experienced by 600,000 women between 1978 and 1992. Although previous studies have suggested older women have higher-risk pregnancies, this study analyzed a very large population over more than a decade.

Also, for the first time, researchers were able to separate the degree of risk according to each woman’s reproductive history; for example, if she had previous children, fertility problems or a history of abortions, researchers were able to track these differences with pregnancy success rates. The rise in miscarriage, stillbirths and ectopic pregnancies increased with age independently of these other factors.

Researchers conclude the study underscores the importance of counseling women about the risks of postponing pregnancy if they are interested in having babies.

Editorial explores other issues
In an accompanying editorial, a research team from Columbia University suggests women and their partners should also consider the risks not analyzed in the Danish study–multiple births and congenital malformations–both of which increase with maternal age.

And, in addition to the added risk of unsuccessful pregnancies and an increase in the number of children born with congenital defects, older women have more difficulty conceiving in the first place. In fact, options for enhancing fertility, according to Zena Stein, professor of epidemiology and psychiatry at Columbia University, have grown over the last few decades, giving women more incentives to postpone pregnancy.

The editorial also points out there are social advantages to postponing pregnancy. Although the biological advantage rests with women in their 20s, women who wait are often better prepared emotionally and financially to assume responsibilities of parenthood.

















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Michael R. Berman, MD

Pregnancy riskier for older women

The Danish study confirms what we’ve known for many years. The older women are when they become pregnant, the higher the likelihood of miscarriage and other types of fetal loss. It’s something we’re seeing more of. I’ve been in practice for 28 years, and when I first started, my obstetrical patients were predominantly in their mid-20s. Now my average obstetrical patient is in her 30s. In addition to an increased risk of losing a baby, older women may also have more difficulty getting pregnant in the first place.

"The older women are when they become pregnant, the higher the likelihood of miscarriage and other types of fetal loss."

Some of the factors that increase fertility problems are also responsible for fetal loss. The eggs women store in their ovaries age along with them, which can result in fertility problems or, once fertilized, can result in chromosomal damage as these eggs begin the process of cell division. About 50 percent of miscarriages result from chromosomal abnormalities in the developing embryo.

Other conditions that are more likely in older women such as high blood pressure and diabetes also create risks for successful pregnancies. Your chances of having twins or triplets also goes up as you age even without fertility treatment. And the possibility of multiple births is riskier than carrying one baby.

What can you do?
Often we don’t have a clear indication of what caused the loss of a baby. Even when we do know the reason, there is often little that a woman could have done to prevent it. However, good health habits can maximize your chances of a healthy pregnancy as can regular prenatal visits.

  • Control existing health problems such as high blood pressure or diabetes
  • Take prenatal vitamins that contain folic acid before getting pregnant to help prevent neural tube defects such as spina bifida, a condition in which the tissue over the baby’s spinal cord doesn’t close
  • Avoid tobacco, alcohol and illegal drugs. All have been linked to poor pregnancy outcomes
  • Lose weight if you’re overweight. Overweight women are more likely to develop problems during pregnancy
  • Learn about your health risks and diagnostic tests you may want to have to detect chromosome abnormalities

Prenatal testing We are now able to detect potential genetic problems, chromosomal defects and physical deformations earlier in pregnancy than ever before, but just because these tests are available does not mean every woman needs to undergo them. Your physician will most likely discuss prenatal tests with you if you are over age 35, have a family history of some genetic conditions or have been exposed to a harmful chemical agent, but it’s important to know testing is not required because a physician offers it. Arming yourself with information and taking time to consider all possible scenarios is key to making the right decision for you.

The most common prenatal tests are chorionic villus sampling (CVS), alpha fetoprotein (AFP), triple screen, ultrasound and amniocentesis. These tests all provide different information and have different applications. Not every disease or condition can be detected prenatally. For more information about these tests, see here.

You might want to ask your doctor the following:

  • How accurate are the test results?
  • What are the risks associated with the test?
  • How often does he/she perform these tests?
  • If a problem is detected, what are the options?

You might want to ask yourself the following:

  • How concerned am I about the risk of miscarriage?
  • Will this information change how I’ll prepare for the birth of my baby?

The future is now
The push is on for more accurate, earlier prenatal tests, but they are just one of the high-tech tools that are giving women a better chance than ever of having a safe pregnancy and a healthy newborn. Technology has gone a long way to make it possible for older couples to have children. It is also making it possible to provide more precise images of babies before they’re born to detect hard-to-spot abnormalities such as cleft lip and palate (one in 930 births) and clubfeet (one in 735), so babies can be treated more quickly.

And before long, it’s quite possible physicians will be able to tell if a fetus is at risk for hundreds of genetic diseases that strike only in adulthood, such as Alzheimer's and cancer. Eventually embryos conceived through in-vitro fertilization could be tested before being implanted in the mother-to-be. Couples could opt not to implant ones at high risk for, say, juvenile diabetes or breast cancer. Or it might be possible to extract genetic material responsible for disease before embryos are implanted.

Clearly, these advances will lead to many complex ethical issues, but women and their partners will be armed with more knowledge so they can make informed decisions based on their own personal beliefs and situations.

Dr. Berman is an attending obstetrician/gynecologist at Yale-New Haven and a clinical professor of obstetrics and gynecology at the Yale School of Medicine. He is president of the County Obstetrics and Gynecology Group and founder of the Hygeia® Foundation for Perinatal Loss and Bereavement. Dr. Berman authored Parenthood Lost, Healing the Pain after Miscarriage, Stillbirth and Infant Death.


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