While the idea of a woman having a “prime” – as CNN host Don Lemon recently ludicrously suggested – is blatantly absurd, age- and sexist, the biological is nevertheless undeniably stacked differently. While men have always had a long time to choose if and when they want to have children, women meanwhile are categorized as “advanced maternal age” once they are over 35 years old. in fertility treatments have increased the chances of getting pregnant and having children more widely than ever. In recent weeks, 48-year-old celebrities Da Brat and Hilary Swank have been happy to share their respective first pregnancies with the press. Last year, Montefiore Medical Center ran a campaign in which a brain tumor survivor welcomed her youngest child at age 57.
But the reality of pregnancy and birth after age 40, 45, and even 50 — especially in the post-Dobbs decision era — is complicated.
Want more health and science stories delivered to your inbox? Subscribe to Salon’s weekly newsletter, The Vulgar Scientist.
First the good news. While the birth rate for women under 30 in the US has been declining for the past three decades, it is exploding in the other direction. The Census reports a 132% increase in births to women over the age of 40 since 1990. That is a clear indication of the possibility of a safe and healthy pregnancy at ages once considered extremely precarious. In addition, there is some evidence that having children over the age of 40 may reduce cognitive decline and extend mothers’ lifespan while allowing their children to enjoy better health and higher educational achievement.
“Some women believe, ‘I’m 47, I’m healthy, I can have a baby with my own eggs.’ That is not the case.”
Concerns about fetal abnormalities – often a concern of those having children at an older age – also need to be viewed in context. That’s because many of the women who conceive at an older age may not be using eggs as old as they are.
“When we see people in the media, celebrities, they won’t announce, ‘I used an egg donor,’ because that’s private,” says Dr. Cynthia M. Murdock, a fertility specialist at Illume Fertility. “But it leads some women to believe that ‘I’m 46, I’m 47, I’m healthy, I can have a baby with my own eggs.’ The reality is that’s not the case, and if you use a donated egg, you don’t run the risk of Down’s syndrome, of chromosomal problems, like a 45-year-old who uses her own eggs. van Down is not associated with the age of the female, but with the age of the eggs.”
Still, conceiving while in perimenopause remains an undeniable challenge. Estrogen levels decrease as you age, and the chances of getting pregnant naturally are negligibly small. Parents note that “At 45 … the chance of getting pregnant is no more than 3% or 4%.” With donor eggs, the chances of getting pregnant improve dramatically and can be as high as 60%, but successful conception may require several attempts, followed by the ever-present risks of miscarriage.
Meanwhile, the fees for donor eggs, insemination, and related procedures can be astronomical. For many, at least part of the cost will have been paid out of pocket. The Resolve infertility foundation reports that only 20 states have passed fertility insurance coverage laws, and only 14 cover IVF. There may be unforeseen network costs and time and wages lost for travel and appointments.
“Above 40, or actually even above 35, most risks go up.”
Even in the best of circumstances, the health risks for a pregnant person will be different after a certain age, in part because health in general is different after a certain age. Preeclampsia and gestational hypertension are “significantly” higher for pregnant people over 40. “With age over 40, or even over 35, most risks increase,” says Dr. David N. Hackney, an associate professor in the Department of Reproductive Biology at Case Western Reserve “The risk of developing gestational diabetes is rising. The risk of stillbirth is rising. The risk of cesarean section is increasing.”
He says: “We tend to accumulate diseases with age, so as time goes on. We tend to develop diabetes, we gain weight, we have high blood pressure more often. It’s always been hard to figure out split what are true differences due to age and what are the differences due to the diseases that we contract over time that said in the best studies that have tried to correct for these confounders there seems to be a really increased risk related only to age, especially after age 40 to 45, where the risk of stillbirth is probably both the most evident in the data and, of course, the most concerning.”
The risks of stillbirth – as well as other forms of loss – are concerning on many levels. There is the obvious physical pain and emotional sadness of the experience. Then there is the confusing and often draconian enforcement of abortion restrictions that seriously endangers the lives of those with pregnancy complications. Between 10 and 20% of all pregnancies end in miscarriage. And while people who use donor eggs have a higher chance of carrying a pregnancy to term, a 2019 study in The BMJ found that miscarriage rates in women 45 and older can be as high as 53%.
“Spontaneous miscarriage is very, very common, especially in older women.”
Coping with a pregnancy loss, or deciding what to do about a nonviable fetus, requires supportive, skilled medical treatment. Patients often require a D&C [dilation and curettage] procedure or prescribed medication to remove the contents of the uterus. Like dr. Sarah Prager told NPR last year, “The challenge is that the treatment for an abortion and the treatment for a miscarriage are exactly the same.”
“Abortion is now essentially banned in about half the country,” says gynecological surgeon Dr. Julia Arnold VanRooyen. “In most of those states, there is language about saving the mother’s life. The problem is that you can’t list all the possible scenarios that can happen during a pregnancy to endanger a mother’s life. You can don’t just list them in bullet points one by one. The ER doctors and the midwives who care for these patients don’t know what will happen if they intervene.”
She continues: “Spontaneous miscarriage is very, very common, especially in older women. In half of the country where abortion is essentially banned, if [the patients] bleeding, or maybe they’re a little bit infected but not yet thoroughly septic, doctors tending to them will rush out and say, “Can we do it?” Can’t we do it? Should we consult the hospital’s lawyer?’ Even having those things in place still causes a delay in care that never would have happened before. So these women get sicker, they bleed more, they get infected more before they can get a simple D&C that’s going to save their lives, even though there’s no chance the pregnancy can continue.”
Abortion restrictions are a problem for every pregnant or potentially pregnant person in America, but they are a uniquely thorny problem for someone over 45 who is pregnant.
When we see radiant celebrities of a certain age proudly showing off their baby bumps or medical centers celebrating AARP cancer survivors holding their babies, it’s easy to come to believe that this is a common and easy occurrence. The fact is that even with incredible advancements enabling more people than ever to achieve their dreams of starting or expanding their families, conception and birth becomes more challenging with age. That doesn’t necessarily take anyone’s dreams off the table. “We have a lot of women who are very healthy,” says Dr. Murdock. “Any way you can build your family, we support and encourage.”
But the truth of this dream for older women is that it almost certainly can’t happen without intervention. If you’re lucky enough to get pregnant, there are health issues to consider, along with punitive, ignorant reproductive laws that can make complications a serious and even life-threatening risk.
“I can’t imagine making the decision to take all that risk and expense of having a child and knowingly doing so in a southern state,” says Dr. Arnold Van Rooyen. “That seems like a big flaw in your plan. Women who have the resources and can really go anywhere should choose a place like New York or Massachusetts, or who still have robust abortion care. It’s part of the health care system, and maybe you need it.”
Abortion restrictions are a problem for every pregnant or possibly pregnant person in America, but they are a uniquely thorny problem for anyone over the age of 45. And anyone in that position, even with the best doctors and the best care, needs to be aware of all those factors and be prepared to have tough conversations about worst-case scenarios.
“If you’re considering getting pregnant, know who your OB-GYN will be,” says Dr. Hackney. “Meet and talk to your obstetrician, who will often be different from the fertility specialist. I would ask them what the current state law is and ask them, ‘What would you do if I miscarried? If I had a serious or fatal birth defect or have a hereditary defect? What if my bag of membranes breaks when I’m 18 weeks? What would you do now?” I think for lack of a better description, do you trust that person? And will that person be brave?”
read more
on pregnancy and abortion rights