In 1970, the average first time mom was 21 years old, according to the American College of Obstetricians and Gynecologists (ACOG). By 2020, that theoretical woman’s theoretical granddaughter wouldn’t give birth for the first time until age 27. In fact, during 2020, 19% of all pregnancies and 11% of first time pregnancies were in women aged 35 and over, according to the CDC. Delayed childbearing, meaning purposeful delay of childbearing into one’s late 30s or beyond, is associated with decreased fertility, but that’s not all [1]. Statistics suggest that over the age of 40 a woman’s risk of death during pregnancy or early postpartum rises dramatically.
Here at Natural Womanhood, we’ve addressed mortalidad materna many times, especially the unacceptably high rates of maternal mortality amongst mujeres negras in the United States. But when we stratify pregnant women by age, women over age 40 of all races are significantly more likely to die than younger women. Why might this be? And what can we do about it?
How much more likely are women over aged 40 to die compared to younger women?
Según la CDC, using data from 2023, the most recent year for which data is available, women over aged 40 were almost five times more likely to die during pregnancy or the first six weeks postpartum compared to women aged 25 and younger. Specifically, “rates in 2023 were 12.5 deaths per 100,000 live births for women younger than age 25, 18.1 for those ages 25–39, and 59.8 for those age 40 and older.”
According to the CDC, using data from 2023, women over aged 40 were almost five times more likely to die during pregnancy or the first six weeks postpartum compared to women aged 25 and younger.
Of note, these high maternal mortality rates for women over aged 40 represent a marked improvement from sky-high 2022 rates of 87.1 deaths/100,000 live births. The 2023 numbers represent a return to 2018 levels, as seen aquí, which had already begun to rise pre-COVID and then sharply increased between 2020 and 2021.
Even with the relative reduction of maternal mortality rates in 2023, when the data were restricted to black mothers over age 40, the rate was an almost unfathomable 239.9 maternal deaths/100,000 live births.
What are the top causes of maternal mortality?
Based on this 2018 report from the Nine Maternal Mortality Review Committees, new mothers of any age were most likely to die in the first six weeks postpartum (45%) compared to during pregnancy (37.6%) or six weeks through one year postpartum (17.5%).
The top causes of death, regardless of age, were postpartum hemorrhage and cardiovascular or coronary (heart blood vessel) conditions (tied at 14% each), infection (10.7%), cardiomyopathy (heart muscle disease, 10.7%), amniotic fluid embolism (8.4%), preeclampsia y eclampsia (7,4%), y enfermedades mentales (7%).
Why are women over aged 40 so much more likely to die during pregnancy or early postpartum?
‘Advanced maternal age,’ a term that makes virtually every woman wince or roll her eyes, is defined as pregnancy at age 35 and above. To be clear, ACOG itself acknowledges the age 35 cutoff “is an arbitrary threshold.” In fact, that specific number reflects research suggesting a relative age-related increase in risk of miscarriage and/or chromosomal abnormality for the baby, not medical risks for the mother.
Still, ACOG notas, “studies evaluating the effect of chronic medical conditions such as diabetes, hypertension, and obesity, which may exacerbate pregnancy-related morbidity, appear to demonstrate an increasing risk with increasing age at the time of pregnancy” (emphasis added) [2][3].
A small 2010 study of pregnant women over age 45 found higher rates of high blood pressure, diabetes, C-sections, placenta previay postpartum hemorrhage compared to younger women [4].
Preexisting medical conditions
The most obvious answer as to why older mothers are more likely to die during pregnancy or early postpartum is that they are more likely to have preexisting conditions such as high blood pressure and diabetes. Unsurprisingly, these can make pregnancy much harder on their bodies.
Multiples pregnancy
Older mothers are also more likely to have a multiples pregnancy (being pregnant with two or more babies at one time), and this can be for one of two reasons. As women age, they are more likely to conceive twins.
Additionally, for first-time mothers who experienced infertility, assisted reproductive technologies (ART) such as in vitro fertilization (IVF) or ovarian hyperstimulation with gonadotropin medications son far more likely than naturally conceived pregnancies to yield multiples [5]. (Of note, there are significantly fewer ART-related multiples pregnancies compared to even a decade ago due to fewer embryos transferred, and to abortion, also known as ‘selective reduction,’ of one or more successfully implanted embryos.)
As could be expected, the highest risks from multiples pregnancies come for the babies themselves. But mothers expecting multiples are also at increased riesgo of high blood pressure, preeclampsia, diabetes gestacional, and postpartum hemorrhage [6].
How can we drive down maternal mortality rates amongst women aged 40 and over?
Keep in mind that mayor risk of death during pregnancy or early postpartum does not mean that mothers aged 40 or above are probablemente to die. It simply means that their risk, on average, is higher than the risk for younger women. In order to drive down risk for todos pregnant women, we need a cultural shift to recognize the value of reproductive life planning (as described at length in this Natural Womanhood podcast episode).
Keep in mind that mayor risk of death during pregnancy or early postpartum does not mean that mothers aged 40 or above are probablemente to die. It simply means that their risk, on average, is higher than the risk for younger women. In order to drive down risk for all pregnant women, we need a cultural shift to recognize the value of reproductive life planning.
Additionally, we can ensure that every C-section is a medically necessary C-section. Access to midwives, particularly for pregnant women whose only ‘risk factor’ is age, and to doula care during labor (including giving dads doula training!) may have an outsized impact on meeting this goal.
Since the majority of mortalidad materna se produce antes de the traditional six-week in-office checkup to sign off on return to working out and sex, earlier, more frequent, in-home postpartum care is necessary. New Jersey’s nurse home visitor program is an excellent example of this concept in action. Across the board, a sea change amongst OB/GYNs is necessary to implement ACOG’s recommendation of two postpartum checkups, including one at or by three weeks postpartum.
The more eyes we can get on a woman in her home setting, the better chance we have for catching problems (be they physical or mental health-related) before they become fatal. Lactation consultants, postpartum doulas, and direct primary care physicians all represent birth workers who may go into the home. The last, but perhaps most crucial and most achievable, line of defense is ensuring broader community support to help postpartum women access adequate nutrition, exposición al sol, ejercicio, childcare, and breastfeeding support. Pregnant and newly postpartum women of every age, and the children who depend on them, deserve nothing less.
