How Old Is Too Old to Have a Baby?

One of the results of assisted reproductive technology (ART) is the increase in the age of new mothers, giving rise to the question of whether women should have a baby at any age. Advanced maternal age (AMA) has typically been defined as age 35 years and older at the estimated date of delivery. Between 1970 and 2000, live births among women aged ≥35 years increased from approximately 5% to approximately 13% of all live births in the United States.¹ By today’s social standards, age 35 is barely considered advanced for becoming a mother, because more women are waiting until their 40s and even into their 50s to begin a family. The birth rate for mothers aged ≥44 years has been increasing in the United States since 1992, from 0.2 live births per 1000 women in the 1970s and 1980s to 0.6 in 2005.²

Before any discussion on the ethics of AMA and pregnancy can begin, it is important to understand the relative medical risks to mother and child.

Pregnancy Complications in Older Age
It is well-established that pregnancy-related complications increase dramatically in older women, including the risk for:

• Cesarean section
• Gestational diabetes
• Maternal and infant mortality
• Pregnancy-induced hypertension/ preeclampsia
• Preterm birth
• Small fetus for gestation age
• Low birth weight.

Much of the increase in delivery rates in this population is the result of the use of donor eggs; therefore, the focus of this article is on pregnancy itself (rather than the risks inherent in the aging egg, including chromosomal abnormalities, congenital anomalies, and miscarriage).

Researchers have investigated the increased risks associated with older age in pregnancy. For example, a 2009 analysis of 16 studies published between 1990 and June 2009 of pregnant women aged ≥44 years showed significant increases in complications in this agegroup (>44 years at time of delivery) compared with the younger control group (age varied, 20-29 years).² Pregnancy-induced hypertension was more likely to occur in the older agegroup, with a relative risk of 2.8. In this analysis, the 2 diagnoses of gestational hypertension and preeclampsia are included in the term “pregnancyinduced hypertension.”²

Cesarean section was more common and prenatal mortality increased in the older age-group. Birth weights in the older group and the controls were 3126 g and 3178 g, respectively.² But although these differences were statistically significant, they were not clinically significant. ² The risk for gestational diabetes was very high for women who delivered after age 44 years (relative risk, 11.2).² However, none of the studies included in this analysis discussed whether the study population had increased risk factors (eg, family history of diabetes, excess maternal weight, or gestational diabetes with a previous pregnancy).

This study showed that women giving birth after age 44 can expect complications. Therefore, patients should be adequately counseled about the risks for these complications. They should also be made aware of the risk for perinatal mortality. Although significant, this latter risk is still generally low, and healthy 44-year-old women can expect largely positive pregnancy outcomes.²

In 2007, Delbaere and colleagues controlled confounding factors and established that after adjusting for hypertension, diabetes, mode of conception, and level of education, rates of most adverse events remained significantly higher in older primiparae. They reported increased rates of very preterm birth, extreme preterm birth, low birth weight, very low birth weight, extreme low birth weight, perinatal death, and an increase in caesarean section rate in the primiparae of AMA.³ Even after adjusting for the confounding factors, maternal age was an independent risk factor for adverse pregnancy outcome. The results also showed that women with hypertension have a 3-fold increased risk of preterm birth and a 3-to 4-fold increased risk for delivering a low-birth-weight child.³

In another randomized, prospective, multicenter investigation of singleton pregnancies, Cleary-Goldman and colleagues controlled for race, parity, body mass index, education, marital status, smoking, medical history, use of assisted conception, and patient’s study site.⁴ AMA (aged 35-39 years and ≥40 years) was associated with an increase in the risk of miscarriage, chromosomal abnormalities, gestational diabetes, placenta previa, and cesarean delivery.⁴ In addition, patients aged ≥40 years at delivery were at increased risk of placental abruption, preterm delivery, low birth weight, and perinatal mortality.⁴ No significant differences were noted for gestational hypertension, preeclampsia, or preterm labor.⁴

An interesting aspect of this study was the lack of association between AMA and the risk for gestational hypertension, which stands in contrast to many reports. The study controlled for covariates associated with gestational hypertension and preeclampsia, including parity, history of medical conditions, and use of ART.⁴ Although chronic hypertension is more common with advancing maternal age, age alone is not responsible for gestational hypertensive complications.⁴ There can also be risks to the infant. In 2001, US infant mortality rates rose for the first time in more than 40 years—to 6.8 deaths per 1000 live births; in 2002, that rate was 7.0.⁵ It has been suggested that one of the main reasons for this is delaying pregnancy to older age, and the use of fertility treatment that is linked to multiple births.⁵ Multiple birth is associated with serious complications, including premature birth; 50% of all twins and 90% of all triplets are born prematurely.⁶ Other serious risks include impaired brain development, such as cerebral palsy and impaired lung development.⁶

Ethical and Social Concerns
At the forefront of the ethical issues involved in AMA and pregnancy is age discrimination, specifically whether it is legal to limit access to “medical treatment.” Other concerns involve laws stipulating that healthcare providers cannot set limits on age, and whether it can be considered age discrimination to set guidelines based on age alone.

The Age Discrimination Act (ADA) of 1975 prohibits discrimination on the basis of age in programs or activities receiving federal financial assistance. The ADA applies to people of all ages, but it does not cover employment discrimination.

The Office of Civil Rights of the US Department of Health and Human Services (HHS) enforces federal laws that prohibit discrimination by healthcare and human service providers that receive funds from HHS.⁷

The problem of clinicians making age-based decisions for older patients has received considerable attention and condemnation from medical and social science researchers in relation to the treatment of chronic and acute illness. When clinicians offer inappropriate or less care to patients because of their advanced chronological age, they potentially violate the ADA. However, a review of the cases litigated under the ADA suggests that advocates, regulators, and elders have not used the ADA to address even the most blatant age discrimination practices in healthcare.

Fertility treatment is generally considered elective and is seldom federally funded. Therefore, reproductive endocrinology centers would seem even less vulnerable to such litigation. Several states limit infertility coverage mandates based on age.

Presently, 4 states have infertility coverage mandates that include a maximum patient age:

• New Jersey permits insurers to limit surgical treatment of infertility to people aged ≤45 years
• New York requires insurers to cover infertility treatment (excluding IVF) for people aged 21 to 44 years, but permits insurers to provide coverage to patients of other ages
• Rhode Island requires coverage for women aged 25 to 42 years (in 2007 the coverage limit was extended from age 40 to 42)
• Connecticut law requires health insurance policies to cover medically necessary expenses incurred for the diagnosis and treatment of infertility but allows policies to limit the coverage to patients aged ≤40 years.

Determining eligibility for fertility treatment based on age alone—although perhaps ethically problematic—is not illegal. Centers should protect themselves by having well-written protocols on age requirements and limitations. Patients should be counseled on topics such as cutoffs at initiation of treatment regimens.

In a 2007 study, 49 women who conceived and delivered after age 50 with the help of ART were matched with 129 women in their 30s and 40s who also conceived via ART. The women were mailed questionnaires on parenting stress and physical and mental well-being. Approximately 50% of the women completed the questionnaire. Their self-reported results showed that the older women had slightly lower physical functioning scores than the younger women, but their mental functioning scores were higher. There was no difference between the older and younger women in overall parenting stress.⁸

It is also relevant to consider current life expectancy, which has increased in the United States over the past few decades, from 69.8 in 1960 to 78.⁴ in 2008.⁹

Practical Implications
The most basic tenet of healthcare providers is “to do no harm.” One must evaluate the relative risks of AMA for each patient individually as it relates to pregnancy and the health of the child.

Patients need to be educated on the increased risks of fertility treatments in older women. Many infertility patients are anxious and overloaded with information, and they do not retain all the information given to them at any given time. This is especially true during a new patient consultation, which can be very overwhelming. Therefore it is crucial to ensure that patients comprehend the increased risks of pregnancy complications on their lives.

Some consideration should also be given to potential offspring and the potential consequences of having elderly parents, including the potential burden of taking care of an elderly parent, potentially growing up without parents, as well as the social impact. Responsible reproductive centers typically have guidelines regarding age limitations, but in the end, individuals must decide for themselves whether they are capable of enduring the rigors of pregnancy and are prepared for parenting.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data from 2001. Nat Vital Stat Rep. 2002;51:1-102.
2. Schoen C, Rosen T. Maternal and perinatal risks for women over 44—a review. Maturitas. 2009;64:109-113.
3. Delbaere I, Verstraelen H, Goetgeluk S, et al. Pregnancy outcome in primiparae of advanced maternal age. Eur J Obstet Gynecol Reprod Biol. 2007;135:41-46.
4. Cleary-Goldman J, Malone FD, Vidaver J, et al. Impact of maternal age on obstetric outcome. Obstet Gynecol. 2005;105:983-990.
5. Infant mortality rate rises in USA, first time in 45 years. February 11, 2004. www.medicalnewstoday.com/articles/5846.php. Accessed May 28, 2010.
6. American Society for Reproductive Medicine. Patient Fact Sheet: Fertility Drugs and the Risk of Multiple Births. 2008. www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact.... Accessed May 28, 2010.
7. US Department of Health & Human Services, Office of Civil Rights. Your rights under the Age Discrimina tion Act. www.hhs.gov/ocr/age.html. Accessed May 28, 2010.
8. Steiner AZ, Paulson RJ. Motherhood after age 50: an evaluation of parenting stress and physical functioning. Fertil Steril. 2007;87:1327-1332.
9. The World Bank Group. World Development Indicators. Health Nutrition and Population Statistics. http://databank.worldbank.org/ddp/home.do?Step=3& id=4. Accessed May 28, 2010.