While the idea that a woman has a "prime" — as CNN anchor Don Lemon ludicrously suggested recently— is patently absurd, ageist and sexist, the biological deck is nevertheless undeniably stacked differently. While men have always enjoyed a lengthy span of time to accommodate the choice of if and when to have children, women are meanwhile categorized as being of "advanced maternal age" as soon as they're over 35. In recent years, though, advancements in fertility treatment have pushed the window of opportunity to conceive and bear children wider than ever. In just the past few weeks, 48-year-old celebrities Da Brat and Hilary Swank have happily shared their respective first-time pregnancies with the press. Last year, the Montefiore Medical Center ran a campaign featuring a brain tumor survivor who welcomed her youngest child at the age of 57.
But the reality of pregnancy and birth after the age of 40, 45 and even 50 — especially in the post Dobbs decision era — is complicated.
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First, the good news. While the birth rate for women under 30 has plunged in the US over the last three decades, it has been exploding in the other direction. The Census reports a 132% increase in births by women over the age of 40 since 1990. That's a clear indication of the possibility of safe and healthy pregnancy at ages that were once considered extremely precarious. Moreover, there is evidence that having children over 40 can reduce cognitive decline and increase life span in mothers, while their children may 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's not the case."
Concerns about fetal abnormalities — often a concern among those who have children at an older age — also need to be thought about in context. That's because many of the women getting pregnant at an older age might not be using eggs that are as old as them.
"When we see people in the media, celebrities, they're not going to announce, 'I used an egg donor,' because that's private," says Dr. Cynthia M. Murdock, a fertility specialist at Illume Fertility. "But it does lead 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 when you're using a donated egg, you don't have the risk of Down syndrome, of chromosomal problems, that you would with a 45-year-old who uses her own eggs. The risk of Down syndrome is associated with not the age of the woman, but the age of the eggs."
Yet getting pregnant while you may also be perimenopausal remains an undeniable challenge. Estrogen levels decline as you age, and the odds of conceiving naturally are vanishingly slim. Parents notes that "At 45… likelihood of getting pregnant is no more than 3% or 4%." With donor eggs, the odds of conceiving improve dramatically and can be as high as 60%, but successful conception can require multiple attempts, followed by the ever-present risks for miscarriage.
Meanwhile, the fees for donor eggs, insemination and related procedures can be astronomical. For many, at least some of the costs will have be shouldered out of pocket. The infertility foundation Resolve reports that only 20 states have have passed fertility insurance coverage laws, and only 14 cover IVF. There can be staggering unforeseen out of network costs, and time and wages lost for travel and appointments.
"Over 40, or really even over 35, most risks go up."
Even in the best of circumstances, the health risks to a pregnant person are going to be different over a certain age, in part because health in general is different after a certain age. Pre-eclampsia and gestational hypertension rates are "significantly" higher for pregnant people over 40. "With age over 40, or really even age over 35, most risks go up," says Dr. David N. Hackney, an associate professor in the Department of Reproductive Biology at Case Western Reserve "The risk of developing gestational diabetes goes up. The risk of stillbirth goes up. The risk of having a C-section goes up."
He says, "We tend to accumulate diseases with age so as time goes on. We tend to develop diabetes, we gain weight, we have higher rates of high blood pressure. It's always been difficult to split out what are true differences due to age and what are differences due to the diseases that we tend to acquire over time. That being said, in the best studies that have attempted to adjust for these confounders, there does appear to be some true core increased risk associated with age alone, especially after age 40 to age 45, with stillbirth risk being the one which is probably both the most clear 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 grief of the experience. And then there is the confusing and often draconian enforcement of abortion restrictions that puts the lives of people experiencing pregnancy complications in serious peril. Between 10 and 20% of all pregnancies end in miscarriage. And while people using donor eggs have better odds of carrying a pregnancy to term, a 2019 study in The BMJ found miscarriage rates in women aged 45 and over can be as high as 53%.
"Spontaneous miscarriage happens very, very frequently, especially in women who are older."
Handling a pregnancy loss, or deciding what to do about a nonviable fetus, requires supportive, skillful medical management. Patients often require a D&C [dilation and curettage] procedure or prescription medication to remove the contents of the uterus. As 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."
"In roughly half the country now, abortion is essentially banned," says gynecologic surgeon Dr. Julia Arnold VanRooyen. "Most of those states do have language in there around saving the life of the mother. The problem is, you can't enumerate all of the possible scenarios that could happen during a pregnancy to put a mother's life in risk. You can't list them out one by one in bullet points. The doctors in the emergency room and the OB-GYNs who are taking care of these patients are stuck not knowing what will happen if they intervene."
She continues, "Spontaneous miscarriage happens very, very frequently, especially in women who are older. In half the country where abortion has been essentially banned, if [the patients] are hemorrhaging, or if they're maybe a little bit infected but not thoroughly septic yet, doctors who are taking care of them are going to scramble and say, 'Can we do it? Can we not do it? Do we need to consult the hospital lawyer?' Even if they have those things in place, that still causes a delay in care that never would have used to happen. So these women are getting sicker, they're bleeding more, they're getting more infected before they can get a simple D&C that's going to save their life, even though there's no chance that the pregnancy can continue."
Abortion restrictions are an issue for every pregnant or potentially pregnant person in America, but they are a uniquely thorny one for someone facing pregnancy over 45.
It's easy, when we see glowing celebrities of a certain age proudly showing off their baby bumps or medical centers celebrating AARP-aged cancer survivors holding their infants, to start to believe that this is a common and easy occurrence. The fact is that even with incredible advancements enabling more people than ever to realize their dreams of starting or expanding their families, conception and birth becomes a more challenging enterprise with age. That doesn't necessarily take anybody's dreams off the table. "We have many women who are very healthy," says Dr. Murdock. "Any way that you can build your family, we're supportive of and we encourage."
But the truth of this dream for older women is that it almost assuredly cannot happen without intervention. If you're fortunate enough to conceive, there then are health issues to consider, along with punitive, ignorant reproductive laws that could make any complications a serious and even life-threatening risk.
"I can't imagine making the decision to go through all of that risk and expense to have a child and doing it knowingly in a state in the south," says Dr. Arnold VanRooyen. "That would seem to be like a big flaw in your plan. Women who have the means and could really go anywhere, they have to pick a place like New York or Massachusetts, or, that still has robust abortion care. It is a part of healthcare, and you might need it."
Abortion restrictions are an issue for every pregnant or potentially pregnant person in America, but they are a uniquely thorny one for someone facing pregnancy over 45. And anyone in that position, even with the best doctors and best care, needs to be aware of all those factors and to be willing to have tough conversations about worst case scenarios.
"If you're considering conceiving, know who your OB-GYN is going to be," says Dr. Hackney. "Meet with and talk to your OB-GYN, which is often going to be different than the fertility specialist. I would ask them what is the current state law and ask them, 'What would you do if I had a miscarriage? What would you do if I had a serious or fatal birth defect or a genetic disorder? What if my bag of water breaks when I'm 18 weeks? What would you do right now?' I guess for lack of a better description, do you trust that person? And is that person going to be brave?"