Pregnancy, for many, is ideally a planned one and looked upon as a precious and intimate journey for a woman. Every pregnancy is different. The time, finances, and emotions invested are unique to every pregnant woman. This is even more so for those who are pregnant for the first time at an older age. Most times, it can bring about anxiety and worry amidst the excitement of the pregnancy. In this day and age, we do see a trend of women getting pregnant at a later age.
The median age of such mothers was 31 last year, higher from 30.5 in 2015 (Figure 1). With such data, there is worry about the impact of advanced maternal age in pregnancy outcomes. Society now may see the importance of being financially stable before embarking on any pregnancy for various reasons. The Report of Registration of Births and Deaths 2020 stated that among first-time mothers, 61.5 percent had university degrees last year, up from 53.5 percent in 2015.
In fact, the number of women conceiving in their 40s has doubled over the past three decades in Singapore. Last year, there were 9 births for every 1,000 women aged 40 to 44, compared to 4.5 in 1985, according to figures from the Singapore Department of Statistics.
Academics interviewed in an article in The Straits Times on 23 July 2021 said as more women have children at an older age, they are likely to have fewer children, given that fertility declines with age. It quoted more Singaporeans remaining single as the main reason for the fall in births last year. We see a possibility of the move towards independence from parents. Hence, this leads to a need to be able to cater for self and to be able to do well in their career before marriage and eventually leading to planning for a baby. In the current setting too, there may be the issues of cost in raising children, childcare, cost of getting a domestic helper to assist with the household chores, other social support when they are out to work, and the list continues. Naturally, once they have children, life priorities change. With good established support, career progression can be much easier.
In the same article, Singapore Management University sociology professor Paulin Straughan mentioned the impact of the COVID-19 pandemic on fertility. Couples may put off getting married and having children when the economy is bad and things are uncertain. She noted that the number of marriages fell by 10.9 percent from 25,434 in 2019 to 22,651 last year, in the data released on July 7. In this pandemic, Dr Mathew Mathews, head of the Institute of Policy Studies’ social lab, said that there is little doubt that the pandemic would have made couples more cautious about starting a family. He said some couples prefer to hold off their baby plans until the COVID-19 situation is more stable, as they are concerned about the risk to the mother and baby if the woman is infected. This is illustrated in the initial hesitation in many pregnant women in accepting the COVID vaccination as part of antenatal care. This marked the awareness of the current situation which encourages society to be on top of health issues prior to getting pregnant.
The pandemic situation continues to evolve and affect people financially. We see many businesses, services and companies downsize or close during the Heightened Alert phases. The financial stress affects relationships, the couple’s goals and of course, their plans for fertility. This shall continue as long as COVID is amongst us. Many may remain hesitant to commit to such planning as they struggle to ensure that they are financially stable before considering a pregnancy.
DEFINITION OF ADVANCED MATERNAL AGE
Fertility starts to decline from 30 years onwards, especially after 35 years, making it harder for women to become pregnant. By 40 years old, only one in six of those who wish to have a baby will be able to do so naturally. However, even with such data, many women can still get pregnant spontaneously after the age of 35. There is definitely a huge difference in terms of probability of pregnancy between a 20-year-old and a 40-year-old woman due to the biological clock. Increasing age affects the number and quality of eggs.
With declining fertility, as a couple decides to try to conceive, they would require to have more regular sexual intercourse. This is encouraged especially during the fertile period. The fertile period is defined as the period when the egg is released. The egg is thought to be released about day 13 to 15 in a regular menstrual cycle. It becomes more difficult to predict when one has irregular or infrequent periods. Few may consider seeing their own gynaecologist for pre-pregnancy investigations. Such investigations are not limited to the woman, but also for the man. The preconceptual period offers an ideal window to recognise and address underlying health issues, social issues and harmful lifestyle behaviours in order to optimise maternal health, ultimately reducing infertility and impact of advanced maternal age on pregnancy outcomes. Preconception tests should be clinically relevant, aiming to identify risk factors and address them to predict and prevent infertility and pregnancy complications.
RISKS OF PREGNANCIES IN ADVANCED MATERNAL AGE
Once one is pregnant at a later age, the early pregnancy symptoms like hyperemesis (excessive nausea and vomiting), feeling lethargic or listless, or change in appetite become more extreme. Every woman’s body will react differently to the change in the hormones. For some, they may not be able to continue working and need to take unpaid leave as they feel giddy and nauseous most of the time. Weight gain may be more evident in more elderly pregnant women due to significant water retention. Early peripheral leg swelling may also be a common complaint. This may worsen as the pregnancy continues. Backache and difficulty in sleeping become a more common complaint as the pregnancy progresses. The emotions can easily be affected with all these changes. The support from their partner and family members is very important.
Advanced maternal age is a strong independent risk factor to first trimester (first 12 weeks of pregnancy or Week 1 to 12) miscarriage. The age group with the lowest risk are women in their 20s with an approximate risk of 8 to 10 percent of first trimester loss followed by a steep rise in miscarriage rates from the age of 30. The rate of first trimester loss for women aged 35 to 40 varies from 17 to 25 percent, for women aged 40 to 45 from 33 to 51 percent, and for women aged above 45 reaches 57 to 75 percent. An explanation could be that the quality of the egg may not be as good as we become older. The risk trend seems to be the same for second trimester (second 12 weeks of pregnancy or Week 13 to 24) miscarriages. One of the most common causes for early miscarriages is chromosomal abnormalities.
With age, there is a risk of chromosomal abnormalities to the baby especially with Down Syndrome. As one reaches the age of 40, the risk of having a Down Syndrome baby is about 1:100. There are currently various screening and diagnostic tests available. These tests are optional. Nevertheless, few tests can be costly. One can speak to their gynaecologist about this. Hence, early antenatal care is important to manage expectations and to look into resources throughout the pregnancy.
In the advanced maternal age group, there is a risk of developing high blood pressure. Few women after the age of 40 already have pre-existing high blood pressure problems. It is important to optimise the blood pressure so as not to have worsening problems throughout the pregnancy. There is a condition called preeclampsia, which is a life-threatening condition to both mother and baby in pregnancy. It is diagnosed with high blood pressure, associated with protein in urine, abnormal blood profile and symptoms like headache, blurring of vision and epigastric pain. Being aware of such conditions is important as early detection will bring about optimal care for both mother and baby. Another complication of pregnancy in advanced maternal age is diabetes at any stage of the pregnancy. This condition can be tested when risk factors are identified and also when one has repeated sugar in their urine tests. Routinely, apart from monitoring sugar in urine tests, we advise oral glucose tolerance test for all pregnant women as early as 20 to 24 weeks, earlier if there is any suspicion of the medical condition. Gestational diabetes mellitus is more common in older mums. Good control of sugar throughout pregnancy will ensure pregnant women remain asymptomatic. Poor control of sugar may affect the baby’s delivery outcome and weight. Poor control of sugar may also progress into long-term diabetes in the mum. Other risks due to medical conditions like preeclampsia or poorly controlled gestational diabetes can lead to the need to deliver early (preterm delivery). Babies, if delivered small, will need Neonatal Intensive Care Unit (NICU) care and a longer stay in hospital. This can incur more costs and other complications to the baby due to prematurity. Several older pregnant women who have pre-existing health problems (thyroid conditions or systemic lupus erythematosus) can either improve or deteriorate in pregnancy. Hence, it is important that one books early with a dedicated gynaecologist. The condition can be co-managed with the respective physician.
Another important factor which contributes to the increased pregnancy complications and increased morbidity in advanced maternal age is placental abnormalities. Older gravidas are at increased risk for placental abruption (mostly related to high blood pressure issues), as well as placenta praevia (commonly known as low-lying placenta). Placenta praevia is the only placental disorder which is strongly and independently linked to increased maternal age. Nulliparous (first pregnancy) women aged more than 40 years have a ten-fold increased risk for placenta previa compared to nulliparous women aged 20 to 29 years, although the absolute risk is low (0.25 percent vs 0.03 percent, respectively).
The rate of caesarean delivery nearly doubles with the increasing maternal age. This increase is linear with advancing age without clear arbitrary cut-offs or threshold effects, consistently seen across healthcare settings. The risks of emergency caesarean delivery secondary to difficulty in labour for women more than 40 years is over twice that of the younger population. One theory behind the rise specifically in labour difficulty in older women is that the ageing uterus is less effective at generating uterine contractions, although in-vitro evidence studying the contractility of human myometrium is mixed. Nevertheless, this could also be a lowered threshold for intervention for older pregnant mums due to the patient preference or the gynaecologist’s advice.
All pregnancies will end, some earlier than expected. Post-delivery is another milestone in the journey of a pregnancy. It is important to include post-delivery as part of the preparation process as this is the start of a commitment in raising a child. This process is dependent on the woman’s health prior to the pregnancy. If an older mum is healthy and fit, she may have better stamina and will recover from labour faster than a younger mum who is less fit or has medical issues. It is advisable to look into the mental wellness of the couple to enable them to manage the post-delivery journey better especially with issues like sleepless nights due to trying to adapt and attend to babies at any time of the night, fatigue, breastfeeding and colic for the baby.
ADVANCES IN MEDICINE
Older mums are commonly more prepared and knowledgeable for the pregnancy. Even with existing medical conditions, older mums can see their gynaecologist early to ensure that the existing medical condition is well-optimised first before embarking on the actual pregnancy journey. As advances in medicine develop further, we learn how to support existing medical conditions in pregnancy with safe new medication, or intervention or procedures where relevant. There are also dedicated high risk pregnancy clinics in various hospitals to tailor to such needs. In view of this, older mums with existing medical conditions have a better chance at enjoying a smooth pregnancy. On the other hand, there is only so much that medical advances can do. While older mums may have medical advances on their side today, the emphasis is that the risks should not be downplayed.
Improvements in screening methods and better ultrasound equipment also mean that abnormalities and birth defects in unborn babies are detected more accurately early in pregnancy. Medical advances have helped us to detect unborn Down Syndrome babies and other syndromic babies more accurately. Despite this, very little can be done to prevent them, other than conceiving at a much younger age. In the midst of the excitement of being pregnant, if the baby has been detected to have any abnormality, there is always the decision to terminate the pregnancy or to continue with the pregnancy. It will again go back to one’s faith, financial status and the ability to support a baby that may require life-long support. This can never be an easy decision, but it definitely will affect a couple financially and emotionally long term.
Advances in artificial reproductive techniques like superovulation and in-uterine insemination (SOIUI) and in-vitro fertilisation (IVF) have made it possible for couples to have babies later in life, especially for those with fertility problems. Age is one of the most important factors in determining whether fertility treatments like IVF work out. Women below the age of 35 have a 30 percent chance of becoming pregnant through IVF. Those above 40 have a 10 to 15 percent chance of becoming pregnant through IVF. There are nevertheless potential risks of ovarian hyperstimulation syndrome, multiple pregnancy, ectopic pregnancy and miscarriage in such treatments. The government allocates budget to aid the financial aspect and allows IVF to boost a woman’s chances of conceiving. From 1 January 2020, up to two of the six cycles can be carried out when the woman is 40 or older, as long as the couple had tried IVF or SOIUI procedures before the woman reached 40. For those with genetic conditions, there is a service called Preimplantation Genetic Diagnosis (PGD). This is a technology in reproduction used along an IVF cycle to reduce the risk of passing on inherited conditions.
With the estimated cost of raising a child in Singapore ranging from $200,000 to $1 million, juggling a child’s education funds and preparing for retirement can be a challenge. Delaying motherhood also means that mums will be close to retirement by the time their child is ready for tertiary education. Although older mums are often deemed more financially secure, there may be a financial implication at the end of the journey of raising that very child. It is important to start saving early if one has made the choice to have a child at a later age. One can consider endowment and retirement policies early to be able to be comfortable at a later age. The financial status is also dependent on the lifestyle one leads.
Being a first-time older mum, antenatal visits may be a point of support and visits may be scheduled more frequently as compared to a low-risk pregnancy. This equates to additional costs. The cost for a caesarean is higher than a normal vaginal delivery. Hence, there can be the potential additional cost to the hospital bill. As stated earlier, the cost will also increase when interventions are required to deliver a baby which is severely pre-term. The extended inpatient hospital stay and admission to Special Care Unit or NICU can add to the financial burden.
THE WAY TO GO
Advanced maternal age is associated with a wide range of adverse perinatal outcomes, although the magnitude of risk for most outcomes is small. With good knowledge and support in many ways, one has the right to plan and decide when one is ready for that first pregnancy. Even if one decides to have her first child at a later age, with awareness of resources, an older mum can have the pregnancy just as well as a younger mum. Optimising any medical condition before pregnancy is essential. Early booking, optimal screening and safe diagnostic procedures should be considered. Majority will do well in the pregnancy with the correct mindset and preparation. So with all this in mind, why not? ⬛
1 Tan, T. First-time mums in Singapore are older, more educated. The Straits Times. 2021, July 23. Available at: https://www.straitstimes.com/singapore/community/first-time-mums-in-singapore-are-older-more-educated; see also: Department of Statistics Singapore. Understanding Age-Specific Fertility Rate & Total Fertility Rate. 2021, June 4. Available at: https://www.singstat.gov.sg/modules/infographics/total-fertility-rate
2 Statista. Fertility rate in Singapore in 2020, by age group (per 1,000 females). 2021, July 5. Retrieved from: https://www.statista.com/statistics/622773/singapore-fertility-rate-by-age-group
4 Tan, T. First-time mums in Singapore are older, more educated. The Straits Times. 2021, July 23. Available at: https://www.straitstimes.com/singapore/community/first-time-mums-in-singapore-are-older-more-educated
5 Gan, E. More Women in Singapore Giving Birth in Their 40s. SingHealth. (undated). Retrieved from: https://www.healthxchange.sg/news/more-women-singapore-giving-birth-in-their-40s
6 Frick, A. P. Advanced maternal age and adverse pregnancy outcomes. Best Practice & Research Clinical Obstetrics & Gynaecology. 2021, January. Vol. 70, pp. 92-100. Retrieved from: https://doi.org/10.1016/j.bpobgyn.2020.07.005
8 Attali, E., and Yogev, Y. The Impact of Advanced Maternal Age on pregnancy outcomes. Best Practice & Research Clinical Obstetrics & Gynaecology. 2021, January. Vol. 70, pp. 2-9. Retrieved from: https://doi.org/10.1016/j.bpobgyn.2020.06.006
9 Goh, Y. H. Govt to lift age limit, increase co-funding for assisted reproduction; more subsidies for child vaccinations. The Straits Times. 2019, August 28. Retrieved from: https://www.straitstimes.com/singapore/health/more-financial-help-for-couples-seeking-fertility-treatments-subsidies-for
10 Gan, E. More Women in Singapore Giving Birth in Their 40s. SingHealth. (undated). Retrieved from: https://www.healthxchange.sg/news/more-women-singapore-giving-birth-in-their-40s
Dr Suzanna Sulaiman is the Head of Department for the Department of Obstetrics and Gynaecology in KK Women’s and Children’s Hospital. She has delivered many babies from mothers of varied ages. Simultaneously, she educates patients, medical students, junior doctors and the public on the importance of good health while co-leading Temasek Foundation Achieving Resilient and Inspiring Families Programme (Project ARIF).