Advanced Maternal Age – Do you have to be induced at 39 weeks?

Just because you’re over 35 — does that mean you need to get induced? Today I want to share why your doctor might recommend an induction at 39 weeks of pregnancy, and how to make the best choice for you — because an induction is always YOUR choice, not your provider’s!

This (or any article on The Pregnancy Nurse) should be taken as medical advice, this purely educational. Please talk with your provider about your specific needs and circumstances.

Increased Risks of Advanced Maternal Age: What the studies show

Because a lot of people are getting pregnant after 35, I feel like we’ve started to act as though there isn’t an increased risk to making that choice. Just because something has been normalized, doesn’t mean that it still can’t be risky.

The fact is that the older you are, the more risky pregnancy gets. But you’ll find that maybe just being 35 isn’t the same as being 40+… so let’s review the studies

TRIGGER WARNING: We are discussing stillbirth a LOT here. If that’s an issue or if you’re like TOO MUCH DATA HILARY — just give me the skinny skip to here.

Ok, jumping into the studies:

This one stratified the data according to age:

• 0.6% among teenage mothers (these girls tend to get poor prenatal care – I believe that’s the issue here)
• 0.5% in mothers between 20 and 39 years (notice the ages here)
• 0.9% among mothers 40 and 49 years
• 1.0% among 50 years and over

Now, that’s your total stillbirth risk — but that is a good sized jump between the 20-39 age vs the 40-49 years old.

Dongarwar D, Aggarwal A, Barning K, Salihu HM. Stillbirths among Advanced Maternal Age Women in the United States: 2003-2017. Int J MCH AIDS. 2020;9(1):153-156. doi: 10.21106/ijma.346. Epub 2020 Feb 10. PMID: 32123639; PMCID: PMC7031887.

I know those percentages do look very small, but for the few that could have been prevented it is a devastating loss to all involved.

---

This one reviewed a few different studies (my favorite way to do it) — and it talks more about the relative risk vs the actual risk — meaning that in the study above the relative risk was 80% higher between 20-39 years and 40-49 years — but that doesn’t meant that 80% had stillbirths… just that it was a much higher risk (even though the risk was still small).

It said:

We found that greater maternal age was significantly associated with an increased risk of stillbirth; relative risks varied from 1.20 to 4.53 for older versus younger women…. Women with advanced maternal age have an increased risk of stillbirth. However, the magnitude and mechanisms of the increased risk are not clear, and prospective studies are warranted.

Greater maternal age was significantly associated with an increased risk of stillbirth

It talked about some of the reasons this risk might be higher:

• Lower blood flow to the placenta due to decreased blood flow everywhere due to age (called vasculature in literature)
• Increased incidence of chronic disease or obstetric complications
• Higher incidences of blood pressure or diabetes in older women
• Increased numbers of twins, triplets (or more) in older women – older women are 1.5 to 2 times more likely than younger women to have this (although some is due to reproductive help like IVF)

It did call-out that Between 50% and 70% of mothers of stillborn infants had medical or pregnancy complications during their pregnancies — meaning a good number do have a complication (but also, a good number do not)

It also mentioned that not enough of the studies showed information about moms who’s previously had children (called parity in the study). Although, the incidence in general of stillbirth is less if you’ve already had a successful pregnancy.

Some of you may just be FREAKING OUT right now — which isn’t unusual — I did appreciate this paragraph:

Women should understand that the risks associated with pregnancy increase as they get older. In this systematic review, we have demonstrated that risk of stillbirth is one of the risks that increases with advanced maternal age. However, since the absolute stillbirth rate among older women is less than 10 per 1000 births in most industrialized countries, a live birth can be expected in most cases if appropriate medical care is provided. Thus, increased maternal age should not be considered an absolute barrier to the decision to have a child, at least in terms of the risk of stillbirth.

Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C. Maternal age and risk of stillbirth: a systematic review. CMAJ. 2008 Jan 15;178(2):165-72. doi: 10.1503/cmaj.070150. PMID: 18195290; PMCID: PMC2175002.

---

I can’t see this entire study — but the basics were:

The rate of antepartum stillbirth in women <35 years was 3.5 per 1000 live births and in women ≥35 years was 4.0 per 1000 live births

Showing there is an increased risk (but I’m not seeing the data stratified by age). It did talk a lot about fetal anomalies overall, which definitely increases your risk (but would likely be seen on ultrasound prior to delivery)

Kate F. Walker, Lucy Bradshaw, George J. Bugg, Jim G. Thornton,
Causes of antepartum stillbirth in women of advanced maternal age,
European Journal of Obstetrics & Gynecology and Reproductive Biology,
Volume 197,
2016,
Pages 86-90,

---

This one had some good data with it much more stratified out by ages. It’s important to know because the risk is very different at 35 than it is at 40+. It ALSO shows the risk based on DAD’s age as well. They have a great chart on page 4 of that study…

Here’s the risk of stillbirth in 1000 live births based on age:

• 28 — 1.0 (this was considered their baseline)
• 30 — 1.08
• 32 — 1.17
• 36 — 1.54
• 40 — 2.16
• 44 — 3.04
• 48 — 4.28
• 50 — 5.07

So, as you can see there is a decent sized jump at 36 (even though relative risk is still pretty small when you’re thinking PER 1,000 babies).

Parental age and stillbirth: a population-based cohort of nearly 10 million California deliveries from 1991 to 2011
Jonathan A. Mayo, MPH a, *, Ying Lu, PhD b, David K. Stevenson, MD a, Gary M. Shaw, DrPH a, 1, Michael L. Eisenberg, MD c,

---

As I look at these studies it is pretty frustrating that all of them are from the 2010’s — it’s important to note that these have to be LONG TERM studies as we have to include hundreds of thousands of births to see trends like this. But also, research dollars are drying up lately — it we want this data, we have to continue to fund good research. Hopefully we get some new studies soon!

ACOG (the American College of Gynecologists — they’re the ones who make the guidelines for OB’s in the US) has a great page that outlines some of the reasons for these increased rates — they include:

• Increased incidence of IVF
• Increased Diabetes
• Increased preeclampisa or hypertension
• Increased risk of genetic conditions (like down syndrome — although that’s not the only one)

Those are called comorbidities. You might also have some that are distinct to just you — like decreased flow to the placenta or baby’s size measuring big or small.

A few recommendations I pulled out…

• They recommend encouraging an induction for those over 40 (even though “advanced maternal age” starts at 35) due to increased stillbirth risks
• They still recommend trying for vaginal delivery in general (although if baby is breech or extra large that may change)

I also want to call out that there is an increased risk for problems with mom as well. Mostly including heart issues like cardiomyopathy as pregnancy continues — especially in older moms. So this isn’t entirely about stillbirths.

Hilary’s Thoughts on This Data

I appreciate the data — but I did want to pull out a few things I personally thought during this:

• Risk at 35 isn’t the same as the risk 40+ (although it is increased from people under 35 overall)
• You want good data on any comorbidities — meaning
  • Getting all your ultrasounds at the right time
  • Doing any testing recommended
  • Attending prenatal appointments (all of them)
• IVF does play a role in this. It’s difficult to tell how much, but a “natural” pregnancy will be different than one via reproductive help.

As always, it is important to apply what you’re learning and seeing in the data, to what YOU want for your pregnancy and what the situation is for YOU. We’re going to talk more about that coming up!

Figuring out what YOU want starts with a birth plan — grab my free Birth Plan Template to start getting clear on your preferences before those provider conversations get real.

Want to know more about inductions? — check out these posts:

• Lies I Used to Believe about Labor & Birth
• Pumping To Induce Labor? Will it work?
• 5 Things NOT to do Before Your Induction
• Pitocin to Induce Labor
• Inducing Labor at 39 Weeks: Pros and Cons

Why They Recommend It

So, as noted above — ACOG recommends an induction of labor in people over 40.

Now, I’m also hearing a LOT of people 35-39 also being recommended to have it… and that could be based on all the data above.

But, ultimately they are recommending it because they want to prevent stillbirth (and possibly poorer outcomes to moms).

And, honestly, the risks to an induction are pretty low.

This study showed there wasn’t an increased risk of cesarean delivery during a 39 week advanced maternal age induction vs someone who was expectantly managed (aka, just watched and went into labor on their own, or needed to be induced). It also showed no adverse short-term effects on maternal or neonatal outcomes.

What I’m not seeing in that study is actually less stillbirths. They did study it — but you need a REALLY LARGE study to check that out as the incidence of stillbirths is so small in both populations.

Randomized Trial of Labor Induction in Women 35 Years of Age or Older Kate F. Walker, M.R.C.O.G., George J. Bugg, M.D., Marion Macpherson, M.D., Carol McCormick, M.Sc., Nicky Grace, M.A., Chris Wildsmith, B.A., Lucy Bradshaw, M.Sc., Gordon C.S. Smith, D.Sc., and James G. Thornton, M.D.

You’re always weighing the risks to the baby, and the mom to the risk of being born early and possibly induction complications. That’s your doctor’s job.

Your job is to weigh all of that against what you want for your birth. And that’s OK too.

Induction Before 39 Weeks?

Now, some of you out there are wishing your baby could be induced before 39 weeks of pregnancy.

It’s very heavily regulated who is offered an induction before 39 weeks pregnancy — and no, advanced maternal age isn’t one of those reasons.

I have a whole post on why you might get induced early — but basic indications include:

• Preeclampsia or gestational hypertension
• Type 1 or Type 2 pre-existing diabetes
• Placental issues or fetal growth restriction (IUGR)
• Premature rupture of membranes

I should say no matter WHEN you’re considering an induction you want to make sure you understand what will happen — I have a whole induction questionnaire that can help you do just that:

Studies vs Your Situation

When you have all that data, you can also ask yourself these questions:

• Was this baby naturally conceived, or did you use IVF?
• Do you have comorbidities — like blood pressure, diabetes or other health issues?
• Multiples (twins, etc — although those are general induced or go into labor early)
• How old ARE you — are you just a few weeks over 35 or 40+
• Any circulatory issues? As blood flow to the placenta is a big concern — how’s your blood flow overall otherwise? (cholesterol, etc)

Those are just some ideas — I think it’s smart to go over with your provider your unique situation.

Making the Choice for YOU

Honestly, many women 35+ are begging for an early induction because they’re miserable. And that’s fine too — this article is just here to give you the facts. But if you ARE getting induced, I extra recommend something like this.

The reality is many doctors recommend an elective induction to everyone at 39 weeks of pregnancy, as stillbirth risks do rise the longer you’re pregnant and the ARRIVE Trial supported that.

It is a controversial trial, and there are some that have come out since then that both support what they learned, and some that show an increased incidence in cesareans with elective 39 week inductions. However, the ARRIVE trial is pretty solid research, and it is worth considering as you make your choice. I actually do a deep dive in the Arrive trial in the bundle in here.

When you make the choice for yourself you’re going to balance all the things I talked about above about if you have comorbities, etc along with your own desires for your birth.

I would also have them check my cervix. I think this is a missing piece a lot of people don’t really consider. I have a whole post on if your body is ready for induction that will help explain that more.

For instance, I was 12 days over my due date with my last one, I had prodromal labor every night, my pelvis had separated and I was miserable. My cervix was also 5 cm and I was very ready for an induction. That’s very different than it being closed, thick and high. But I waited and cried and cried when I was actually induced. Needlessly — the induction was actually really easy!

If you want a more “natural” birth that is valid. There is some middle ground:

• Get NST’s weekly, possibly also a BPP to check on baby (I talk more about 3rd trimester testing in lesson 2 in here)
• Setting an appointment in a couple of days to consider it again (and re-look at the current situation — things can change rapidly in those last few days)
• There ARE things you can do to prep your cervix in advance (best done starting at 36’ish weeks, but you can try at any point after talking with your provider.
• Doing your kick counts — SO IMPORTANT to do these correctly and it can prevent stillbirth — I have a kick count cheat sheet here:

It feels like people think birth is very black and white, and while your provider may encourage an induction, it doesn’t mean you have to take one if you really don’t want to (there is a lot of grey area) — but it is important to talk about your risks and then some of the middle ground I mentioned above. And remember you can always change your mind. If an induction starts to feel more right, don’t be afraid to call them!

So, what do you think you’ll do? Tell us in the comments. I think it’s good to learn from others — see how they made THEIR choice and figure out how to manage things for yourself. I also found this very helpful handout made by a clinic in Canada to talk more about your risks if you want more info!

Evidence based birth also has an article on this that you might find helpful too!