Routine Planned Cesareans in Older Mothers Do More Harm Than Good

Many care providers push strongly for elective (planned) cesareans in older moms. However, a recent study challenges the wisdom of this common practice.

This extremely large study confirms that planned cesareans as a routine intervention for older moms is a bad idea. It increased their risk for infection, hysterectomy, kidney failure, cardiac arrest, and death.

This is an issue close to my heart as I was an "AMA" (Advanced Maternal Age, or 35 or older) mom for three of my four pregnancies.

In many practices, a woman like me ─ an older "morbidly obese" mother with a prior cesarean ─ would have faced intense pressure for a planned cesarean. I was fortunate to have care providers that didn't pressure me to have a cesarean just because of my age or weight. (Then again, I purposely chose providers who utilized a more low-intervention model.)

But the pressure for a planned cesarean can be quite strong on older mothers in many practices, especially if the mother is a first-time mom or received fertility treatment. One study found four times the rate of elective cesareans in older first-time moms. But why?

Some doctors see vaginal birth in an older mom as so risky that they prefer to just bypass labor altogether and plan a cesarean. Although the risk for stillbirth does seem to go up somewhat as women age, recent research confirms that this risk is quite modest (and not all research finds an increase in risk). Most healthy older women will do just fine.

Furthermore, a recent study confirms that the difference in outcomes between planned cesareans and planned vaginal births in older moms is quite small. Each choice has its own pros and cons to consider.

Risks probably increase as a woman ages; a woman of 54 probably has a much different risk than a woman of 41. However, many women with very advanced maternal ages have safe vaginal births too. Age alone should not be used as an absolute guide for a planned cesarean.

Although the risk for needing a cesarean during labor does increase as a woman gets older, the research shows that the majority of older women who are given a chance at having a vaginal birth actually do give birth normally. Giving birth under the care of midwives or in a non-obstetric unit setting may improve chances for a vaginal birth in older women who labor.

That is not to say that a planned cesarean is never appropriate in an older mom, only that the decision should be a nuanced one. Risks are higher in those with multiples, with those who have their first pregnancies after 40, and in those who required fertility treatments. Older women who have serious pre-existing health conditions, who have multiple major risk factors, or whose babies do not seem to be growing well have a much different risk profile than an older woman who is healthy, has no pregnancy complications, and has a healthy baby who is growing well.

It would be nice to see further research that provided concrete quantification of absolute risks at various ages in combination with various risk factors. That would be more helpful in guiding decision-making.

Still, all the factors must be considered and birth decisions should be made by the woman and her providers together. The decision should never be imposed on a woman by her provider; age does not negate a woman's right to personal autonomy in her medical decisions.

The bottom line is that routine use of a planned cesarean in older women simply because of age puts that mother's health at risk. Better to have the mother go into labor and see how labor goes. A cesarean can be done in labor if needed, but this very large study shows that routine cesareans for age leads to greater harm overall.

As the authors of the study conclude:

Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.

For an excellent review of the overall research around pregnancy in ages 35 and older, please see this article.


Reference

Matern Child Health J. 2016 Jul 29. [Epub ahead of print] Effect of Planned Mode of Delivery in Women with Advanced Maternal Age. Lavecchia M1, Sabbah M1, Abenhaim HA2,3. PMID: 27473092

OBJECTIVES: The purpose of this study was to determine the prognostic value of planned primary elective cesarean section versus planned vaginal delivery in women with advanced maternal age. METHODS: We conducted a population-based, retrospective cohort study using the United States' Health Care Cost and Utilization Project's Nationwide Inpatient Sample to evaluate maternal outcomes in women with advanced maternal age delivering from 2003 to 2012. Healthy women who underwent primary elective cesarean section constituted a surrogate for low-risk planned cesarean delivery. Logistic regression was used to compare outcomes between women with planned cesarean and planned vaginal delivery. RESULTS: Among seven million births, we identified 442,067 deliveries in healthy women with advanced maternal age. The planned cesarean group comprised 7.96 % of women in the cohort. When compared to healthy women in the planned vaginal group, women in the planned cesarean group had a significantly higher mortality ratio (2.56/10,000 vs. 0.44/10,000, p < 0.01). The planned cesarean group was also at higher odds of numerous complications, including peripartum hysterectomy OR 1.81 (1.36-2.40), p < 0.01, cardiac arrest OR 5.39 (4.54-6.38), p < 0.01, acute renal failure OR 3.39 (1.78-6.46), p < 0.01 and sepsis OR 2.27 (1.25-4.14), p < 0.01. CONCLUSIONS FOR PRACTICE: Planned cesarean section is a key factor significantly influencing maternal morbidity and mortality in healthy women with advanced maternal age. When possible, planned cesarean deliveries should be avoided in this population.

Cesarean Rates: Debunking the Mother-Blaming

It's April, Cesarean Awareness Month, so I'll be blogging about several cesarean-related topics this month.

Let's start off with an interesting video from Eugene DeClercq about the rise in cesarean rates. The video was done about data through 2009, so it doesn't have the most recent information in it, but it still has some valuable observations and commentary.

First, look at the cesarean rate graphs above.  Notice the c-section rate in 1970 vs. 2010.  Huge increase.  This is not all bad, as some babies and mothers are undoubtedly saved by cesareans. However, a too-high rate exposes mothers and babies to significant risks, presenting more risks than benefits.  So what we need is to find the right balance.

It's important to notice that the increase in cesareans hasn't been steady. It exploded in the late 70s and early 80s, dipped in the late 80s and early-to-mid 90s when there was pressure to reduce rates, and then steeply increased again until just recently when it leveled off a bit for the first time in years.  This fluctuating rate is important when examining the usual mother-blaming excuses for why the cesarean rate has risen over the years.

DeClercq debunks the usual excuses given by many in the maternity care community for why the cesarean rate has risen so much, including:

• Women are too old
• Women are having more twins
• Babies are getting bigger
• Women are requesting more cesareans

DeClercq addresses and debunks each of these.

For example, he notes that the trend towards older mothers slowed greatly a while ago, as did the trend towards more twins.....yet the cesarean rate continued to rise strongly afterwards. It wouldn't have done so if these factors were really what was pushing the rise in cesareans.

And in fact, babies are NOT getting bigger.  However, our management of big babies has changed.  As Henci Goer and CNM Amy Romano note in their book, "Optimal Care in Childbirth":

Cesarean rates have increased in all weight categories, the incidence of macrosomia declined from 1990 to 2000, and cesarean rates with macrosomia have soared: U.K. physicians delivered only 3% of babies weighing 4000 g or more via cesarean in 1958, while U.S. obstetricians today may perform cesareans on as many as half the women with babies of this size.  

And most women are NOT requesting elective cesareans.  While there are some women who do want elective primary cesareans, the number of these women is quite small, probably less than 1%.  So this factor can't be blamed for the rising cesarean rate either.

DeClercq also addresses the common defensive reply from some OBs that "There is nothing wrong with a high cesarean rate," because they feel a cesarean is the best way to guarantee a good outcome.  Turns out it's not.  Non-indicated cesareans increases risks for both mothers and babies. What a shock.

DeClercq is a professor at Boston University School of Public Health, and has an MBA and a PhD.  He's not afraid to speak his truths, whatever the audience.  You have to love his Baaawstan accent, but he has a great way of being able to communicate complicated concepts in simple and understandable ways.  I'm a big fan.

I saw him speak at an ICAN conference a few years ago.  I was quite impressed by him. He's a data wonk, but a layperson's data wonk as well as a data wonk's data wonk (if you know what I mean). I like that he can communicate effectively both with the statisticians/medicos and with the general public ─ without dumbing things down.

An Unquestioning Eye Towards Obesity?

That doesn't mean we agree about everything. In that lecture at our ICAN conference, he pointed out the problems with blaming women for the rise in cesarean rates, and debunked everything but obesity.

He noted that many doctors are blaming increasing cesarean rates on the "obesity epidemic." When he looked at the data, he found that high-BMI women do have high cesarean rates and have for a while. So he basically said there might be some truth to obesity being tied to a rise in cesarean rates. Augh!

Yet Goer and Romano point out in their book that, like the trends in older mothers and twin births, the rise in maternal weight leveled off a while ago, yet the cesarean rate kept on rising:

The relationship between maternal weight and cesarean rate cannot be ascertained directly, but the proportion of high-weight women increased from 1991 to 1996 while cesarean rates were falling and held steady from 1999 to 2004 when cesarean rates were once again on the rise.  

This casts doubt on the idea that obesity is to blame for the rise in cesarean rates.

I'd also point out that while it's true that high-BMI women have a high cesarean rate now, he didn't go back far enough into the past.  If you go back far enough, high-BMI women didn't have cesarean rates anywhere nearly as high as now, and often had very similar cesarean rates to average-BMI women.

I think that debunks the idea that obesity itself causes a high cesarean rate, and suggests instead that the highly-interventive way obese pregnancies/labors are now being handled, with more intervention and a lower surgical threshold, has more to do with higher cesarean rates in obese women.

In other words, it's how the management of obese women has changed that has impacted the cesarean rate, rather than obesity itself, and perhaps a more realistic solution than universal weight loss is to change the way those pregnancies are managed instead.  That will help lower the cesarean rate in this group.

In other words, yes, the cesarean rate in fat women is high.....but it probably doesn't have to be that way.  If we change the over-interventive way we manage pregnancy and labor in obese women, then that will lower the c-section rate in them, and in turn may have a modest influence on the overall cesarean rate.

I've written about this many times before on this blog and elsewhere.  Rather than repeat the information here again, I've included links to articles I've written about the idea that obesity causes cesareans and an increase in fat mothers automatically necessitates a high cesarean rate:

• Supersized Women and Cesareans: A Tale of Two Cities - blog post comparing two recent research studies with similar populations (BMI of 50 and up) but one had twice the cesarean rate of the other. If obesity were an intractable "cause" of cesareans, their cesarean rates should have been similar, but one was much higher, nearly twice the rate of the other. Obviously, management is relevant too
• News Flash: Labor Managed Differently in High-BMI Women! - blog post discussing a recent study that found that the labors of high-BMI women had more interventions, were intervened in earlier, and had a lower threshold for surgery.  When interventions were controlled for, the difference in cesarean rate was far smaller.  In other words, it's not just about women's obesity, it's also about the way our labors are over-intervened in and the fear level among some providers
• The Fat Vagina Theory: "Soft Tissue Dystocia" - blog post debunking one of the most common reasons given for a higher cesarean rate in obese women, Soft Tissue Dystocia (adipose tissue crowding the vagina and not letting a baby pass)
• Ghettoizing Fat Pregnant Women - blog post decrying the new trend to limit fat women's choices in birthplace, care provider, and birth options, solely by BMI
• Scapegoating Fat Women Once Again - blog post debunking yet another media press release blaming fat women for the rise in cesarean rates and calling for a more nuanced (and less mother-blaming) approach
• Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery - article for the Our Bodies, Ourselves website, with practical ways that women of size can lower their risk for a cesarean and increase their chances of a VBAC
• Avoiding Surgery: Lowering the Cesarean Rate in Big Moms - article I wrote for a healthcare consumers e-zine about lowering your risk for a cesarean

Finally, for care providers reading this blog, I'd suggest reading the series I wrote on the Science and Sensibility blog last year. While acknowledging the potential risks of obesity and pregnancy, it also suggests rethinking the paradigm with which most care providers approach obese pregnant women.

Science and Sensibility: Rethinking the Obesity Paradigm: An Insider's View

• Part I: Discussing Risk

• Part II: Analyzing Research

• Part III: Preventing Complications

Declercq is right that cesarean rates are elevated in high-BMI women, but they don't have to be.  It's not a causal relationship. And it's not what drove the rise in cesarean rates in recent years.  I wish he would acknowledge that, and the fact that cesarean rates in this group can be reduced.

If the desired end is improved outcomes for women of size and their babies, then we need to consider all possible management options for them, not just the highly-interventive management style currently used for them, and individualize our approach based on the actual needs of the woman.  

Yes, some obese women will have complications and require more interventive care, but many will not, and we do considerable harm (via very high cesarean rates, risky inductions, and more iatrogenic premature births) when we force highly-interventive management on all obese women, as the trend towards "bariatric obstetrics" does.

Save the high-intervention management for those cases that truly need it; utilize the low-tech tools that work well to lower cesarean rates in other groups (fewer early inductions, more quality labor support, more attention to fetal position and fetal re-positioning techniques, more patience in labor, fewer automatic repeat cesareans, etc.). In that way we can likely bring down the cesarean rate in women of size too.

Care providers (and public health advocates) must stop shrugging their shoulders and writing off women of size as a lost cause in the cesarean department.  A high cesarean rate is NOT endemic to obesity if we change our management of it, our fear of it, and our nearly-automatic reach for the scalpel when a fat pregnant women walks into the hospital.

Final Thoughts

Many care providers have excused the rising cesarean rate by blaming mothers.  According to them, women are too old, too fat, gain too much weight in pregnancy, have huge babies, have too many multiple births, or are requesting all these cesareans.

No, these factors are not entirely irrelevant, but by and large they are NOT responsible for the tremendous rise in cesarean rates in recent years.  As Goer and Romano note:

U.S. cesarean rates have increased sharply at every maternal age, in every ethnic group, and for every demographic or medical risk factor.

This is not a matter of a rising tide of high-risk mothers driving up the cesarean rate, but rather a deep and increasing trend towards more intervention (and a lower surgical threshold) in ALL groups.

By blaming mothers, caregivers avoid taking responsibility for their own actions which have pushed up the cesarean rate. 

The induction and "pushed birth" epidemic, the over-intervention in normal labors, the lack of support for vaginal breech birth, the virtual abandonment of VBAC, the loss of skills in manually turning poorly-positioned babies, the lack of patience during labor, the increasingly narrow definition of "normal," and the lowering of surgical thresholds have all been caregiver-driven reasons for the rise in the cesarean rate.

Eugene DeClerq has been one of the leading voices pointing out the flaws in blaming mothers for the rising cesarean rate, and bravo to him for doing so.  We need MORE respected voices speaking up and pushing back against the mother-blaming culture of many maternity care providers.

Unfortunately, the one finger-pointing he doesn't seem to question is obesity.  I wish he would apply the same questioning eye to the historical data on cesareans in obese women that he does to other possible "causes."  I'm tired of obesity-blaming getting a free ride (no questions asked!) from even the best public health advocates.

However, I'm pleased to report that a few researchers and childbirth advocates (like Goer and Romano) are beginning to push back on this issue.  Let's hope this is the start of a new trend.

Even though Eugene and I don't see completely eye-to-eye about this one issue, I still find much to admire in his writings and his research analysis.  He has a lot of valuable things to say about cesarean rates and birth in general, he says it in a very understandable way, and we need to listen carefully to it.

Now if we can only get him to dig a little deeper on the obesity question....


References

Pediatrics. 2003 May;111(5 Pt 2):1181-5. Contribution of excess weight gain during pregnancy and macrosomia to the cesarean delivery rate, 1990-2000. Rhodes JC, Schoendorf KC, Parker JD.  PMID: 12728135

OBJECTIVE: After declining for many years, cesarean delivery rates recently increased. To explore whether this increase is associated with excess weight gain during pregnancy, resulting in macrosomic infants who require cesarean delivery, we examined trends in excess weight gain, macrosomia, and cesarean delivery...CONCLUSIONS: Excess weight gain and macrosomia do not seem to be the primary factors that contribute to the recent increase in cesarean delivery because cesarean delivery rates have increased in all weight gain categories and macrosomia rates have decreased steadily from 1990-2000. Nonetheless, women who gain excess weight account for a growing proportion of cesarean deliveries because their relative numbers have grown.

Am J Public Health. 2006 May;96(5):867-72. Epub 2006 Mar 29. Maternal risk profiles and the primary cesarean rate in the United States, 1991-2002. Declercq E, Menacker F, Macdorman M. PMID: 16571712

OBJECTIVES: We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002. METHODS: US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined. RESULTS: More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers' medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates. CONCLUSIONS: Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.

J Matern Fetal Neonatal Med. 2013 Apr;26(6):547-51. doi: 10.3109/14767058.2012.745506. Epub 2012 Nov 28. Cesarean delivery in obese women: a comprehensive review. Wispelwey BP, Sheiner E.  PMID: 23130683

BACKGROUND: Obesity (BMI ≥30) is a significant independent risk factor for many gestational complications, including cesarean delivery (CD). While CD rates are increasing in women of every BMI, the trend is more pronounced as maternal weight increases. OBJECTIVE: This review seeks to describe the risk modulators that explain the high prevalence of CD in obese women, as well as to discuss the excess complications of the procedure in this group of parturients. In assessing the rationale for the procedure and weighing this against the excess risks involved, a clearer indication of when to perform CD in obese women might be developed. RESULTS: A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD. CONCLUSIONS: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.

J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963

BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models. RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P < 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.

Thoughts for the Old, Fat and Pregnant

Picasso

This is a comment turned post from here.*

A fat woman shared on a forum that she was unexpectedly pregnant in her 40s and was asking for resources and hints on pregnancy in this situation.  Several folks responded by recommending my sites (thanks for recommending me, folks!), which alerted me to the post.

I left a comment about things to think about as a fat, old pregnant person.  Then it struck me that I really should expand on this for my blog!  Who knows this topic more personally than I do?

I know pregnancy as a fat and old person.  I had three of my four children at "advanced maternal age" (35 or over) and my last was at age 42.  I was "morbidly obese" for all four pregnancies.  I know pregnancy as an old, fat chick.

And having done it several times, I definitely have some suggestions for things to consider for those contemplating the journey.

Find Your Tribe

Honestly, pregnancy as an old fat chick was really no big deal, at least to me.  My babies were healthy every time, and everything was fine.  Did I worry?  Yes, but what mother doesn't?  I didn't obsess about age.

The doctors, on the other hand, were a different story.  Some saw me as a ticking time bomb.  They particularly feared what they saw as the additive risks of being both an older mom and a morbidly obese one.  They slated me for all kinds of extra tests, induction of labor, and extra monitoring. They assumed that I would develop a complication, not that I might develop one.

I was pressured into the high-tech, highly-tested route with my first child (ironically, the only one not born at advanced maternal age), and was traumatized by the fear-laden, interventive "birth" that followed. When I saw that even more interventions were being suggested for the next pregnancy, based on my age, I bolted.  I found that my sanity was better when I found caregivers who didn't freak out about my age or size, which for me meant midwives.  I also had way easier births when I saw less-interventive caregivers.

However, that was me.  You have to find the level of care that YOU are comfortable with. I found I strongly preferred the less-interventive care model, but not everyone does. Some older or bigger moms are comforted by more intervention. Some just want it. A few truly need it. There's no "right" or "wrong" approach here, just one that aligns with your personal birthing preferences and medical needs.

Therefore, I'd recommend exploring different birth options and figuring out ahead of time which care model you prefer and which is appropriate for your unique needs.  (You can read more about that here.)  Interview several types of care providers, ask lots of open-ended questions about their protocols for you given your age and size, then make a decision based on their answers and your intuitive reaction to the provider and his/her practice.

Be An Educated Consumer

Go into your provider interviews knowing that it's true that there is an increased risk for certain complications when you are an older mom.  There are higher rates of blood pressure and blood sugar issues, for example, and higher rates of birth defects.  And it's true that there is an increased risk for these things as well when you are "obese."

However, being at an increased risk for a problem does not mean that this risk will occur, only that it is a possibility.  The question is how your provider responds to this possibility.

Does the provider intend to order every test under the sun?  Is he/she comfortable with you declining tests?  Or wanting a particular test?  Does the provider truly provide informed consent about tests?  The key is to become an educated consumer about the various tests and procedures that may be suggested to an older obese mother, to know the benefits and risks of each, and to weigh them against your own values.

For example, there will be lots of pressure for prenatal tests because of the potential for birth defects.  Media reports make it sound like the risk is huge, but the absolute numerical risk of a birth defect is small.  So while it's important to know that the risk is increased somewhat, it's also important to keep that risk in perspective.  The vast majority of old moms, fat moms, and old fat moms will have healthy babies.  

Remember, all prenatal tests have pros and cons. Some providers downplay the potential risks (i.e., miscarriage), and women only come to appreciate these risks after they have experienced them. Some of these tests have high false-positive rates, and may create a strong fear that something is wrong when nothing actually is.

On the other hand, prenatal testing has potential benefits. It can be helpful to know about certain conditions ahead of time because some problems can be fixed in utero. Or additional plans can be made for the birth based on baby's condition, like giving birth in a hospital with a level III neonatal care unit, or having certain specialists immediately available at the birth.

Some couples feel it is best to know about problems ahead of time so they can become more informed about the baby's diagnosis, grieve the loss of a "normal" child, and therefore be more ready to welcome that unique baby into the world at its birth.

However, this knowledge can be a double-edged sword. Some parents feel like their experiences of pregnancy and birth were tainted by foreknowledge of a baby's problems, and that knowing of even very minor problems took much of the joy and anticipation out of their pregnancies. And all these tests raise the specter of what you would do if tests indicated a problem.

So the prenatal testing decision is a complex one. Parents need to be sure they really understand the following issues before any prenatal test takes place:

• What is being tested for
• What the test measures and how accurate it is
• The difference between a screening test and a diagnostic test
• What it means if they get a non-reassuring screening test result
• What their choices would be if they had a non-reassuring test result
• What further testing might be available
• What kind of possible treatment might be available if a condition did exist
• Whether this information before birth would be an advantage or disadvantage to them
• What they would do with the information once they got it

Some older and larger moms choose to have these tests, some don't. Some love the tests, some do not.   It's really a very personal thing.

I was pressured into having all the prenatal tests in my first pregnancy and had a terrible experience with them, so I chose much more limited testing in future pregnancies, despite an older age each time.  However, I did choose to have at least an ultrasound each time, so I didn't refuse all testing either.  I found a middle ground that met my comfort level and needs.

Like me, some women feel that these tests are a mixed blessing and choose to opt out of them or to use them in limited ways.  Other women have good experiences with these tests and felt very reassured by having them.

No one can tell you what's right for you in the prenatal testing realm, but do know that it's always YOUR choice how much and what testing to do.  You don't "have" to do anything just because of your age or weight.  Research the issue and then find a provider who is supportive of your choices.

(You can read more about certain types of prenatal testing and how they are impacted by a high BMI here.)

Consider Delivery Protocols

Pressure for early delivery can be intense in both older pregnancies and in the pregnancies of women of size.  This intense pressure to deliver no later than the due date means the induction rate in both groups is very high, and is intricately related to the high cesarean rates in these groups.

Much of the pressure for early delivery is because of the fear of stillbirth. Providers rightly point out that the risk of stillbirth at term is higher in older mothers, and is probably higher in high-BMI women too (although some research suggests that this risk may be more limited to those with growth-restricted babies, or is particularly strong in black women).

However, while elevated, the risk for stillbirth in these groups is still relatively low in absolute numerical terms, even for the oldest mothers.  It is a concern, but one that must be kept in perspective.

This concern over stillbirth leads many providers to routinely induce all older women and heavier women at 39-40 weeks, even when there is no other medical indication for induction.  The question is whether early induction helps lower the risk for stillbirth, or whether it stresses the baby and leads to more complications than it alleviates. Certainly, it likely strongly increases the chances for a cesarean.

In other words, is the risk of continuing the pregnancy higher than the risks of an induction?  Frankly, that is not clear at this point.  Most care providers simply assume inducing early will lower stillbirths in these groups, but more research is needed.  However, there are alternatives.  For some providers, the increased risk for stillbirth is simply seen as an indication for more prenatal monitoring, with early delivery only being considered if the results are not reassuring. This will likely catch some cases where stillbirth might be preventable, but realistically, will not prevent all stillbirths.

Some women are uncomfortable with any possibility of increased risk of stillbirth, and are happy to agree to early induction or even elective cesareans, despite the known potential harms of inductions and cesareans.  And of course, that's their right.  These women will be most comfortable with the delivery protocols of most OBs, and will probably feel reassured by frequent prenatal monitoring near term.

On the other hand, many women recognize that even with a somewhat elevated risk, the likelihood of stillbirth is still quite low and they are comfortable not rushing the birth process at all.  These women are more likely to be comfortable with a hands-off midwife or OB, one who won't require delivery by a certain date on a calendar.

Either way, it is very important for you to be "in sync" with your provider's philosophy and protocols for due dates in older or heavier women.  Ask about their concerns and protocols ahead of time so there are no surprises.  Don't be afraid to switch to a provider that is more in line with your preferences.  It's better to switch now than to try and fight a protocol you don't want later on.

If you choose induction at 39 or 40 weeks, remember that inductions are more successful if done when the cervix is ripe and the baby is in a good position for birth.  Ask what your Bishop's Score is and if the baby is anterior.  See if you can hold off inducing if your Bishop's Score is low, and do what you can to ripen the cervix ahead of time.  Serial induction (doing a slow induction over several days) and avoiding breaking the water too early may increase the chances for a vaginal birth.  There is also research to suggest that more patience may be needed in the labors of induced mothers; as long as baby is doing well, make sure your provider is not too quick to intervene surgically.

If you think induction is likely because of a medical issue or a strict due dates protocol from your provider, acupuncture can help gently prepare your body for labor. That way, if an induction happens, it is more likely to be successful.  The key with acupuncture is to allow it enough time to work.  It's not like medical induction, meant to work in a short period of time. It's most effective when it's done gradually, over a period of several weeks, rather than done once or twice near the very end of pregnancy when there's no time left.

It's important to know that there are also providers who are supportive of waiting for spontaneous labor, even in older, heavier women.  You may have to ask a lot of questions and interview a lot of providers to find one, but they are out there if you want one.

Because I was healthy (no blood pressure or blood sugar issues) and my baby looked good, the midwives in my last pregnancy were comfortable waiting for spontaneous labor, even though I was 42 and "morbidly obese."  Baby was born at almost 43 weeks by LMP; just over 41 weeks by adjusted due date.  We were both fine, and it was my easiest birth by far.  However, my choices are my own and may not be right for you.

It's not easy to know what to do about due date protocols when you are in a group that is at increased risk for stillbirth.  Early intervention may sometimes save lives, but that may come at a price of a very high c-section rate and all the harms that can come from inductions and cesareans.  Bottom line, it is a question that deserves careful contemplation and great care when choosing a provider.

Be Proactive

Although no one can promise mothers of any age a perfectly healthy pregnancy, being proactive in your health habits may increase your chances of avoiding the more common complications.

Primary among these is the importance of getting good nutrition and regular exercise. Older women and fatter women are both at increased risk for blood pressure and blood sugar issues, so a woman who is both older and fat is at significant risk for these issues.  The good news is that nutrition and exercise can go a long way towards reducing those risks.

For example, some research suggests that regular, daily exercise can lower the risk for blood pressure/pre-eclampsia issues.  Some research also suggests a similar effect for blood sugar issues.  The beneficial effect is marginal in average-sized women but may be more powerful in women of size, so that's even more reason for older, heavier women to be proactive about this.

Sensible nutritional hints, like avoiding large amounts of simple carbohydrates at once, eating a lower-glycemic or moderate carb diet, and eating protein with your carbs may also lower your chances for blood sugar issues. There is no need to be neurotic about this, but a sensible, moderate approach is a reasonable goal that may help reduce risks.

For those at particularly high risk for pre-eclampsia (i.e., women with a history of prior pre-eclampsia, a family history of it, those with blood clotting issues), there may be other options to consider as well.  For example, some research suggests that low-dose aspirin or supplemental calcium may be helpful in lowering the risk for pre-eclampsia in high-risk women.

For those women at particularly high risk for gestational diabetes (i.e., women with severe PCOS, a strong family history of diabetes, or preexisting impaired glucose tolerance), other choices might include considering metformin or supplements like chromium, d-chiro inositol or myo-inositol prophylactically.

However, decisions on medications and supplements are ones that should only be considered in conjunction with your care provider, since they also may carry risks as well as benefits. Discuss these carefully before proceeding with any of them.

The benefit of a strong focus on nutrition and exercise is that a reasonable lifestyle approach has many potential benefits and very little risk.  For those at particular risk for complications, further interventions may be helpful, but pros and cons have to be weighed first.  Good nutrition and regular exercise doesn't have that downside.  It's one of the strongest and most effective things you can do to increase your chances of a healthy pregnancy and baby.

If you can avoid complications like gestational diabetes or pre-eclampsia, that goes a long way towards giving you more choices during your birth.  Develop those complications, and your choices are more limited. So it is vitally important to be as proactive about your health as possible during pregnancy.

Consider Body Work in Pregnancy

There's no question that pregnancy is harder on a 40-year-old body than it is on a 25-year-old body.  Life is just harder on an older body than a younger one, so you usually have more aches and pains to deal with when you are pregnant at an older age.  However, that doesn't mean that pregnancy in a 40-year-old is all that bad.  The key is to stay as active as you can, and to not be afraid to use bodywork to help you be more comfortable.

I personally found that regular chiropractic care (from a chiropractor with special training in pregnancy, like those with Bagnell or Webster Technique training) was important in helping my old pregnant body be more comfortable. It was also key in promoting a good fetal position (which makes birth a LOT easier, trust me). I think it's especially important for those with a history of car accidents, significant falls, sports injuries, or other body trauma.  Honestly, chiropractic care was one of the most important things I did for myself as an old, fat pregnant chick.  However, as always, it's a choice up to the individual.

Prenatal massage is definitely a wonderful treat for any pregnant body, young or old, and can also help with aches and pains.  There are many massage therapists who specialize in prenatal massage, and it's well worth looking into if you can afford it.  If you can't afford it, you might be able to find a massage-therapist-in-training who would work on you for free or for a reduced fee.

If you have a history of body trauma or experience significant pain in pregnancy, gentle myofascial work may be a good addition to traditional relaxation massage.  Craniosacral Therapy is another complementary bodywork technique that many women find helpful.

Acupuncture can be useful for the aches and pains of pregnancy in an older body too. It can also be extremely effective for other pregnancy complaints like blood pressure issues, heartburn, morning sickness, and headaches. I used acupuncture in my last pregnancy and found it helpful for aches and pains, for heartburn, and for headaches. I also used acupuncture during my labor for pain relief and encouraging a good labor pattern.  Although I didn't use it for ripening the cervix, it can be helpful in preparing the body for labor, for those being pressured to give birth by a certain date, as noted above.

(Not all acupuncturists see pregnant women, so check around with your local doulas and midwives to get a recommendation for one comfortable with pregnancy.)

Bodywork is one of the kindest things you can do for your body in pregnancy, especially as you get older.  If your budget allows it, it can be a wonderful addition to your prenatal care.  If your budget is strained, remember that many bodyworkers will utilize a sliding scale fee or bartering if asked, because they feel it is so important for pregnant women to receive this work.

Other Issues to Think About

Older women and heavier women may be more prone to thyroid issues during and after pregnancy, so ask your provider to watch your thyroid levels carefully, especially if you have a history of depression or PCOS.  Thyroid levels can quickly go out of whack in pregnancy or postpartum in some folks, even those who never had a problem with it previously, so it's worth monitoring for carefully.

If you tend towards depression and are concerned about post-partum depression (PPD), some people swear by placenta encapsulation for preventing PPD.  However, this is a little more on the "alternative" side of the spectrum, so you might want to choose a midwife if you are interested in this.

Final Thoughts

Don't let the scare-mongers frighten you away from being an older mother or a fat mother.  It's definitely doable, and many of us have done it.  You can too.

Certainly, it's important to be aware of the possible risks of being an older mom (or a heavier mom), but remember that being a member of a group at risk for something doesn't guarantee anything for an individual's outcome.

However, it is a call to be particularly proactive about your self-care and your choice of provider.

• Find your tribe by finding a care provider who aligns with your birth preferences and will honor your birthing choices
• Be an educated consumer by doing your research on prenatal testing, delivery protocols, and birthing choices
• Be proactive in your health habits, with special emphasis on nutrition and exercise
• Look into bodywork for making pregnancy more comfortable and your body optimally functional during this important time

Best wishes to anyone out there thinking about becoming a mother.  Although it can be scary to read about risks, remember that most mothers, regardless of age or size, do just fine.

Be aware of the risks, but focus your energies on proactive behaviors and the knowledge that most women will have good outcomes, whatever their risk factors.

Old or fat or both, you CAN do this. Enjoy your new direction in life, and don't spend much time worrying about what-ifs.  Being a mom can be a tumultuous journey, yes, but it's also one of life's greatest blessings.  Don't be afraid to embrace it whole-heartedly, whatever your age or size.


**Do you have any experience as an older mom of size?  Do you have any great websites with information for older moms?  Share your stories or resources in the comments section.