This week we are breaking down the terminology stigma around "AMA" or advanced maternal age, exploring the nuances of risk management in pregnancies over the age of 35, & highlighting the benefits that should be discussed in any conversation around age & family planning.
Ray Rachlin of Refuge Midwifery shares how their personal practice centers patient autonomy through fertility support, pregnancy monitoring, & birth care for this population, how they discuss relative risk surrounding age with their otherwise low-risk clientele, and how we can change the narrative around pregnancies over the age of 35.
This week we are breaking down the terminology stigma around "AMA" or advanced maternal age, exploring the nuances of risk management in pregnancies over the age of 35, & highlighting the benefits that should be discussed in any conversation around age & family planning.
Ray Rachlin of Refuge Midwifery shares how their personal practice centers patient autonomy through fertility support, pregnancy monitoring, & birth care for this population, how they discuss relative risk surrounding age with their otherwise low-risk clientele, and how we can change the narrative around pregnancies over the age of 35.
Maggie, RNC-OB 0:06
Welcome to Your BIRTH Partners where our mission is to cultivate inclusive collaborative birthcare communities rooted in autonomy respect and equity i'm your host maggie Runyon labor and birth nurse educator and advocate and i invite you to join us in conversation as we step out of our silos, break down barriers and hierarchies, and step into the future of better birth care.
This week we are turning our attention to pregnancies over the age of 35 this is certainly a topic that we have developed bias around as a society as birth professionals and sometimes is internalized by many pregnant folks who are considering what our options around fertility and pregnancy as we get older so today we want to come on and have a chance to break down this issue and consider what the purpose is of discussing age with clients at different stages in their reproductive journey...when they are considering pregnancy, when they're already pregnant, and then once they are preparing to give birth. We want to talk about the terminology and how that has perpetuated stigma and adds often unnecessary anxiety at a time when so many people are already feeling hyper conscious of their body and their abilities. In addition there are several potential benefits of having children at a later age and those are so often left out of the narrative in discussions around family planning. There are a lot of great resources already that discuss the evidence around pregnancies over the age of 35 in terms of relative risk so rather than focusing solely on that we wanted to focus on the biases that we carry into this space, how those are perpetuated by the terms we use, and consider how pregnancy support can look in otherwise lowers pregnancy over the age of 35. And we have Ray Rachlin on to share their experience with this and explain more about how they hold this information, educate about risks and benefits, and support patient autonomy around this in their practice. On to the show!
All right so we are going to be discussing advanced maternal age or discussing any of the pregnancies that happen after 35 years and so on here with us is Ray Rachlin. If you want to remind so who you are real quick and we'll dive into that.
Ray, CPM 2:21
Yeah sure. I'm Ray Rachlin i'm my pronouns are she and they. I'm a certified professional midwife based in philadelphia and i do homebirth throughout the greater philadelphia area and south jersey and also a lot of fertility care of my practice as well as provider education
Maggie, RNC-OB 2:37
Great awesome so yeah so i think maybe if we could just first start by talking about like the terminology when we're looking at kind of like biases and how we're setting ourselves up as care providers and birth professionals to think about this and then also the impact that it has on those in our care i feel like the terminology piece around these pregnancies adds a lot of unnecessary stigma.
Ray, CPM 3:00
Yeah i mean i also personally try and use like gender inclusive language and like having ama and like not having an alternative to like advanced maternal age is like you know and also like i think there's like two kind of parts of the question the first is like on the language front you know we have this like idea of declining fertility which is true for some but not for many and also we see that like you know bodies change as they get older. Like we're more likely to develop diabetes as we get older and that's also true in pregnancy and then there's the question of stillbirth which we definitely see an increase of after 40, under 40 is more unclear, there's also genetic conditions things like that but in trying to, something like bmi, and trying to like capture who's at risk for more conditions we end up just being really offensive and rude to most people. Where like most people over 35 can like have healthy normal pregnancies, some are going to have additional complications and we're going to see that it increased rates but that doesn't does that mean we need to treat everyone over 35 or everyone over 40 as like a walking disaster no. And the language or like especially the geriatric pregnancy stuff you know really fuels the fire i'm like treating people like a potential bomb versus like they're having a pregnancy and maybe a little bit more likely to experience a complication but also probably not, because most pregnancies are not high risk.
Maggie, RNC-OB 4:21
Yeah oh absolutely I think being labeled geriatric pregnancy or an elderly pregnancy like feeling like a dinosaur walking into your pregnancy like that isn't adding anything positive to the experience and i don't...I assume that those terminologies were developed they felt convenient to whatever researcher was looking into it and i would love to see just like you said i would love to see a more like neutral term for it something that also like kind of flows more quickly so we could all be referencing it as something that is both like gender inclusive and also just more fact based and and not trying to make it into something that it isn't. I think that as you touched on too, is that I think when we consider all of these potential risks and the conditions associated, there are different things for like, fertility, pregnancy and birth. Do you want to speak a little bit during like, oh, when would you perhaps like to have a baby? There are a couple of different pieces within that, that that relate to like your odds of becoming pregnant versus your odds of having a successful pregnancy?
Ray, CPM 5:22
Yeah. So yeah, I think like, the first thing is like the kind of the the number of like, you know, 35 years being like this, like cliff of fertility, that data comes from milkmaids in the 1700s in France. So we have the general decline in fertility with age. And also, like, infertility in our society is really common, like one in eight people, or heterosexual couples will experience in fertility. So, you know, I think that there's a lot of things that are affecting egg quality, sperm quality life, we live in a very toxic environment, and those things are reflected in our genes. So you know, while we like, we do have like stricter criteria. So like that diagnosis of infertility comes up, like after 12 months of trying, if you're under 35, in six months, if you're over 35. And then if anyone like meets the diagnostic criteria, they're like, the general kind of counseling and fertility clinics, and that your chance to get conceiving on your own is 5% per cycle, which is like, scary and hard. But also, it is like hard for, like, you know, because like where are we getting this data? This data is, like, an infertility, we're primarily getting from people seeking infertility treatment, that does happen as people get older, as they also have better access to health insurance, you know, because of infertility treatment is not covered by lots of insurances. So there's still like, it's like, yes, egg quality can decline with age. Also, it's like not necessarily like the cliff that we all think of, it's just more like a gradual decline. And you might be a little bit more likely or even moderately more likely, but you don't know unless you try. But I think sometimes also, like egg freezing is sold as like a, you know, a solution to age and I don't, unless you freeze an embryo, like frozen eggs, don't always successfully like thaw and be made into embryos. So I don't always love that as like, an alternative is like perfect solution that you're going to have these young eggs as old as you want. Like, it's just, you know, bodies are imperfect, and also really resilient. And fertility is like a thing that we really can't control. Like we have, like, we can have some effect on with like, the way that we live, like, if we're getting sleep, if you're getting enough calories, if you're moving your body, if you're like reducing your toxin exposure, like environmental toxins, but it's a process that's largely out of our control, which is really hard in our society. And like the medical model, like we have some tools, but you know, they aren't like perfect fixes, either.
Maggie, RNC-OB 7:49
Yeah, absolutely, I do. And I wonder how that impacts the emotional, mental health piece of going into conception, if you're already feeling like you're carrying this weight of being that much older, and your eggs aren't, you know, like, they're maybe not going to work, and then people around you. Again, just because our society has been so focused on this, they're already talking about that, you know, other people when I was talking to a friend, when she was considering getting pregnant again, with her second, her mother was really adamant that like, you have to do that now or else. Like, this is a foregone conclusion, you're not gonna get pregnant again. And she really didn't want to space her children that closely. And so it just added this extra like, tension and feeling like she had already, she'd already failed. They haven't even tried to get pregnant, over 35. And already, they were like, behind the eight ball, I would love to see that change and how we're, like you said, how we're kind of presenting that cliff versus slope of fertility potential. Yeah.
Ray, CPM 8:52
Yeah. And I think like, you know, also like, some people will get pregnant on their own at 40. And will like, be fine, and other people will like struggle greatly at 32. Like there's not, there's no absolutes in any of this. I do think, though, that like, because of the way society set it up, like there's this, like, emotional pressure that comes with age, and like the feeling that you're already behind, which, you know, you don't know until you try.
Maggie, RNC-OB 9:14
Yeah, absolutely.
Ray, CPM 9:16
Like, it is true that people who like have a hard time getting pregnant, like people who have IVF pregnancies do tend to have more complications. And like, you know, as a midwife, I'm just like, here are the things that were preventing you from getting pregnant also going to show up and like, it'd be important to carry but like, we don't, we don't have clear answers on that either.
Maggie, RNC-OB 9:34
Yeah, absolutely. I think the other piece, so if you kind of can talk through a little bit, because I think that piece of how you explain this to clients to those in your care, like if you have someone who comes into care, and they are over 35 How do you kind of set up that discussion about what relative risks might be there?
Ray, CPM 9:55
Yeah, so over 35, you know, I mean, we counsel everyone on genetic screening so just like what your genetic screening options are, what they're looking for, like what you might do with that information and i think people who feel the pressure of age like are probably more likely to do some than others but you know others don't. They're like i don't you know this information wouldn't change my to do with this pregnancy and so we're still having an informed conversation about that you know and just like also having an informed choice conversation about gestational diabetes screening well because we do see that in higher rates and when we're doing normal prenatal care screening for blood pressure issues. You know between 35 and 39 we don't have clear guidance on like, we do see there's like this general slope of like we're maybe seeing increasing complications and then the thing that we're the most scared of is stillbirth and we still you know as a profession like no like we have never figured out how to keep all babies alive and I doubt we ever will, like we've never been more powerful than nature but we're like trying to identify like who's at risk and there's not a consensus and so some places do nothing other places do a lot. I think the arrive trial has changed things where everyone's like well let's just induce everyone at 39 weeks that's where we have the best outcomes but you know inductions are not without risk and also we're adding incredible amount of expense to the healthcare system without clear benefit that. it's not like we're lowering the stillbirth rate like the NICU outcomes weren't different in the arrive trial so it's really unclear and i say between 35 and 39 aside from like genetic screening gestational diabetes like just talking like yeah you're at increased risk like it's normal care. When someone's over 40 i do have a more intense conversation with them about advanced age and pregnancy and i often times i'm like let's start with evidence based birth article on AMA you know i think Rebecca Dekker and her team did like an incredible job really like pulling through like all this like really scary information to be like what are the actual risks and the actual like the general increased risk of stillbirth is 3.92 in 1000 and you know that's not nothing; it's higher if it's your first baby over 40, and it's like a little bit lower if it's not and then we talk about like what are the tool proriders are trying to use to catch this risk.
Maggie, RNC-OB 12:16
Yeah i mean i love the evidence based birth pieces i think it's really important in all of the work that Dr Dekker has done to really distill all of this like complicated and nuanced information in these research studies and call out the kind of were some of the gaps in what they were looking at. I was reviewing the article and you know getting ready for this podcast and it was one that they talked about like just the huge variety in some of the studies that have been referenced and the time period you know we have changed a lot in terms of our overall birth outcomes from the 50s 60s 70s till now so in some ways when we're looking at that evidence and then using that to like extrapolate to our population today it's apples and oranges you know to some point and that's outside of the the age discrepancy.
Ray, CPM 13:04
yeah it's like unclear and i think that thing i always like to kind of like send home to people is that you know like we do know that there's like a general increased risk over 40 and we have really mediocre tools to try to figure out which babies are at risk like we know some things like people who have growth restriction like those babies are at risk, people who have a genetic issue those babies are at risk people with gestational diabetes like those babies are at increased risk, but for everyone else like the people who actually have low risk pregnancies you know we're not sure and we're trying to figure out who by doing lots of ultrasounds, like lots of non stress tests and it's not clear that doing a lot of non stress tests improves outcomes. This puts people in this like challenging ethical quandary because like we don't know how to figure out like which babies are going to need help and which are not you know. And maternal fetal medicine practice or you know in a high risk or hospitals they're just like why would we go past 40 weeks like we know you know this the safest time for a baby to be born is between 39 and zero and 40 and six and you know since we do see stillbirth rates go up like the longer you're pregnant they're like why would we even try? But there's lots of reasons, you know? There's lots of reasons to stay pregnant just like there's lots of reasons to induce and you know like informed choice and shared decision making should be at the heart of all prenatal care, but it isn't always. When i think i feel the same way about increased monitoring where you know we don't have like clear good data that it's going to improve outcomes but you know like it might sometimes pick up a baby that's struggling and also more likely it's going to lead to an induction than it is going to prevent the stillbirth. and like where do people fall on the like how much monitor do you want to do, like how much information do you need, what's gonna make you feel like safe in your pregnancy or what if you had an adverse outcome like would you feel a lot of like regret and shame that you didn't do those things? Or would you feel like solid and that you're like, yeah, this is not gonna improve things. So why would I do it?
Maggie, RNC-OB 15:09
Yeah, absolutely. I feel like that's a theme, obviously, that we've talked about in some of these conversations is that coming back to that autonomy piece and actually having spelling out all of that for the client, so that they are able to choose what makes sense for for their risk profile and for what their desires are around birth? And what would I guess, you know, one of the things too, when, when I was talking to a couple friends about this, one of them said, like they actually incurred a lot higher costs with their ama pregnancy, because they had additional screenings and ultrasounds and everything that actually ended up to like, several $1,000 more than they otherwise had, because the way their insurance was covering for the birth, which is fine. But that didn't necessarily line up with what they actually felt like their risk was, how they felt like the pregnancy was going and was otherwise low risk. And so it ended up feeling that they were kind of pressured or coerced into doing all these extra tests that didn't actually line up with what they needed, and then cause some extra financial strain, that was not really appreciated when also welcoming a new baby into their family. So I think that piece of it too isn't you have to consider with like how the health insurance and reimbursement landscape is that sometimes when we're asking people to do all of these additional tests, like in addition to the the impact it potentially has on like, their well being in fetal well being is the like, the overall picture of how it's how often I have to take off work to come and fracture screenings, how are they paying for all of this? So that's like an important piece of it, too. And then if you can see a little bit for, like, from the home birth side? How does that impact? Like, are there...do you have a strict cutoff for in terms of if people are still able to birth at home based on age do you do you have any kind of like screening qualifications around that
Ray, CPM 16:59
I don't have an age cutoff, I do like do a formal informed choice conversation over 40. And like, we do talk about transferring for induction earlier, like sometimes maybe going 41 instead of 42 weeks of pregnancy. But you know, like people to be able to start labor at home like you need to be like really, really low risk. And we don't also don't have data if like, you know, differentiating between pregnancy stillbirth versus intrapartum stillbirth, so we don't actually like, once you're in labor, I treat you like every other person in labor. It's not like there is the point where babies like the placenta suddenly is pooping out and and if like the placenta starts to poop out, we're gonna hear that in the hearttones. So like that, yeah, we just kind of do like, yeah, if you make it to like spontaneous natural labor, we're just doing normal birth. Yeah.
Maggie, RNC-OB 17:45
I think what's interesting about what you just said to is your perception of the birth at that point. It's, it's equal, kind of feel like, right. Okay, so now we're in labor, you obviously have all the same monitoring that you're doing for everyone the same things you're watching for, you know, as a clinician, but I do think that broadly, in our society, it like that piece of it, the provider's perception of risk plays a huge role in how labor progresses, how they are, you know, "managed," I do think, and I know, it was, you know, reflected in some of the articles, I was reading that piece of whether the provider thinks like, Ooh, this is, you know, an AMA, this a older pregnancy, we've got, you know, placenta, that might be, you know, deteriorating, you know, the egg was older to begin with, all these different things that are kind of like, lining up in their head, kind of all, like those strikes against the pregnancy or against the birth, that changes the management piece of labor. And do you feel like that? Was that like, a very intentional piece of your practice of kind of, like, separating waste from that, then once you're in labor, you're kind of treating it like anything else?
Ray, CPM 18:49
I mean, I think that was just how I was trained, you know? Yeah, like, if someone has, like, you know, conceives, has a normal course of pregnancy, like, the chance of like, going from low risk to high risk during a birth is low, like most people that enter labor, low risk, stay low risk. And so people have been having babies for a really long time. And like, the point of having a provider is to like pick up when something is shifting, so that from that's going from normal to not normal, so we can treat it and like that's my whole job is to like, hold space for normal, and identify when not normal is coming up. And like, that's also going to be true for age, like do I hold a little bit more like, you know, the oldest person I've attended to homeless 46 and I definitely think about that pelvis and like, that pelvis has is a little bit more rigid than someone who's 36 or 26. Yeah, like so I think a little bit more about shoulder dystocia. Maybe I would even transfer more conservatively. I think, you know, something that maybe people don't realize homebirth midwives do is like we're sitting calmly and like smiling and like in my head, like I'm having a million thoughts a minute. I'm just like, Is this okay? Let me like, constantly like assessing and being very alert while like appearing very calm. And so yes, I'm always having a conversation in my head about, like, is so safe and appropriate, like, you know, is this like, is home like a safe and reasonable option? Or is it not? And also, like, I can kind of hold that and both use, like my clinical guidelines and experience to be like, are we in the range of normal? Or are we not? If we're not in the range? Normal? I don't want to be home.
Maggie, RNC-OB 20:25
Right? Absolutely. Yeah, I do. I like how you explain that piece of it. Because I do think there is that perception that homebirth midwives are sitting there attending birth, like in some ethereal zone, and maybe some are, but...
Ray, CPM 20:38
I feel like I just doing math in my head all the time, I'm like, okay, you know, this person was this dilation at this point. And then they're this dilation at this point, this is their rate of dilation. So if that point happens then we'll be here, and if not like, these, the points that I need to do these interventions, to, like, try and move things along with these positions, like, I'm just like, doing like math and physics in my head, like, constantly. And then like, yeah, it's taking this long, because it is, but like, doesn't mean like, my wheels aren't like turning like, you know, constantly.
Maggie, RNC-OB 21:08
Yeah, absolutely. What is it like that range of normal that it that is very large, in labor and birth, about, like, what is accepted, and what your, you know, kind of what your tolerance is for recognizing that and not feeling like you need to, you know, rush or control the process overtly. We touched on this briefly, was there anything else you want to add in terms of like, you know, we we know that there are outside of age, all those other factors in terms of like, diabetes, and preeclampsia other blood pressure issues? Like, those are potentially at you know, that risk obviously, is going higher? And that could be what is more what is impacting the pregnancy outcome? labor outcome, then, like, age as a separate entity that we can't totally, you know, take out of the mix? Do you encourage people to be kind of like more aware? Do you do anything extra around that to try to, like, decrease those risks?
Ray, CPM 22:01
Yeah so I think like, I, philosophically, I'm not a huge fan of treating things that aren't a problem. But I do like to counsel people on like, what are the things that we know have healthy pregnancy, like exercising like 150 minutes a week, so like, three to four times a week, you know, decreases pregnancy complication by 60%, like so we have really good evidence that like getting regular exercise is going to help you control your blood sugar and help you control your blood pressure, blood pressure issues, like lead to like preeclampsia growth restriction, like all these things that are going to like put you and your baby at increased risk. And then like counseling on like diet, and like doing a diet diary to folks and giving, like direct feedback around like, protein intake, vegetables, water, like how to actually, like, eat a well rounded pregnancy diet, I care way more about what people are putting on their body than the number on the scale. And also, like health history. So like I do sometimes use like herbs to help people who either have a history or have like creeping blood pressures, try and keep their blood pressure within a normal range. And, you know, always transferring if we get to, like above 140 over 90, but you know, sometimes, you know, with like herbs and exercise and lots of Epsom salt and, you know, dietary changes, like we can either like keep people's blood pressure within normal limits, or like keep their blood pressure normal for longer, which is also going to improve their outcomes. Absolutely.
Maggie, RNC-OB 23:26
Okay, great. That's really helpful. And then, I think as we were like, kind of wrapping it up, I want to just kind of also touch like, I think for people out there who have been feeling all of these kind of just like, there's all these things that can go wrong with a later pregnancy, that there's a lot of concerns, we have around there, I think we don't talk about like the potential benefits to people who have their babies later. And that those are like things that we can encourage and counsel people about as they are like considering what their fertility options if they're trying to think is it time, like do I need to start making a family right now? Or is there time for anything else that might be you know, going on in their life? I know I saw some you know really interesting answers about like, like you said, in just feeling more stable obviously, as we get older, potentially get more stable housing or jobs have been you know, family situation stuff and then also kind of the impact of like I was reading recently that there's some evidence to that like having your baby actually keeps you living longer like that the act of having a baby over 35 like it keeps you younger, and that they women who were able to have their last child after 33 are actually more likely to live to 95 and are twice as likely than those who had their last child before their 30th birthday. So there's like actually like a big like there's good evidence to that shows that like there are benefits as well to this not just like you might be okay, you might actually have other like positive things that come from it to that I think we should probably be like encouraging more clients.
Ray, CPM 24:48
Like kids have like higher literacy levels. You know, I think the thing that best prepares people to parent is to be as ready as possible, you know, and having unplanned pregnancies while they can be ready welcome and really joyful if you're like not ready emotionally physically financially spiritually it's harder and it's like harder on your mental health and that's harder to like attach to the child it's harder to parent you know i think i like in the realm of enthusiastic consent like i want people to like be able to like actively choose and be like i am prepared i'm wanting this and welcoming this and sometimes age can really offer that like i felt the things i want to do and you know like this is something i'm like really choosing this life change and everything that comes along with it and it's what a blessing to be able to really enthusiastically consent to you know like a really really really big change in like life and attitude and everything else.
Maggie, RNC-OB 25:47
Yeah absolutely yeah and i think i mean obviously that's what i think we hope for all people going into you know pregnancy that through that process they are able to get that feeling of feeling like yes they have the support that they need they are emotionally mentally prepared for this huge transition that does not happen at some magical time there is no universal time yet that ticking clock is pretend you know so there is it's not like oh at 30 or 32 years was to suddenly know like yes it's time to be a parent. I think because there's been just such a shift worldwide you know people having their you know babies later we're gonna keep continue to see more of that and you know because we have better access to fertility options to help people who you know who needed who haven't been able to conceive that that's you know that's going to continue and having more kind of confidence in caring for those people without feeling like there is a black cloud over their pregnancy will help everyone all around have a better better outcomes better experiences because we don't need to be carrying our like biases and baggage into someone else's ideal birth time.
Unknown Speaker 26:55
We don't.
Maggie, RNC-OB 26:57
Anything else you'd like to add on this, any other takeaways?
Ray, CPM 27:01
I don't think so i think we've had to cover the gamut you know it's hard because there's a lot of prejudice but i always want to say like you know if you get to labor like the birth part is normal it's like the pregnancy stuff is the one that like you have to make these like do more evaluating or making more decisions around but like the birth is the same yeah we don't have any evidence that it's different .
Maggie, RNC-OB 27:21
That's great perfect well thank you so much for having this conversation together
Ray, CPM 27:25
yeah thanks for having me
Maggie, RNC-OB 27:29
Thanks for tuning in we'd love to connect about what struck you about this episode how have you supported birth and pregnancies over the age of 35. If you are someone who had a pregnancy over the age of 35 how were you best supported by your providers? what were the things that were done or not done that moved your experience? we love to learn and grow alongside with you, please follow us at Your BIRTH Partners across social media and in particular we'd love to invite you to join us in our facebook group Your BIRTH Partners Community and there we have a chance to break down the topics for each week's podcast and work through some of the parts of applying these concepts and change your practices out in the real world as we all work together for more collaborative inclusive and equitable care. You'll find more information about the evidence surrounding pregnancies over the age of 35 in our show notes; we look forward to hearing what you think. Till next time!