Association of Prenatal Care Services, Maternal Morbidity, and Perinatal Mortality With the Advanced Maternal Age Cutoff of 35 Years

Abstract

IMPORTANCE Maternal and perinatal mortality remain high in the US despite growing rates of prenatal services and spending, and little rigorous evidence exists regarding the impact of prenatal care intensity on pregnancy outcomes. Patients with an expected date of delivery just after their 35th birthday may receive more intensive care owing to the advanced maternal age (AMA) designation; whether this increase in prenatal care is associated with improvements in outcomes has not been explored. OBJECTIVETo determine the association between the AMA designation and prenatal care services, severe maternal morbidity, and perinatal mortality. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study used a regression discontinuity design to compare individuals just above vs just below the 35-year AMA cutoff, using unidentifiable administrative claims data from a large, nationwide commercial insurer. All individuals with a delivery between January 1, 2008, and December 31, 2019, who were aged 35 years within 120 days of their expected date of delivery were included in the study. Analyses were performed from July 1, 2020, to February 1, 2021. EXPOSURES Individuals who were aged 35.0 through 35.3 years on the expected date of delivery were designated as AMA. MAIN OUTCOMES AND MEASURES Outcomes were visits with specialists (obstetriciangynecologists and maternal-fetal medicine), ultrasound scan use, antepartum fetal surveillance, aneuploidy screening, severe maternal morbidity, preterm birth or low birth weight, and perinatal mortality. RESULTSThe analysis included 51 290 individuals (mean [SD] age; 34.5 [0.5] years); 26 108 individuals (50.9%) were aged 34.7 to 34.9 years and 25 182 individuals (49.1%) were aged 35.0 to 35.3 years on the expected date of delivery. A total of 2407 pregnant individuals (4.7%) had multiple gestation, 2438 (4.8%) had pregestational diabetes, 2265 (4.4%) had chronic hypertension, and 4963 (9.7%) had obesity. Advanced maternal age was associated with a 4.27 percentage point increase in maternal-fetal medicine visits (95% CI, 2.27-6.26 percentage points; P < .001), a 0.21 unit increase in total ultrasound scans (95% CI, 0.06-0.37; P = .006), a 15.67 percentage point increase in detailed ultrasound scans (95% CI, 13.68-17.66 percentage points; P < .001), and a 4.86 percentage point increase in antepartum surveillance (95% CI, 2.83-6.89 percentage points; P < .001). The AMA designation was associated with a 0.39 percentage point decline in perinatal mortality (95% CI, −0.77 to −0.01 percentage points; P = .04). CONCLUSIONS AND RELEVANCEIn this cross-sectional study, the AMA designation at age 35 years was associated with an increase in receipt of prenatal monitoring and a small decrease in perinatal (continued) Key Points Question What is the association between the advanced maternal age (AMA) cutoff of 35 years and prenatal care service intensity, severe maternal morbidity, and perinatal mortality? Findings In this cross-sectional study of 51 290 deliveries, using regression discontinuity methods,...

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“…For instance, women aged 35–39 years had the highest likelihood of receiving antenatal care visits, care from skilled antenatal care providers, while women aged over 40 years had the highest likelihood of receiving skilled birth assistance and accessing facility-based delivery. This finding is consistent with earlier studies conducted in the USA and Mexico ( 29 , 30 ).…”

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“…This is consistent with previous studies that have shown an association between inadequate prenatal care utilization with low levels of education, poor social support, unplanned pregnancy, and poverty, 26 and that higher education is protective 27 . Additionally, a study in the USA showed that perinatal outcomes were better for pregnant women just over the 35‐year cut‐off when compared with those just under this age, suggesting that the additional age‐related pregnancy monitoring may play a role in improving outcomes 5 . Together these studies highlight that many factors influence utilization of prenatal services.…”

“…Widespread use of family planning, postponing pregnancy because of education or career goals, and advances in assisted reproductive technology contribute to pregnancy later in life 4 . Prenatal care is important for a healthy pregnancy and birth outcomes, especially for older women 5 . Enhanced prenatal care that includes additional monitoring during pregnancy and birth is recommended for women over the age of 35 years due to associated health risks 6 .…”

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“…Consistent with prior research, individuals were required to meet one of the following requirements on the date of delivery: (1) two unique delivery‐related diagnosis codes, (2) two unique delivery‐related procedure codes, or (3) one delivery‐related diagnosis and one delivery‐related procedure code. 10 , 11 Dates with two or more delivery‐related diagnosis and/or procedure codes within 100 days of each other were grouped together and the date with the greatest number of diagnosis and/or procedure codes was flagged as the date of delivery. When an individual had more than one birth episode during the study period (3% of births), we randomly chose one birth to maintain the independence of observations.…”