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

      , PhD 1 , 2 , , , MD, MPH 3 , , PhD 4
      JAMA Health Forum
      American Medical Association

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          This cross-sectional study investigates the association between the advanced maternal age cutoff of 35 years and prenatal care service intensity, severe maternal morbidity, and perinatal mortality.

          Key Points


          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?


          In this cross-sectional study of 51 290 deliveries, using regression discontinuity methods, the AMA designation was associated with a significant increase in prenatal care services, including prenatal visits, ultrasound scans, and antepartum surveillance. The AMA designation was associated with a large decline in perinatal mortality but not severe maternal morbidity.


          Results suggest that increases in prenatal care intensity associated with the commonly applied AMA designation may have important benefits for perinatal survival for patients aged approximately 35 years.



          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.


          To determine the association between the AMA designation and prenatal care services, severe maternal morbidity, and perinatal mortality.

          Design, Setting, and Participants

          This 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.


          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 (obstetrician-gynecologists and maternal-fetal medicine), ultrasound scan use, antepartum fetal surveillance, aneuploidy screening, severe maternal morbidity, preterm birth or low birth weight, and perinatal mortality.


          The 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 Relevance

          In 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 mortality, suggesting that the AMA designation may be associated with clinical decision-making, with individuals just older than 35 years receiving more prenatal monitoring. These results suggest that increases in prenatal care services stemming from the AMA designation may have important benefits for fetal and infant survival for patients in this age range.

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          Most cited references41

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          Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

          On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.
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            Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

            In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015.
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              National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis

              Previous estimates have highlighted a large global burden of stillbirths, with an absence of reliable data from regions where most stillbirths occur. The Every Newborn Action Plan (ENAP) targets national stillbirth rates (SBRs) of 12 or fewer stillbirths per 1000 births by 2030. We estimate SBRs and numbers for 195 countries, including trends from 2000 to 2015.

                Author and article information

                JAMA Health Forum
                JAMA Health Forum
                JAMA Health Forum
                American Medical Association
                3 December 2021
                December 2021
                3 December 2021
                : 2
                : 12
                [1 ]Harvard University, Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
                [2 ]Evidence for Access, Genentech Inc, South San Francisco, California
                [3 ]Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
                [4 ]Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
                Author notes
                Article Information
                Accepted for Publication: October 15, 2021.
                Published: December 3, 2021. doi:10.1001/jamahealthforum.2021.4044
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Geiger CK et al. JAMA Health Forum.
                Corresponding Author: Caroline K. Geiger, PhD, Evidence for Access, Genentech Inc, One DNA Way, South San Francisco, CA 94080 ( cgkelley13@ 123456gmail.com ).
                Author Contributions: Dr Geiger had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: All authors.
                Acquisition, analysis, or interpretation of data: All authors.
                Drafting of the manuscript: All authors.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Geiger, Cohen.
                Obtained funding: Geiger.
                Administrative, technical, or material support: Geiger.
                Supervision: Clapp, Cohen.
                Conflict of Interest Disclosures: Dr Geiger reported being a PhD student during the conduct of the study. No other disclosures were reported.
                Funding/Support: This study was supported by grant DGE1745303 from the National Science Foundation Graduate Research Fellowship Program (Dr Geiger).
                Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Disclaimer: This article was conceived and drafted while Caroline Geiger was a PhD candidate at Harvard University, and the findings and views in this article do not reflect the official views or policy of Genentech Inc. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.
                Acknowledgment: We thank Anna Sinaiko, PhD, and Grant Miller, PhD, for their helpful comments and feedback on this study. They did not receive any compensation for their contribution to this work.
                Copyright 2021 Geiger CK et al. JAMA Health Forum.

                This is an open access article distributed under the terms of the CC-BY License.

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