Journal of Obstetrics and Gynaecology, July 2009; 29(5): 378383

OBSTETRICS

Pregnancy outcome after age 40 and risk of low birth weight

C. TABCHAROEN, S. PINJAROEN, C. SUWANRATH & O. KRISANAPAN

Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

Summary
A historical cohort study was conducted to examine the pregnancy outcome in women aged 40 or older and determine the
effect of age on low birth weight. The pregnancy outcomes of 789 mothers aged 40 years or older were analysed and
compared with those of 20,852 mothers aged 2034 years. There were differences in socioeconomic status and obstetric
characteristics between the two groups. The older group had more medical and obstetric complications (diabetes mellitus,
chronic hypertension, malpresentation, pregnancy-induced hypertension, placenta praevia, multiple pregnancies, pre-term
labour, fetal distress, retained placenta, postpartum haemorrhage and endometritis), more adverse fetal outcomes (low birth
weight, low Apgar scores and congenital anomalies) and a higher caesarean section rate. The multivariate logistic regression
analysis confirmed that maternal age was an independent risk factor for low birth weight. These data will be useful in
counselling patients about their expectations and the risk of adverse outcomes and in providing the appropriate necessary
care.
Keywords
Advanced maternal age, low birth weight, pregnancy outcome

Introduction
In modern society, womens life patterns have changed.
They are gaining higher education, working and having
careers rather than just staying at home. More women are
choosing to delay marriage and child-bearing until their
education is complete or their professional careers are
established. As a result, there is an increase in advanced
maternal age women.
Between 1992 and 2005, evidence shows that the number
of mothers who deliver at age 40 or older in the Department
of Obstetrics and Gynaecology, Faculty of Medicine,
Prince of Songkla University, Thailand, has progressively
increased to approximately three times the base rate
(Pinjaroen et al. 1992, 2004).
Traditionally, pregnant women of advanced maternal age
have been regarded as high risk pregnancies because they
tend to have higher obstetric complications and also more
chronic illnesses, such as diabetes and chronic hypertension,
which are known risk factors for adverse obstetric outcomes
(Cleary-Goldman et al. 2005; Berkowitz et al. 1990;
Hoffman et al. 2007; Prysak et al. 1995; Simchen et al.
2006; Ziadeh and Yahaya 2001). Many adverse perinatal
outcomes, such as perinatal morbidity, mortality (ClearyGoldman et al. 2005; Hoffman et al. 2007; Prysak et al.
1995; Simchen et al. 2006), birth asphyxia and low birth
weight (Cleary-Goldman et al. 2005; Delbaere et al. 2007;
Hoffman et al. 2007; Reddy et al. 2006; Scholz et al. 1999)
tend to occur more frequently in older women. A low birth

weight is particularly important because it increases the risk

of perinatal morbidity, mortality, neurodevelopment impairment and has a high financial cost of care (Whitaker
et al. 2006).
The outcome of pregnancies in very advanced maternal
age, especially at age 40 or older, has raised concerns and
has been studied worldwide (Berkowitz et al. 1990;
Hoffman et al. 2007; Scholz et al. 1999; Ziadeh and
Yahaya 2001). However, most Asian studies have
reported on pregnancy outcomes of maternal age 35
years. It is of interest to know what adverse outcomes
increase in much older-age Thai mothers and with what
frequency, as well as the effect of age on low birth weight.
We conducted an analysis to evaluate the pregnancy
outcomes in mothers aged 40 or older (older-age
mothers). In addition, we also aimed to identify whether
maternal age was an independent risk factor for low birth
weight.

Materials and methods

This was a historical cohort study of all the mothers who
have delivered at Songklanagarind Hospital, a university
hospital in Southern Thailand, between 1 January 1997
and 31 December 2006 with either a gestational age at
delivery of 28 weeks or greater, or a birth weight of 1,000 g
or greater.
With regard to the practice guideline for prenatal
diagnosis at our institute, fetal karyotyping will be offered

Correspondence: C. Suwanrath, Department of Obstetrics and Gynaecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110,
Thailand. E-mail: schitkas@yahoo.co.uk
ISSN 0144-3615 print/ISSN 1364-6893 online 2009 Informa Healthcare USA, Inc.
DOI: 10.1080/01443610902929537

Pregnancy outcome after age 40

in all women with high risk of fetal aneuploidy, such as
singleton pregnancy with age 35 years at delivery,
previous abnormal chromosome birth, a carrier of chromosome translocation, etc. Biochemical screening test for
Down syndrome is not available in our hospital.
The study group consisted of all delivering women who
were 40 years of age or older on the day of delivery and the
control group consisted of those who were 2034 years old.
The data were retrieved from the database of the
Statistical unit in the Department of Obstetrics and

Table I. Demographic and obstetric characteristics.

Characteristics
Age (years) (median)
Occupation
Government employee
Trained worker
Housewife
Agriculturist
Business
Other
Religion
Buddhist
Muslim
Christian
Parity
Nulliparity
Multiparity
Private care cases
Mode of delivery
Vaginal delivery
Caesarean section
*MannWhitney U-test.

40 years
(n 789)
(%)

2034 years
(n 20,852)
(%)

41

28

31.3
25.7
20.9
12.3
9.8
0

14.7
40.8
24.4
8.7
10.3
1.1

87.6
11.9
0.5

88.8
11.0
0.2

20.8
79.2
56.3

49.4
50.6
46.3

48.3
51.7

66.2
33.8

p
value
50.001*
50.001

0.17

50.001
50.001
50.001

379

Gynaecology at Songklanagarind Hospital and extracted

for demographic characteristics, types of service received,
obstetric and medical complications, mode of delivery, and
fetal outcomes. They were checked for validity or missing
values and corrected by reviewing the medical records.
SPSS for Windows version 13.0 (Chicago, IL, USA) was
used for data analysis. The students t-test, MannWhitney
U test, and the w2-test were used for descriptive analysis.
To determine that maternal age was an independent risk
factor of low birth weight, the multivariate logistic
regression analysis was used to control confounding
variables; a p value of 50.05 was considered significant.
For comparative analysis of low birth weight and low Apgar
scores between the two groups, multiple pregnancies and
stillbirths were excluded.

Results
During the study period, a total of 26,844 women delivered
at Songklanagarind Hospital, of which, 789 were in the
older group (aged 40 years or older) and 20,852 were in the
younger group (aged 2034 years).
Demographic and obstetric data are shown in Table I.
The oldest mother was 54 years old. The age distribution of
the older group is shown in Figure 1. Approximately 97%
of cases were in the range of 4044 years and only one case
was beyond 50 years old. The proportion of government
employees in the older group was higher than that in the
younger group. The mean of the maternal height in the
older group was significantly lower than that in the younger
group. The older group was more multiparous and private
care cases (patients who requested for care by specific
obstetrician). The gestational age at the time of delivery
in the older group was slightly lower than that in the
younger group (38.1 (2.1) wk vs 38.6 (1.9) wk, p 5 0.001).
Even if the elective caesarean section cases were excluded,

Figure 1. Age distribution of the older-age mothers.

380

C. Tabcharoen et al.

the gestational age at the time of delivery in the older group

was still significantly lower than the younger one. Regarding the mode of delivery, the older group had a significantly
higher caesarean section rate.
With regard to maternal complications, the older group
had significantly higher rates of medical and obstetric
complications including chronic hypertension, diabetes
mellitus, malpresentation, pregnancy-induced hypertension, placenta praevia, multiple pregnancies, preterm
labour, fetal distress, retained placenta, postpartum haemorrhage, and endometritis (Table II).
Adverse fetal outcomes were significantly higher in the
older group including gross anomalies and low birth
weight. The older group had a higher stillbirth rate, but it
did not reach statistical significance. Concerning the low
birth weight analysis (excluding multiple pregnancies and
stillbirths), 767 women in the older group and 20,547
women in the younger group were included. The mean
birth weight was slightly lower in the older group (3,094.9
(570.1) g vs 3,129.0 (476.3) g, p 0.047). The older
group had a significantly higher rate of low birth weight.
A significantly increased rate of low Apgar scores was also
found in the older group (Table III).
In the analysis of the low birth weight predictors, the
potential predictor variables consisted of maternal age,
parity, maternal height, private care received, gestational
age at delivery, diabetes mellitus, chronic hypertension,
pregnancy-induced hypertension, congenital anomalies,
premature rupture of the membranes, and placenta
praevia. They were all included in the multivariate logistic
regression model. The conclusion was that maternal age
was an independent risk factor for low birth weight with an
adjusted odds ratio of 1.6 (95% CI 1.2, 2.3). In addition,

we also found that parity of 4 strongly decreased the risk

of low birth weight with an adjusted odds ratio of 0.27, as
compared with the nulliparity (Table IV).
The subgroup analysis of the very advanced age mothers
is shown in Table V. It revealed that nulliparous and
multiparous women had different characteristics. The
nulliparous women were predominantly private care cases
and more government employees, while multiparous
women were predominantly housewives. In addition, there
was a higher proportion of Muslims in multiparous women,

Table IV. Multivariate regression analysis of low birth weight.

Variables
Age 40 years
Pregnancy-induced
hypertension
Congenital anomalies
Premature rupture of
the membranes
Height 150 cm
Private care cases
Gestational age at
delivery (weeks)
Parity
0
1
2
3
4

Odds
ratio*

95% CI

p value

1.64
3.86

1.202.25
2.835.26

0.02
50.001

3.72
1.83

2.385.80
1.252.68

50.001
0.002

1.66
0.71
0.48

1.382.00
0.620.82
0.460.50

50.001
50.001
50.001

1.0
0.51
0.40
0.54
0.27

0.440.60
0.310.51
0.350.84
0.120.62

50.001
50.001
0.006
0.001

*Adjusted for maternal age, pregnancy-induced hypertension,

placenta praevia, congenital anomalies, premature rupture of the
membranes, maternal height, private care cases, diabetes mellitus,
chronic hypertension, gestational age at delivery and parity.

Table II. Maternal complications.

Characteristics
Diabetes mellitus
Chronic hypertension
Malpresentation
Pregnancy-induced
hypertension
Placenta praevia
Multiple pregnancies
Premature rupture of the
membranes
Pre-term labour
Fetal distress
Postpartum haemorrhage
Retained placenta
Metritis

40 years
(n 789)
(%)

2034 years
(n 20,852)
(%)

p value

2.9
0.8
5.4
3.7

0.6
0.1
3.5
1.8

50.001
50.001
0.004
50.001

2.5
1.8
2.0

0.9
0.9
1.4

50.001
0.009
0.12

13.7
6.2
1.6
1.6
0.4

9.8
4.1
0.7
0.6
0.1

50.001
50.001
50.001
50.001
0.04

Table V. Subgroup analysis of nulliparous and multiparous olderage mothers.

Table III. Fetal outcome.

Characteristics
Stillbirth
Congenital anomalies
Low birth weight (g)
Apgar score at 1 min 7
Apgar score at 5 min 7

40
years (%)

2034
years (%)

p value

1.1
2.9
12.1
10.7
2.1

0.6
1.0
7.6
7.1
1.1

0.07
50.001
50.001
50.001
0.02

Variables
Age (years) median
(min-max)
Occupation (%)
Housewife
Business
Trained worker
Agriculturist
Government employee
Muslim
Private care cases
Caesarean section
Pregnancy-induced
hypertension
Malpresentation
Premature rupture
of the membranes
Placenta praevia
Fetal distress
Postpartum haemorrhage
Pre-term labour
Low birth weight
Apgar score at 1 min 7
Apgar score at 5 min 7

Nulliparous
(n 164)

Multiparous
(n 625)

p value

41 (4054)

41 (4048)

0.72*

13.4
8.5
33.5
7.9
36.7
8.5
73.9
67.1
8.5

22.9
10.1
23.7
13.4
29.9
12.8
51.6
47.7
2.4

50.001
50.001
50.001
50.001

9.8
3.0

4.3
1.8

0.01
0.34

1.8
16.5
0.6
7.9
15.1
12.7
1.9

2.7
4.5
1.9
11.2
11.7
10.2
2.1

0.78**
50.001
0.32**
0.22
0.49
0.39
1.0*

0.003

*MannWhitney U-test, **Fishers exact test.

Pregnancy outcome after age 40

especially in those with a parity of 3, which was
approximately three times higher than the rate of those
with parity of 53. The caesarean section rate in the
nulliparous group was approximately two-thirds of all
deliveries. The caesarean section rate among multiparous
women was slightly less than half of all deliveries, of which
62% were previous caesarean section cases. With regard to
obstetric complications, pregnancy-induced hypertension
in the nulliparous group was approximately 3.5 times
higher than that of the multiparous one. The nulliparous
older-age mothers had higher rates of malpresentation and
fetal distress also. The mean birth weight was lower in the
nulliparous group as compared with the multiparous one,
but it did not reach statistical significance (3,026.2
(601.3) g vs 3,112.8 (560.8) g, p 0.09). The rates of
pre-term births, low birth weight, and low Apgar scores
were not significantly different.

Discussion
This study found that mothers who gave birth at age
40 or older had different social characteristics from
the younger ones. Medical and obstetric complications
(including diabetes mellitus, chronic hypertension, pregnancy-induced hypertension, pre-term labour, malpresentation, placenta praevia, multiple pregnancies, fetal
distress, retained placenta, postpartum haemorrhage
and endometritis) and adverse fetal outcomes (including
low Apgar scores, fetal anomalies and low birth weight)
were more common in the older group. The older group
also had a higher caesarean section rate. In addition,
advanced age was an independent risk factor for low birth
weight.
This study benefited from the large and comprehensive
database which was created by the standard record form,
validated and pooled immediately during admissions.
However, we did lack some data influencing fetal birth
weight, such as weight gain during pregnancy, minor
complications and we could not track long-term fetal
outcomes. In addition, our institute is a tertiary centre, so
this does not represent a population study. High-risk
pregnant women together with referral cases tend to deliver
at our hospital and this might underestimate the risk to
older mothers.
The older group included more women who
were government employees, while the younger group
included a higher proportion of trained workers and
housewives. Among older-age mothers, government
employees were more nulliparous than multiparous.

381

This confirms the consequences of childbearing delay

due to changes in social roles, such as studying for
higher education, and late marriage. Government employees tended to delay childbearing more than women of
any other career. Private care cases were also more
common in the older group, especially among nulliparous
women, implying that this group was associated with a
higher socioeconomic status than the younger one. We also
found a higher proportion of Muslim among older-age
mothers, whose parity of 3 (25% vs 8% in nulliparous
ones).
The gestational age at the time of delivery in the older
group was slightly lower than that in the younger group
even after the elective caesarean section cases were
excluded. Regarding the mode of delivery, the older group
had a significantly higher caesarean section rate than the
younger group, which is consistent with other studies
(Gilbert et al. 1999; Suwanrath and Pinjaroen 1998;
Treacy et al. 2006). In the detailed analysis, the difference
in caesarean section rate was mainly due to a higher
proportion of women who had undergone a previous
caesarean section in the older group (62% in the multiparous subgroup). Among nulliparous older-age mothers,
the caesarean section was as high as 67% and the most
common indication for caesarean section was cephalopelvic
disproportion (26.3%) followed by fetal distress (22.7%)
and malpresentation (14.5%).
The very advanced maternal age had a significantly
increased risk of complications including chronic hypertension, diabetes mellitus, malpresentation, pre-term
labour, pregnancy-induced hypertension, placenta praevia,
multiple pregnancies, fetal distress, retained placenta,
postpartum haemorrhage and endometritis, which concurs
with previous findings (Cleary-Goldman et al. 2005;
Gilbert et al. 1999; Hoffman et al. 2007; Jacobsson
et al. 2004; Simchen et al. 2006; Suwanrath and
Pinjaroen 1998).
In regards to malpresentation, the in-depth analysis,
stratified by parity between the older and the younger
groups revealed that the high prevalence rate of malpresentation was intensely evident among nulliparous olderage mothers as compared with the younger nulliparous
ones (9.8% vs 3.9%, p 0.001). Meanwhile, the malpresentation rate among multiparous older-age mothers was
not significantly different from that in the multiparous
younger group (4.3% vs 3.1%, p 0.059). It could be that
only older-age nulliparous women were affected, and that
age was not a factor for malpresentation in the multiparous
ones.

Table VI. Recommendation for management of older-age mothers.

Period

Recommended management

Preconception

Counselling for medical and obstetric risk*

Check up and eliminate treatable/preventable risks (genetics, STD, infection, etc.)
Check up and treat for underlying medical complications (such as diabetes mellitus, hypertension, etc.)
Prenatal diagnosis
High risk care for early detection and treatment of obstetric complications
Close observe for fetal asphyxia and abnormal labour progression
Prepare for appropriate operative obstetric for dystocia
Prevent and prompt treatment of postpartum haemorrhage
Early detection and prompt treatment of puerperal infection
Family planning

Antepartum
Intrapartum
Postpartum

*As shown in this text.

382

C. Tabcharoen et al.

With regard to pregnancy-induced hypertension, the

overall prevalence rate in the older group was 2.1 times
higher than that in the younger one, and the detailed
analysis revealed that the nulliparous older-age mothers
carried the highest risk, which was approximately 3.5 times
higher than that of the multiparous older-age mothers
(8.5% vs 2.4%), while the total rate in the younger group
was only 1.8% (2.4% and 1.1% in the nulliparous and
multiparous subgroups, respectively). This means that both
age and parity have an effect on pregnancy-induced
hypertension with nulliparity having a probably stronger
effect than older age.
Concerning placenta praevia, the prevalence rate was
higher in older-age mothers as compared with the younger
ones. Among the older-age group, the prevalence rate in
the multiparous subgroup seemed to be higher than in the
nulliparous one, but not statistically significant. Sample
size was possibly not large enough to show the difference.
Considering fetal distress, it was shown that the diagnosis
of this condition was highest in the nulliparous older-age
mothers, while the rate of low Apgar scores among the olderage group did not differ between the nulliparous and the
multiparous subgroups. We speculate this to the obstetricians tendency to make a decision to perform a caesarean
section in the older nulliparous mothers earlier than the
older multiparous ones, especially whenever non-reassuring
fetal heart rate patterns were diagnosed.
As far as postpartum complications are concerned, we
found a significantly higher rate of postpartum haemorrhage, retained placenta and endometritis in the older
group. Among the older-age group, our sample size was
not large enough to show the differences of postpartum
complications between the nulliparous and the multiparous
subgroups.
Regarding fetal outcomes, we found that the rates of low
Apgar scores and congenital anomalies in the older group
were higher than those in the younger group. The
explanation for the higher incidence of low Apgar scores
and fetal distress in the older group is possibly related to the
natural ageing processes causing uteroplacental insufficiencies, which lead to fetal hypoxia. Concerning congenital
anomalies, ageing increases the risk of congenital malformation. Our data did not include women who had termination
of pregnancy for malformation; therefore the rates in both
groups seemed to be underestimated.
The mean birth weight in the older group was
significantly lower than that in the younger group and the
rate of low birth weight in the older group was higher than
that in the younger one. Subgroup analysis among olderage mothers did not find a significant difference in the
mean birth weight, the rates of low birth weight and low
Apgar scores between the nulliparous and the multiparous
subgroups.
It seems that maternal age had a significant effect on low
birth weight. To confirm this hypothesis, logistic regression
analysis was used to control the other variables affecting
low birth weight. It showed that being an older-age mother
is, in fact, an independent risk factor for low birth weight
with an adjusted odds ratio of 1.6, which corresponds to
that found in previous studies (Cleary-Goldman et al.
2005; Delbaere et al. 2007; Hoffman et al. 2007; Prysak
et al. 1995; Simchen et al. 2006). Interestingly, it was
shown in the final logistic regression model that parity of
4 significantly decreased the risk of low birth weight as
compared with nulliparity with an adjusted odds ratio of

0.27, while the parity of 13 decreased the risk for only

about half of the nulliparity.
Based on our findings, we summarise the recommendation plan of management for older-age mothers as shown in
Table VI.
In conclusion, mothers whose age is 40 years or older
have specific social characteristics, more complications and
worse pregnancy outcomes than mothers in the 2034 year
range. In addition, the older-age nulliparous women have
higher risk of pregnancy-induced hypertension, malpresentation, fetal distress and caesarean section than do the
multiparous older-age women. These data will be useful in
counselling patients about their expectations and the
adverse outcome risks and in providing the appropriate
necessary care.

Acknowledgement
The authors wish to thank the Faculty of Medicine, Prince
of Songkla University for funding support.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.

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