Original Research ajog.

org

OBSTETRICS
Maternal age and risk for adverse outcomes
Jean-Ju Sheen, MD; Jason D. Wright, MD; Dena Goffman, MD; Adina R. Kern-Goldberger, MD; Whitney Booker, MD;
Zainab Siddiq, MS; Mary E. D’Alton, MD; Alexander M. Friedman, MD, MPH

OBJECTIVE: The objective of this study was to characterize the risk for
severe maternal morbidity and other pregnancy complications by maternal
age during delivery hospitalizations.
STUDY DESIGN: This retrospective cohort analysis used the
Perspective database to characterize the risk for adverse maternal out-
comes from 2006 to 2015 based on maternal age. Women were divided
into 7 categories based on maternal age: 15e17, 18e24, 25e29,
30e34, 35e39, 40e44, and 45e54 years of age. The primary outcome
of this study was severe maternal morbidity as defined by the Centers for
Disease Control and Prevention. Secondary outcomes included (1) overall
comorbid risk; (2) risk for pregnancy complications such as postpartum
hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery;
and (3) risk for individual severe morbidity diagnoses such as stroke,
embolism, eclampsia, and hysterectomy. Adjusted models were fitted to
assess factors associated with severe morbidity with adjusted risk ratios
(aRRs) and 95% confidence intervals (CI) as measures of effect. Population
weights were applied to create national estimates.
RESULTS: Of 36,944,292 deliveries included, 2.5% occurred among
women aged 15e17 years (n ¼ 921,236), 29.1% to women aged 18e24
years (n ¼ 10,732,715), 28.6% to women aged 25e29 years (n ¼
10,564,850), 24.9% to women aged 30e34 years (n ¼ 9,213,227),
12.1% to women aged 35e39 years (n ¼ 4,479,236), 2.6% to women
aged 40e44 years (n ¼ 974,289), and 0.2% to women aged 45e54
years (n ¼ 58,739). In unadjusted analyses, severe morbidity was more
than 3 times higher (risk ratio [RR], 3.33, 95% confidence interval [CI],
3.03e3.66) for women 45-54 years compared with women 25e29
years. Women aged 40e44, 35e39, and 15e17 years were also at
increased risk (RR, 1.83, 95% CI, 1.77e1.89; RR, 1.36, 95% CI,
1.33e1.39; RR, 1.39, 95% CI, 1.34e1.45, respectively). In the adjusted
model, the 45e54 year old group was associated with the highest relative
risk (aRR, 3.46, 95% CI, 3.15e3.80) followed by the 40e44 year old
group (aRR 1.90, 95% CI, 1.84e1.97), the 35e39 year old group (aRR,
1.43, 95% CI, 1.40e1.47), and the 15e17 year old group (aRR, 1.20,
95% CI, 1.15e1.24). Cesarean delivery, preeclampsia, postpartum
hemorrhage, and gestational diabetes were most common among women
aged 45e54 years, as were thrombosis and hysterectomy.
CONCLUSION: While differential risk was noted across maternal age
categories, women aged 45 years old and older were at highest risk for a
broad range of adverse outcomes during delivery hospitalizations.
Key words: very advanced maternal age, severe morbidity, maternal
risk

W hile the overall birth rate in the

United States has declined over
the past decade, births to women aged 30
years old and older have risen. Socio-
economic trends and advances in assis-
ted reproductive technology have
resulted in women having children at
later ages. From 2007 to 2016, birth rates
rose 2% for women in their early 30s,
11% for women in their late30s, and
19% for women in their early 40s.1
In 2016, the birth rate for women
45e49 years old (and including births to
women 50 years old and older) was 0.9
per 1000 women, the highest rate for this
age group since 1963.2 The trend of more
frequent births among older women,
particularly those of very advanced
Cite this article as: Sheen J-J, Wright JD, Goffman D,
et al. Maternal age and risk for adverse outcomes. Am J
Obstet Gynecol 2018;219:390.e1-15.
0002-9378/$36.00
ª 2018 Published by Elsevier Inc.
https://doi.org/10.1016/j.ajog.2018.08.034
maternal age (45 years of age), is likely
to continue as newer reproductive tech-
nologies become more widely available.3
For older women intending to
become pregnant, data on the risk for
adverse outcomes may represent an
important consideration. While
advanced maternal age of 35 years of
age is generally associated with both
adverse maternal and neonatal preg-
nancy outcomes, there may be impor-
tant differentials in the risk for women
35e39, 40e45, and older than 45 years.
While some risks, such as aneuploidy,
may decrease with oocyte donation or be
detected through prenatal screening,4e7
the degree of age-based risk for adverse
outcomes in the population of advanced
maternal age is unclear, particularly for
women aged 45 years and older.
Older women are more likely to have
underlying comorbid conditions such as
obesity, diabetes, and hypertension;
even accounting for preexisting
illness, healthy women of advanced
maternal age have increased pregnancy
complication rates.4,8e10 Population-
based data on how age relates to
adverse maternal outcomes in the setting
of comorbidity are limited.
Given that knowledge of population-
based risk related to adverse maternal
outcomes may be of use to both patients
and providers, the objective of this study
was to characterize the maternal age-
related risk for severe maternal
morbidity and pregnancy complications
such as cesarean delivery, preeclampsia,
gestational diabetes, and postpartum
hemorrhage.
Materials and Methods
The Perspective database was used for
this analysis. Perspective is maintained
by Premier Incorporated (Charlotte,
NC) and includes patient demographics,
hospital characteristics, and discharge
diagnosis codes as well as medications
and devices administered during acute
care hospitalizations.
Within Perspective, 100% of hospi-
talizations for individual hospitals are

390.e1 American Journal of Obstetrics & Gynecology OCTOBER 2018

ajog.org
AJOG at a Glance
Why was this study conducted?
To evaluate risk for adverse outcomes by maternal age.
Key findings
While differential risk was noted across maternal age categories, women 45 years
old and older were at highest risk for a broad range of adverse outcomes during
delivery hospitalizations.
What does this add to what is known?
Women aged 45 years old and older are at more than 3 times higher risk for severe
morbidity when compared with women 25e29 years old.
reported. Ninety-five quality assurance
and validation checks are performed on
data each year prior to being released.11
Perspective is routinely used for
research on trends during delivery
hospitalizations.12e14 The discharges
included in the Perspective database ac-
count for approximately 15% of inpa-
tient hospital stays annually in the
United States. The Columbia University
Institutional Review Board deemed the
study exempt, given that all data are
deidentified.
Women 15e54 years of age were
included in this analysis if they were
admitted for a delivery hospitalization
between January 2006 and March 2015.
Delivery hospitalizations were captured
with International Classification of Dis-
eases, ninth revision, Clinical Modifica-
tion (ICD-9-CM) diagnosis codes 650
and V27.x. These criteria ascertain
>95% of delivery hospitalizations.15
For this analysis women were divided
into 7 categories based on maternal age:
15e17, 18e24, 25e29, 30e34, 35e39,
40e44, and 45e54 years of age. We
compared demographic and hospital
characteristics of women based on
maternal age. Demographic character-
istics included maternal race (white,
black, Hispanic, other), marital status
(married, single, unknown), year of
delivery (2006e2015), and insurance
status (commercial, Medicare,
Medicaid, uninsured, and unknown).
Hospital characteristics included loca-
tion (urban vs rural), teaching status
(teaching vs nonteaching), geographic
region (Midwest, Northeast, South,
West), and hospital bed size (small,
medium, large).
OBSTETRICS
The primary outcome of this study
was severe maternal morbidity, as
defined by the Centers for Disease
Control and Prevention (CDC).16 The
CDC definition of severe maternal
morbidity encompasses 21 diagnoses
such as shock, stroke, heart failure,
transfusion, and other conditions, all
identified using ICD-9-CM codes
(Table 1).17 Additionally, because the
most common diagnosis in the severe
morbidity composite is transfusion
(ICD-9-CM 99.0x) a sensitivity analysis
was performed excluding transfusion
and was restricted to the remaining 20
conditions representative of non-
transfusion severe morbidity.
We evaluated 5 sets of secondary
outcomes. First, we evaluated temporal
trends by maternal age for the diagnoses
of preeclampsia, cesarean delivery,
postpartum hemorrhage, and gesta-
tional diabetes.
Second, we evaluated the risk for in-
dividual severe morbidity conditions
including stroke, embolism, eclampsia,
and hysterectomy.
Third, we evaluated temporal trends
in comorbid risk by maternal age as
measured by an obstetric comorbidity
index.18 This comorbidity index pro-
vides weighted comorbidity scores for
individual patients based on the presence
of specific diagnosis codes and de-
mographic factors present in adminis-
trative data. Higher scores are associated
with an increased risk for severe
morbidity. In the initial study validating
the comorbidity index, patients with the
lowest score of 0 had a 0.68% risk of
severe morbidity, whereas a score of >10
was associated with a 10.9% risk of
OCTOBER 2018 American Journal of Obstetrics & Gynecology
Original Research
TABLE 1
Centers for Disease Control and
Prevention Severe Maternal
Morbidity Indicators
Conditions
Acute myocardial infarction
Aneurysm
Acute renal failure
Adult respiratory distress syndrome
Amniotic fluid embolism
Cardiac arrest/ventricular fibrillation
Conversion of cardiac rhythm
Disseminated intravascular
coagulation
Eclampsia
Heart failure/arrest during surgery or
procedure
Puerperal cerebrovascular disorders
Pulmonary edema/acute heart failure
Severe anesthesia complications
Sepsis
Shock
Sickle cell disease with crisis
Air and thrombotic embolism
Blood transfusion
Hysterectomy
Temporary tracheostomy
Ventilation
Modified from Centers for Disease Control and Preven-
tion: Severe maternal morbidity indicators and corre-
sponding International Classification of Diseases codes
during delivery hospitalizations. Available at: https://
www.cdc.gov/reproductivehealth/maternalinfanthealth/
smm/severe-morbidity-ICD.htm. Accessed July 2, 2018.
Sheen et al. Maternal age, adverse outcomes, and
maternal risk. Am J Obstet Gynecol 2018.
severe morbidity.18 This comorbidity
index was subsequently validated in an
external population.19 Because the co-
morbidity index includes maternal age,
we modified this scoring system
excluding maternal age for the present
analysis.
Fourth, we determined the degree to
which severe morbidity differed by
maternal age for women with the same
comorbidity index score. Fifth, we eval-
uated the risk for the following individ-
ual severe morbidity outcome diagnoses
390.e2
Original Research OBSTETRICS
within the CDC composite: (1)
eclampsia, (2) embolism, (3) hysterec-
tomy, and (4) stroke.16
Dichotomous outcomes were evalu-
ated using the c2 test. Adjusted risk ra-
tios (aRRs) for severe morbidity with
95% confidence intervals (CI) as mea-
sures of effect accounting for maternal
age categories, other demographic fac-
tors, and hospital characteristics were
derived from fitting a log-linear regres-
sion model. As a sensitivity analysis, this
model was subsequently repeated after
including the comorbidity index to
determine the degree to which risk was
attenuated by accounting for comorbid
conditions. Population weights within
the Perspective database can be applied
to create estimates for the entire US
population. These weights were used for
this analysis. All analyses were per-
formed with SAS 9.4 (SAS Institute,
Cary, NC).
Results
A total of 36,944,292 weighted delivery
hospitalizations were included in the
analysis. Of these, 2.5% of births
occurred among women aged 15e17
years (n ¼ 921,236), 29.1% to women
aged 18e24 years (n ¼ 10,732,715),
28.6% to women 25e29 years (n ¼
10,564,850), 24.9% to women 30e34
years (n ¼ 9,213,227), 12.1% to women
35e39 years (n ¼ 4,479,236), 2.6% to
women 40e44 years (n ¼ 974,289), and
0.2% to women 45e54 years (n ¼
58,739) (Supplemental Figure 1).
Women aged 24 years or younger were
more likely to be single and receive
Medicaid insurance, while women aged
25 years or older were more likely to be
married and have private insurance
(Table 2). From 2006e2007 to
2014e2015, the proportion of births to
women aged 15e17 years decreased by
47% and to women 18e24 years of age,
15%. The proportion of births increased
4% for women 25e29 years, 18% for
women 30e34 years, 5% for women
35e39 years, 8% for women 40e44
years, and 26% for women 45e54 years
(Figure 1).
Risk for severe morbidity both with
and without transfusion was highest
among women aged 45e54 years. For
390.e3 American Journal of Obstetrics & Gynecology OCTOBER 2018
the last 3 years of the study period
(2012e2014), the risk for severe
morbidity excluding transfusion in
women of advanced maternal age was
3.0% for women aged 45e54 years, 1.5%
for women aged 40e44 years, and 1.0%
for women aged 35e39 years (P < .01)
(Figure 2A). Including transfusion, the
risk for severe morbidity was 5.3% for
women aged 45e54 years, 2.7% for
women aged 40e44 years, and 2.0% for
women aged 35e39 years (P < .01)
(Figure 2B).
In the unadjusted model, the risk for
severe morbidity was more than 3 times
higher (risk ratio (RR) of 3.33, 95% CI,
3.03e3.66) for women 45e54 years
compared with women 25e29 years
(Table 3). Women aged 40e44, 35e39,
and 15e17 years were also at increased
risk compared with women 25e29 years
(RR, 1.83, 95% CI, 1.77e1.89; RR, 1.36,
95% CI, 1.33e1.39; RR, 1.39, 95% CI,
1.34e1.45, respectively).
Other factors associated with
increased risk for severe morbidity in the
unadjusted model included year of de-
livery (higher risk in 2015 compared
with 2006 [RR, 1.36, 95% CI,
1.32e1.45]), insurance type (higher risk
with Medicare compared with com-
mercial insurance [RR, 2.00, 95% CI,
1.89e2.11]), and race (higher risks with
black compared with white race [RR,
1.75, 95% CI, 1.72e1.78]). In the
adjusted model, maternal age retained
significance. Age group 45e54 years was
associated with the highest relative risk,
with women aged 25e29 years as the
reference group (aRR, 3.46, 95% CI,
3.15e3.80) followed by age 40e44 years
(aRR, 1.90, 95% CI, 1.84e1.97), age
35e39 years (aRR, 1.43, 95% CI,
1.40e1.47), and age 15e17 years (aRR,
1.20, 95% CI, 1.15e1.24) (Table 3).
When the obstetric comorbidity index
was included in the model, risk was
attenuated for women aged 45e54 years
(aRR, 2.83, 95% CI, 2.58e3.11), 40e44
years (aRR, 1.65, 95% CI, 1.59e1.71),
and 35e39 years (aRR, 1.30, 95% CI,
1.27-1.33) but not women 15e17 years
(aRR, 1.38, 95% CI, 1.33e1.44)
(Supplemental Table 1).
Cesarean deliveries increased with
higher maternal age category, and were
ajog.org
most common among women 40e54
(Figure 3A). For women 15e17 years,
18.9% of births occurred by cesarean
delivery from 2012 to 2014 compared
with 26.6% for women 18e24 years,
31.7% for women 25e29 years, 36.2%
for women 30e34 years, 42.5% for
women 35e39 years, 49.2% for women
40e44 years, and 62.8% for women 45e
54 years (P < .01).
Preeclampsia was also most common
among women aged 45e54 years. From
2012 to 2014, 10.4% of women aged
45e54 years were diagnosed with pre-
eclampsia compared with 6.1% of
women 40e44 years and 4.5% of women
35e39 years (P < .01) (Figure 3B).
Among women younger than 35 years,
women aged 15e17 years had the high-
est risk of preeclampsia (5.4%).
Postpartum hemorrhage similarly
demonstrated a bimodal distribution,
with women aged 45e54 years most
likely to experience hemorrhage (4.8%
from 2012 to 2014) followed by women
aged 15e17 years (3.3% from 2012 to
2014) (Figure 3C).
Finally, gestational diabetes was also
most common among women aged
45e54 years (Figure 3D); the rate was
lowest among women aged 15e17 years
(1.5% from 2012 to 2014), increasing for
each subsequent maternal age category to
reach 16.4% of women aged 45e54 years.
In evaluating risk for specific severe
morbidity diagnoses, maternal age
45e54 years was associated with the
highest risk for hysterectomy and
thrombosis (Figure 4). Hysterectomy
occurred in 103 per 10,000 deliveries for
women 45e54 years (95% CI, 85e126
per 10,000) vs 36 per 10,000 deliveries
(95% CI, 33e39 per 10,000) in the next
highest-risk group, women 40e44 years.
Risk was highest for maternal stroke
among women aged 45e54 and 40e44
years and lowest among women 15e17,
18e24, and 25e29 years. The risk for
eclampsia was highest among women
aged 15e17 years (26 per 10,000, 95%
CI, 24e29 per 10,000) followed by
women aged 18e24 years (10 per 10,000,
95% CI, 10e11 per 10,000).
In evaluating comorbidity by
maternal age, the proportion of women
with the lowest comorbidity score of
ajog.org OBSTETRICS Original Research

TABLE 2
Patient demographics
Age Age Age Age Age Age Age
Variables 15e17 y, n 18e24 y, n 25e29 y, n 30e34 y, n 35e39 y, n 40e44 y, n 45e54 y, n
All patients 921,236 10,732,715 10,564,850 9,213,227 4,479,236 974,289 58,739
Year
2006 128,250 1,308,914 1,177,199 981,420 516,744 107,119 5470
2007 131,657 1,336,000 1,228,694 1,004,333 519,876 107,320 6215
2008 128,171 1,291,345 1,204,729 984,761 500,378 106,251 6284
2009 113,856 1,213,233 1,154,921 973,902 476,659 106,242 6826
2010 101,767 1,129,219 1,120,239 975,159 466,194 103,714 6288
2011 90,846 1,107,812 1,121,125 992,677 468,286 107,391 6735
2012 82,668 1,102,427 1,120,293 1,015,316 466,836 106,255 6137
2013 70,775 1,058,863 1,119,311 1,040,668 486,210 107,526 7004
2014 60,478 970,241 1,078,977 1,022,580 473,313 100,367 6315
2015 12,768 214,662 239,364 222,411 104,741 22,104 1463
Hospital bed size
Small 574,451 6,896,587 6,771,499 5,816,990 2,786,069 599,194 34,885
Medium 231,489 2,486,083 2,420,042 2,147,477 1,058,210 231,547 14,242
Large 115,295 1,350,044 1,363,309 1,248,759 634,957 143,547 9612
Insurance status
Commercial 202,676 2,938,406 5,755,066 6,398,370 3,240,026 686,909 43,950
Medicare 2,421 63,755 81,783 70,351 38,595 10,769 523
Medicaid 668,860 7,061,942 4,098,955 2,275,735 980,153 226,151 11,143
Uninsured 26,910 268,366 250,481 205,559 109,998 27,336 1681
Other 20,369 400,245 378,565 263,212 110,465 23,124 1441
Hospital location
Rural 40,418 497,833 399,459 283,424 121,858 25,527 1495
Urban 880,818 10,234,882 10,165,391 8,929,803 4,357,379 948,762 57,244
Marital status
Married 38,555 2,679,524 5,729,365 6,070,577 3,016,066 631,119 38,118
Single 754,623 6,603263 3,455,024 1,940,115 862,747 207,380 11,770
Unknown 128,058 1,449,928 1,380,461 1,202,536 600,423 135,790 8851
Race
White 340,810 5,158,001 5,880,169 5,321,558 2,529,087 539,545 33,034
Black 209,484 1,955,111 1,196,611 787,313 379,944 90,245 5604
Other 370,430 3,613579 3,482,001 3,099,566 1,567,998 344,178 20,081
Unknown 511 6024 6070 4791 2208 321 20
Comorbidity index
0 79,3159 8,458,694 7,833,194 6,428,585 2,866,827 585,296 33,044
1 80,849 1,635,390 2,081,994 2,184,832 1,256,804 291,177 17,747
2 41,175 520,896 505,158 455,819 263,646 71,749 5715
>2 6053 117,735 144,507 143,993 91,960 26,067 2233
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018. (continued)

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TABLE 2
Patient demographics (continued)
Age Age Age Age Age Age Age
Variables 15e17 y, n 18e24 y, n 25e29 y, n 30e34 y, n 35e39 y, n 40e44 y, n 45e54 y, n
Hospital region
Northeast 92,168 1,312,104 1,545,202 1,695,809 1,695,809 215,718 14,658
Midwest 201,978 2,352,970 2,416,084 1,988,915 1,988,915 164,423 9246
South 409,534 4,596008 4,162,822 3,337,739 3,337,739 321,389 17,164
West 217,556 2,471,633 2,440,742 2,190,765 2,190,765 272,759 17,671
Teaching
Nonteaching 729,306 8,628,574 8,457,462 7,243,851 3,488,870 753,796 43,686
Teaching 191,930 2,104,141 2,107,388 1,969,377 990,366 220,493 15,053
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

0 was highest among women age 15e17 In contrast, women 45e54 years had a years. Postpartum hemorrhage, pre-
years (86%) and decreased for each much higher likelihood for severe eclampsia, and specific morbidity di-
subsequent maternal age group morbidity, with risk >100% greater in agnoses such as thrombosis and
(Supplemental Figure 2), with the lowest unadjusted and adjusted models, hysterectomy were similarly much more
proportion among women aged 45e54 compared with women aged 35e39 likely among women aged 45e54 years.
years (56%) (P <.01). The proportion of
women in each of the higher comor-
bidity score categories (1, 2, >2) FIGURE 1
increased with each maternal age group. Change in proportion of births by maternal age categories
When risk for severe morbidity was
30%
stratified by maternal age group, bimodal
curves were again noted, with risk among
Change in proportion of births by maternal age

20%
those aged 15e17 years being higher than
for women 18e24, 25e29, and 30e34
years (Supplemental Figure 3). For each 10%
comorbidity category, the risk among
women aged 45e54 years was the highest 0%
(P <.01). For example, for women with a
comorbidity score of 0, the risk for severe -10%
morbidity was 3.7% for women 45e54
years compared with 1.4% for women -20%
35e39 years, and for comorbidity scores
of >2, the risk for severe morbidity was -30%
14.4% compared with 8.5% for women
35e39 years (P < .01 for both). -40%

Comment -50%
This analysis demonstrated that for 2006-7 2008-9 2010-1 2012-3 2014-5
women aged 40e44 years, the likelihoods
for most adverse outcomes such as overall
Maternal age in years:
severe morbidity as well as pregnancy
complications including postpartum 15-17 18-24 25-29 30-24 35-39 40-44 45-54
hemorrhage, preeclampsia, gestational
The figure demonstrates the changes in the proportion of births by maternal age by year with
diabetes, and cesarean delivery were
2006e2007 as a reference. Over the study period, births to women aged 45e54 years underwent
modestly increased compared with the largest proportionate change while births to women aged 15e17 years underwent the largest
women aged 35e39 years, with risks decrease.
generally 20e30% higher than this latter Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.
group.

390.e5 American Journal of Obstetrics & Gynecology OCTOBER 2018

ajog.org OBSTETRICS Original Research

studies of women in their late 40s have

FIGURE 2
noted similar findings.8,22,23
Severe morbidity including and excluding transfusion by maternal age
Findings from our study support that
category
counseling regarding maternal risks for
women 45 years and older should be
A
different from that for women aged
3.5%
Severe morbidity excluding transfusion

40e44 years, particularly in the setting of

significant underlying comorbidity.
3.0%
Given the magnitude of risk present,
consultation with a maternal-fetal med-
2.5%
icine specialist for women 45 years and
older may be indicated during preg-
2.0%
nancy in areas in which such services are
2006-08
available. Additionally, for women 45
1.5% 2009-11 years or older with underlying medical
2012-14 comorbidity who are planning the use of
1.0%
assisted reproductive technology, pre-
conception consultation may be benefi-
0.5%
cial. If maternal-fetal medicine services
0.0%
are not available, a consultation with
15-17 18-24 25-29 30-34 35-39 40-44 45-54
medical specialists and anesthesiologists
may be required.
Maternal age in years For a number of adverse outcomes in
this study, maternal ageebased risk was
B
6% bimodal. Absolute risk for severe
Severe morbidity including transfusion

morbidity including transfusion was

higher for women aged 15e17 years
5%
than for women 18e34 years, with risk
similarly higher for preeclampsia and
4% postpartum hemorrhage. The adjusted
model accounting for comorbidity
3% 2006-08 demonstrated the risk for severe
morbidity to be more than a third higher
2009-11 for women aged 15e17 years than
2%
2012-14 women 25e29 years. Women aged
15e17 years were at higher risk for
1% eclampsia than any other group. When
stratified by obstetric comorbidity index
0% score, bimodal risk for severe morbidity
15-17 18-24 25-29 30-34 35-39 40-44 45-54 was similarly observed. The cause of
overall increased risk among the youn-
Maternal age in years
gest group is unclear; risk may be in part
A, Severe morbidity excluding transfusion by maternal age category. B, Severe morbidity including due to social factors and physiology that
transfusion by maternal age category. The figures demonstrates risk for severe morbidity excluding cannot be accounted for within our
(A) and including (B) transfusion based on Centers for Disease Control and Prevention criteria by
study models.
maternal age category in the Premier Perspective database from 2006 through 2014.
Several limitations are important to
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.
consider when interpreting our data.
First, the data analyzed were collected
from an administrative database and
When the cohort was stratified based on older.20 Data from the United Kingdom’s billing codes for secondary diagnoses are
comorbidity, women aged 45e54 years Obstetric Surveillance System found likely tied to reimbursement. There may
remained at high risk for severe increased risk for postpartum hemor- be significant underascertainment of
morbidity. rhage, gestational diabetes, cesarean de- many predictors of severe morbidity that
These findings align with prior studies livery, preeclampsia, and intensive are more prevalent among older women,
that have also demonstrated increased therapy unit admissions among women resulting in our adjusted models over-
risk for women aged 45 years and older than 47 years of age.21 Other estimating the effect of maternal age.

OCTOBER 2018 American Journal of Obstetrics & Gynecology 390.e6

Original Research OBSTETRICS ajog.org

TABLE 3
Unadjusted and adjusted models for severe morbidity including transfusion
Unadjusted model Adjusted model
Variables RR 95% CI aRR 95% CI
Age, y
15e17 1.39 (1.34e1.45) 1.20 (1.15e1.24)
18e24 1.12 (1.10e1.14) 1.00 (0.99e1.02)
25e29 1.00 (Reference) 1.00 (Reference)
30e34 1.07 (1.05e1.09) 1.12 (1.10e1.14)
35e39 1.36 (1.33e1.39) 1.43 (1.40e1.47)
40e44 1.83 (1.77e1.89) 1.90 (1.84e1.97)
45e54 3.33 (3.03e3.66) 3.46 (3.15e3.80)
Year
2006 1.00 (Reference) 1.00 (Reference)
2007 1.04 (1.01e1.08) 1.04 (1.01e1.08)
2008 1.16 (1.13e1.20) 1.16 (1.12e1.20)
2009 1.32 (1.28-1.36) 1.31 (1.27e1.35)
2010 1.31 (1.27e1.35) 1.30 (1.26e1.34)
2011 1.35 (1.31e1.39) 1.33 (1.29e1.38)
2012 1.36 (1.32e1.40) 1.34 (1.30e1.38)
2013 1.36 (1.32e1.40) 1.34 (1.30e1.38)
2014 1.39 (1.35e1.43) 1.36 (1.32e1.40)
2015 1.39 (1.32e1.45) 1.34 (1.28e1.41)
Hospital bed size
Small 1.00 (Reference) 1.00 (Reference)
Medium 1.14 (1.12e1.16) 1.04 (1.02e1.06)
Large 1.24 (1.22e1.26) 1.06 (1.04e1.08)
Insurance status
Commercial 1.00 (Reference) 1.00 (Reference)
Medicare 2.00 (1.89e2.11) 1.72 (1.63e1.83)
Medicaid 1.21 (1.19e1.23) 1.15 (1.13e1.16)
Uninsured 1.24 (1.19e1.29) 1.18 (1.13e1.23)
Other 1.13 (1.09e1.17) 1.16 (1.12e1.21)
Urban location 1.11 (1.09e1.14) 1.00 (0.98e1.02)
Marital status
Married 1.00 (reference) 1.00 (Reference)
Single 1.27 (1.25e1.28) 1.15 (1.13e1.16)
Unknown 1.22 (1.20e1.25) 1.13 (1.11e1.16)
Race
White 1.00 (Reference) 1.00 (Reference)
Black 1.75 (1.72e1.78) 1.58 (1.55e1.61)
Hispanic 1.15 (1.13e1.16) 1.13 (1.12e1.15)
Other 1.21 (0.91e1.60) 1.09 (0.82e1.45)
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018. (continued)

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TABLE 3
Unadjusted and adjusted models for severe morbidity including transfusion (continued)
Unadjusted model Adjusted model
Variables RR 95% CI aRR 95% CI
Hospital region
Northeast 1.00 (Reference) 1.00 (Reference)
Midwest 0.90 (0.88e0.92) 1.00 (0.98e1.03)
South 0.96 (0.95e0.98) 1.05 (1.03e1.07)
West 0.71 (0.79e0.73) 0.85 (0.83e0.87)
Teaching 1.28 (1.27e1.30) 1.19 (1.17e1.21)
Urban hospital location is in reference to rural location; teaching hospitals are in reference to nonteaching.
aRR, adjusted risk ratio; CI, confidence interval; RR, risk ratio.
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

Consequently, women in the 45e54 year Similarly, we do not have granular care. For these reasons, we are limited
age group with no medical comorbidity data available regarding social and in our determination of why younger
may be at lower relative risk than our physiological characteristics; our patients are at higher risk for adverse
models suggest. model includes no data on outpatient outcomes and to what degree social

FIGURE 3
Pregnancy outcomes and complications by maternal age category and year
70% 6%
A C
60%
5%
50%
4%
Proportion of all births
Proportion of all births

40%
2006-08
3% 2006-08
30% 2009-11
2009-11
20% 2012-14 2%
2012-14
10% 1%

0% 0%
15-17 18-24 25-29 30-34 35-39 40-44 45-54
15-17 18-24 25-29 30-34 35-39 40-44 45-54
Maternal age
Maternal age

B 12% D
18%
16%
10%
14%
ProporƟon of all births

Proportion of all births

8% 12%
10%
6% 2006-08 2006-08
8%
2009-11 2009-11
4% 6%
2012-14
2012-14
4%
2%
2%
0% 0%
15-17 18-24 25-29 30-34 35-39 40-44 45-54 15-17 18-24 25-29 30-34 35-39 40-44 45-54
Maternal age Maternal age

A, Cesarean delivery by maternal age category by year. B, Preeclampsia by maternal age category by year. C, Postpartum hemorrhage by maternal age
category by year. D, Gestational diabetes by maternal age category by year. Figure 3, AeD, demonstrates temporal trends in risk for cesarean delivery,
preeclampsia, postpartum hemorrhage, and gestational diabetes by maternal age group by 3 year periods: 2006e2008, 2009e2011, and
2012e2014. Risk for all outcomes was highest for women 45e54 years, with risks significantly higher for this group than women aged 40e44 years
(P < .01).
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

OCTOBER 2018 American Journal of Obstetrics & Gynecology 390.e8

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FIGURE 4
Risks for severe morbidity diagnoses per 10,000 deliveries

A 6 C 30

Cases of eclampsia per 10,000 deliveries

Stroke per 10,000 deliveries

5
25
4
20
3
15
2
10
1
5
0
15-17 18-24 25-29 30-34 35-39 40-44 45-54 0
Maternal age 15-17 18-24 25-29 30-34 35-39 40-44 45-54
Maternal age
B 7 D
120
Thrombosis per 10,000 deliveries

Hysterectomy per 10,000 deliveries

6
100
5
80
4
3 60

2 40

1 20
0 0
15-17 18-24 25-29 30-34 35-39 40-44 45-54 15-17 18-24 25-29 30-34 35-39 40-44 45-54
Maternal age Maternal age
A, Risk for stroke by maternal age per 10,000 deliveries. B, Risk for thrombosis by maternal age per 10,000 deliveries. C, Risk for eclampsia by maternal
age per 10,000 deliveries. D, Risk for hysterectomy by maternal age per 10,000 deliveries. Figure 4, AeD, demonstrates rates of severe morbidity
diagnoses based on Centers for Disease and Prevention criteria for puerperal cerebrovascular disorders, air and thrombotic embolism, eclampsia, and
hysterectomy. Results are reported per 10,000 deliveries per maternal age category. Significant risk occurred across maternal age categories for each
outcome (P < .01).
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

factors vs medical or obstetrical com- A third limitation is that, because an important consideration for women
plications are responsible for the maternal mortality is relatively rare the of advanced maternal age considering
increased risk for morbidity. For denominators for some groups were pregnancy with assisted reproductive
example, while we did find that risk relatively small, we were not able to technology, particularly in the setting of
among women 15e17 years persisted perform meaningful comparisons across other preexisting comorbidities. n
in models adjusted for comorbidity groups for mortality.
including the presence of preeclampsia, Strengths of this study include a large References
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Births in the United States, 2016. NCHS Data
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Author and article information
From the Department of Obstetrics and Gynecology,
College of Physicians and Surgeons, Columbia University,
New York, NY.
Received April 19, 2018; revised July 30, 2018;
accepted Aug. 20, 2018.
Dr Friedman is supported by a career development
award (K08HD082287) from the Eunice Kennedy Shriver
National Institute of Child Health and Human Develop-
ment, National Institutes of Health.
Dr Wright has served as a consultant for Tesaro and
Clovis Oncology. The other authors report no conflict of
interest. Each author has indicated that he or she has met
the journal’s requirements for authorship.
Corresponding author: Alexander Friedman, MD,
MPH. amf2104@cumc.columbia.edu
390.e10
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SUPPLEMENTAL FIGURE 1
Proportion of births by maternal age group by year
100%
Proportion of all births

10%

1%

0%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Maternal age:

15-17 20-24 25-29 30-34 35-39 40-44 45-54

The figure demonstrates the proportion of births by maternal age by year in the Premier Perspective
database from 2006 through 2014. Given the small proportion of births to women aged 45e54
years, the data are presented on a logarithmic scale to facilitate interpretation.
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

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SUPPLEMENTAL FIGURE 2
Proportion of patients with individual comorbidity scores by age group

100%

90%
Proportion of patients with each comorbidity score

80%

70%
Comorbidity
60% index score:
>2 2
50% 1 0

40%

30%

20%

10%

0%
15-17 18-24 25-29 30-34 35-39 40-44 45-54
Maternal age
This figure demonstrates the proportion of patients by age group with comorbidity scores of 0, 1, 2,
and >2. Scores of 0 are representative of the lowest comorbidity. The comorbidity index was
modified to exclude maternal age.
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

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SUPPLEMENTAL FIGURE 3
Risk for severe morbidity by comorbidity score and maternal age

16%
Percent of patients wiht severe morbidity

14%

12%

10%

8%

6%

4%

2%

0%
0 1 2 >2
Obstetric comorbidity score

Maternal age in years:

15-17 18-24 25-29 30-34 35-39 40-44 45-54
The figure demonstrates the risk for severe morbidity including transfusion by comorbidity score by
age group. The comorbidity index was modified to exclude maternal age. For obstetric comorbidity
scores of 0, 1, 2, and >2, women aged 45e54 years were at highest risk for severe morbidity.
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

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SUPPLEMENTAL TABLE 1
Adjusted models for severe morbidity including transfusion including
comorbidity index
Adjusted model
Variables aRR 95% CI
Age, y
15e17 1.38 (1.33e1.44)
18e24 1.08 (1.06e1.10)
25e29 1.00 (Reference)
30e34 1.07 (1.05e1.10)
35e39 1.30 (1.27e1.33)
40e44 1.65 (1.59e1.71)
45e54 2.83 (2.58e3.11)
Year
2006 1.00 (Reference)
2007 1.04 (1.01e1.07)
2008 1.15 (1.11e1.19)
2009 1.29 (1.25e1.33)
2010 1.28 (1.25e1.33)
2011 1.32 (1.28e1.36)
2012 1.32 (1.28e1.36)
2013 1.30 (1.27e1.34)
2014 1.31 (1.27e1.35)
2015 1.28 (1.22e1.35)
Hospital bed size
Small 1.00 (Reference)
Medium 1.03 (1.02e1.05)
Large 1.05 (1.03e1.07)
Insurance status
Commercial 1.00 (Reference)
Medicare 1.43 (1.35e1.52)
Medicaid 1.08 (1.06e1.09)
Uninsured 1.16 (1.11e1.21)
Other 1.14 (1.10e1.18)
Urban location 1.01 (0.99e1.04)
Marital status
Married 1.00 (Reference)
Single 1.10 (1.08e1.12)
Unknown 1.10 (1.08e1.13)
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SUPPLEMENTAL TABLE 1
Adjusted models for severe morbidity including transfusion including
comorbidity index (continued)
Adjusted model
Variables aRR 95% CI
Race
White 1.00 (Reference)
Black 1.48 (1.45e1.51)
Other 1.09 (0.82e1.45)
Comorbidity index
0 1.00 (Reference)
1 1.65 (1.62e1.67)
2 2.66 (2.61e2.72)
>2 5.62 (5.48e5.77)
Hospital region
Northeast 1.00 (Reference)
Midwest 1.00 (0.98e1.02)
South 1.03 (1.01e1.05)
West 0.85 (0.83e0.87)
Teaching 1.13 (1.11e1.15)
Urban hospital location is in reference to rural location; teaching hospitals are in reference to nonteaching.
aRR, adjusted risk ratio; CI, confidence interval; RR, risk ratio.
Sheen et al. Maternal age, adverse outcomes, and maternal risk. Am J Obstet Gynecol 2018.

390.e15 American Journal of Obstetrics & Gynecology OCTOBER 2018