Australian and New Zealand Journal of Obstetrics and Gynaecology 2012; 52: 235241

DOI: 10.1111/j.1479-828X.2012.01442.x

Original Article

Pregnancy outcomes for nulliparous women of advanced maternal age

in South Australia, 19982008
Isobel LUDFORD,1 Wendy SCHEIL,2 Graeme TUCKER3 and Rosalie GRIVELL4
1

Office of Public Health, Department for Health and Ageing, 2Pregnancy Outcome Unit, Epidemiology Branch, Department for Health
and Ageing, 3Health Statistics Unit, Epidemiology Branch, Department for Health and Ageing, Adelaide and 4Discipline of Obstetrics
and Gynaecology, Womens and Childrens Hospital, University of Adelaide, North Adelaide, South Australia, Australia

Background: Child bearing in the later reproductive years has become increasingly common in Australia with potential
implications for clinical practice.
Aim: To examine pregnancy outcomes for nulliparous women of advanced maternal age with singleton pregnancies.
Methods: A retrospective population-based cohort study was conducted to compare the pregnancy outcomes for women
aged 3539 years and  40 years with women aged 2529 years, analysing 34 695 records from the South Australian
Perinatal Database between 1998 and 2008.
Results: Pre-existing hypertension [relative risks (RR) 1.98 and 2.94 for women aged 3539 years and  40 years,
respectively], placenta praevia (RR 2.88 and 3.68), suspected intrauterine growth restriction (RR 1.33 and 1.77) and
gestational diabetes (RR 1.97 and 2.53) increased with age. Women of advanced maternal age were more likely to have
not laboured prior to birth (RR 2.19 and 3.28), be induced (RR 1.12 and 1.27) and have a breech presentation (RR
1.57 and 1.60). The likelihood of fetal distress increased with advancing maternal age (RR 1.15 and 1.24). Regression
analyses revealed women of advanced maternal age were significantly more likely to have small for gestational age infants
[adjusted odds ratios (AOR) 1.26 and 1.50], preterm birth (AOR 1.26 and 1.43), elective caesarean [relative risk ratios
(RRR) 2.55 and 4.52], emergency caesarean (RRR 1.59 and 2.21) and experience a perinatal death (RRR 1.94 and
2.18).
Conclusions: The likelihood of pre-existing medical conditions, obstetric complications, adverse labour and birth
outcomes and complications increased with advancing maternal age. Advanced maternal age was also independently
associated with selected adverse pregnancy and infant outcomes.
Key words: maternal age, nulliparity, pregnancy outcome, obstetrics.

Introduction
Delaying child bearing to the later reproductive years has
become increasingly common in developed countries.1,2
Advances in reproductive medicine as well as social,
educational and economic factors have contributed to this
trend.3 In Australia, the mean age of first birth increased
over the last decade from 27.0 years in 1998 to 28.3 years

Correspondence: Ms Isobel Ludford, Office of Public Health,

Department for Health and Ageing, Citi Centre Building,
11 Hindmarsh Square, Adelaide, SA 5000, Australia.
Email: isobel.ludford@health.sa.gov.au or Dr Wendy Scheil,
Epidemiology Branch, Department for Health and Ageing,
Citi Centre Building, 11 Hindmarsh Square, Adelaide, SA
5000, Australia. Email: wendy.scheil@health.sa.gov.au
Received 6 October 2011; accepted 21 March 2012.

in 2008, and the proportion of first births to women of

advanced maternal age (  35 years) increased from 9.1%
to 14.5%.4,5
The ageing profile of the maternal population has
implications for the woman and her infant, as well as
approaches to clinical management. Women of advanced
maternal age have been reported to smoke less, be of
higher socio-economic status (SES), be more likely to
attend antenatal classes and maintain private health
insurance.68 Biological and physiological changes
associated with advancing age have been associated
with an increased likelihood of pre-existing medical conditions such as hypertension and diabetes, and a greater
risk of obstetric complications including antepartum
haemorrhage (APH) and gestational diabetes.812
Age-related physiological changes have also been
implicated in the differing labour and birth characteristics
of the older maternal population. Previous studies have

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ANZJOG 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology

235

I. Ludford et al.

shown women aged  35 years were less likely to labour

spontaneously and were more likely to be induced than
younger women, and be at greater risk of birth
complications
including
postpartum
haemorrhage
(PPH).10,11,13
Advancing maternal age has also been found to be
highly associated with caesarean birth, an association that
persists after adjustment for known risk factors such as
smoking, pre-existing medical conditions and patient
type.6,9,14 Smith et al.15 reported the rate of caesarean
birth doubled in Scotland between 1980 and 2005, with
the ageing profile of nulliparous women accounting for
38% of additional caesarean births during this period.
The risk of preterm birth, small for gestational age
(SGA) infants and perinatal death have also been
reported to increase with maternal age.8,9,12,16,17 A
number of studies have reported that the effect of age
appears to be additive.9,14
Few studies have examined the pregnancy outcomes for
women of advanced maternal age in the Australian
context. Three studies conducted in the early 1990s
reported an increased risk of medical, obstetric and labour
complications in women aged  35 years compared to
their younger counterparts.6,18,19 More recently, it has
been reported that the risk of labour interventions and
caesarean birth is also increased for Australian women of
advanced maternal age.10,20
The purpose of this study was to update the evidence
around pregnancy outcomes for women of advanced
maternal age in South Australia (SA), using a population
drawn from the SA Perinatal Database. The aims of the
study were to describe the maternal characteristics,
obstetric and labour profiles and birth outcomes for
women aged 3539 years and  40 years, and to examine
the relationship between advanced maternal age and SGA
infants, preterm birth, elective and emergency caesarean
birth, prolonged infant stay in hospital and perinatal
death. As clinical risks, obstetric management and the risk
of adverse pregnancy outcomes differ according to parity
and plurality, and this study examined nulliparous women
with singleton pregnancies only.

Materials and Methods

A retrospective population-based cohort study was
conducted using data extracted from the SA Perinatal
Database. The database has collected data on the
characteristics and outcomes of all births in SA
 20 weeks gestation and/or  400 g birth weight since
1981. Data are collected using standardised outcome
measures and the database has demonstrated reliability.21
The study was approved by the SA Department for
Health and Ageing Human Research Ethics Committee
and the SA Aboriginal Human Research Ethics
Committee.
Data were analysed for SA resident nulliparous women
aged 2529, 3539 and  40 years with singletons births
between 1 January 1998 and 31 December 2008
236

(N = 34 695). The 25- to 29-year-old group was selected

as the reference group as this age group contained the
mean age of first birth in SA for the period 19982008
(27.9 years). Advanced maternal age was defined as 35
39 years and  40 years.
The cohort was described in terms of family status
(married/defacto or other), patient type (public, private),
region (metropolitan, country), smoking status (smoker,
non-smoker) and number of antenatal visits (06,  7).
SES was measured using the Socio-Economic Index for
Areas (SEIFA) categories 15, with category 3 as the
reference category. The likelihood of being higher SES
category 4 or category 5 or lower SES category 1 or
category 2 was calculated. Similarly, the likelihood of
being Aboriginal and/or Torres Strait Islander, or Asian,
was examined using White European as the reference
category.
The presence of any pre-existing medical condition,
pre-existing hypertension, anaemia, pre-existing diabetes,
epilepsy, asthma and urinary tract infections was
described. Obstetric complications included the presence
of any complication, pregnancy induced hypertension,
gestational diabetes, suspected intrauterine growth
restriction (IUGR) and APH defined separately as
abruption, placenta praevia or because of other/unknown
cause. Onset of labour (spontaneous, induced, no labour),
presentation (cephalic, breech/other) and the presence of
complications including PPH, fetal distress, retained
placenta and failure to progress were examined. SGA
infants, preterm birth (<37 weeks), method of birth
(vaginal, elective caesarean, emergency caesarean) and
infant outcome (normal hospital stay, prolonged hospital
stay >28 days, perinatal death) were also examined.
The relationship between advanced maternal age and
SGA infants, preterm birth, method of birth and infant
outcome was examined after adjustment for demographic
characteristics, obstetric complications and adverse
birthing characteristics and complications, which could
confound the association between advanced maternal age
and the outcome of interest.
Statistical analyses were conducted using SPSS
version 17.0.22 A priori power calculations indicated that
there was sufficient power to detect a relative risk (RR)
of 2.0 for the outcomes of interest. Pearsons chisquared test was applied to categorical data and used to
identify medical conditions, obstetric complications and
risk factors with a significant relationship to SGA
infants, preterm birth, method of birth and infant
outcome, for adjustment in the regression models.
Fishers exact test was applied where cell sizes were <5.
The results of the tests were reported as RR with 95%
confidence intervals (P < 0.05). Logistic regression with
backwards elimination was used to test the association
between maternal age and preterm birth, and maternal
age and SGA infants. Multinomial regression was
applied to method of birth and infant outcome, as there
were three possible outcomes categories for these
variables.
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Advanced maternal age and pregnancy outcomes

likely, to be of higher SES than their younger

counterparts. The proportion of women attending  7
antenatal visits was consistent across all age groups
(range 95.1% to 96.3%).
Women of advanced maternal age were more likely to
have a pre-existing medical condition, and the risk of preexisting hypertension, in particular, was significantly
higher for women aged 3539 years (RR 1.98, 95% CI
1.65, 2.38) and  40 years (RR 2.94, 95% CI 2.19,
3.97). The risk of obstetric complications including
suspected IUGR and gestational diabetes also increased
with maternal age (Table 2). The most marked increase in
risk was observed for placenta praevia (RR 2.88, 95% CI
2.15, 3.84 and RR 3.68, 95% CI 2.26, 5.97, respectively).
Women aged 3539 years and  40 years were significantly more likely not to have laboured prior to birth
(RR 2.19, 95% CI 2.05, 2.35 and RR 3.28, 95% CI 2.97,
3.63, respectively), be induced and have a breech
presentation (Table 3). Older women were also more likely
to experience a complication during labour, and in
particular, the likelihood of fetal distress significantly

The results of the final regression models were reported

as adjusted odds ratios (AOR) for the logistic regression
and relative risk ratios (RRR) for the multinomial
regression, with 95% confidence intervals (P < 0.05).

Results
There were 7116 women aged 3539 years and 1306
women aged  40 years who delivered their first baby in
SA between 1998 and 2008. During this period, 26 273
women aged 2529 years gave birth to their first baby.
Women aged 3539 years and  40 years were more
likely to be private patients (RR 1.58, 95% CI 1.54, 1.62
and RR 1.68, 95% CI 1.60, 1.76, respectively) and be
non-smokers (RR 0.83, 95% CI 0.78, 0.88 and RR 0.81,
95% CI 0.71, 0.92, respectively) than their younger
counterparts (Table 1). Older women were also more
likely to reside in metropolitan areas and be of higher
SES. For example, of the women in SEIFA categories 3
and 5, women aged 3539 years were 1.24 times as
likely, and women aged  40 years were 1.29 times as
Table 1 Maternal characteristics

Maternal characteristics

2529 years
(n = 26 273)

3539 years
(n = 7116)

 40 years
(n = 1306)

Proportion
within age
group (%)

Proportion
within age
group (%)

Proportion
within age
group (%)

RR (95% CI)

RR (95% CI)

93.0

89.4

0.84 (0.76, 0.92)

<0.001

1.27 (1.08, 1.49)

0.005

55.4

58.7

1.58 (1.54, 1.62)

<0.001

1.68 (1.60, 1.76)

<0.001

17.3

16.7

0.64 (0.61, 0.68)

<0.001

0.62 (0.55, 0.70)

<0.001

0.5
5.6

0.3
6.6

0.72 (0.50, 1.03)

0.86 (0.77, 0.95)

0.072
0.004

0.45 (0.17, 1.22)

1.00 (0.81, 1.24)

13.5
17.8
21.5
28.3

11.8
16.6
22.7
30.2

0.84
0.95
1.06
1.24

0.88)
0.99)
1.10)
1.29)

<0.001
0.015
0.004
<0.001

0.78
0.93
1.10
1.29

0.89)
1.02)
1.19)
1.37)

<0.001
0.108
0.026
<0.001

15.6

15.2

0.83 (0.78, 0.88)

<0.001

0.81 (0.71, 0.92)

0.001

96.1

96.3

1.01 (1.00, 1.02)

<0.001

1.01 (1.00, 1.03)

0.580

28.5
2.5
4.6
0.6
0.6
5.3
1.3

34.1
3.7
5.6
0.7
0.4
5.7
1.9

1.12
1.98
1.03
1.30
1.26
0.81
0.57

<0.001
<0.001
0.672
0.157
0.180
<0.001
<0.001

1.33
2.94
1.22
1.59
0.76
0.87
0.81

Family status (Ref: other)

Married/defacto
91.6
Patient type (Ref: public)
Private
35.0
Region (Ref: metropolitan)
Country South Australia
26.8
Race (Ref: White European)
Aboriginal/Torres Strait Islander
0.7
Asian
6.5
SEIFA (Ref: category 3)
Category 1
19.9
Category 2
21.0
Category 4
20.2
Category 5
18.7
Smoking status (Ref: non-smoker)
Smoker
18.9
Antenatal visits (Ref: 06 visits)
 7 visits
95.1
Medical condition (Ref: without condition)
Any condition
25.6
Pre-existing hypertension
1.2
Anaemia
4.7
Pre-existing diabetes
0.4
Epilepsy
0.5
Asthma
6.6
Urinary tract infection
2.4

 40 years

3539 years

(0.79,
(0.91,
(1.02,
(1.20,

(0.17,
(1.65,
(0.91,
(0.91,
(0.90,
(0.72,
(0.46,

1.16)
2.38)
1.16)
1.86)
1.76)
0.90)
0.71)

(0.69,
(0.84,
(1.02,
(1.21,

(1.23,
(2.19,
(0.97,
(0.81,
(0.31,
(0.69,
(0.55,

1.44)
3.97)
1.54)
3.12)
1.86)
1.09)
1.20)

0.115
0.979

<0.001
<0.001
0.088
0.177
0.549
0.212
0.302

RR, relative risks; SEIFA, Socio Economic Index for Areas.

Includes never married, widowed, separated and divorced.
P value for Fishers exact test where comparison included cell size <5.
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I. Ludford et al.

Table 2 Obstetric complications

Obstetric outcomes

2529 years
(n = 26 273)

3539 years
(n = 7116)

 40 years
(n = 1306)

Proportion
within age
group (%)

Proportion
within age
group (%)

Proportion
within age
group (%)

36.6
0.7
1.1
2.5
11.6
3.2
6.5

41.1
0.4
1.5
3.1
11.7
4.3
8.3

Obstetric complications (Ref: without complication)

Any complication
31.0
APH abruption
0.8
APH placenta praevia
0.4
APH other/unknown cause
2.4
Pregnancy induced hypertension
11.0
Suspected IUGR
2.4
Gestational diabetes
3.3

 40 years

3539 years

RR (95% CI)
1.18
1.14
2.88
1.05
1.05
1.33
1.97

(1.14,
(0.84,
(2.15,
(0.89,
(0.98,
(1.14,
(1.77,

1.22)
1.53)
3.84)
1.24)
1.13)
1.54)
2.20)

P
<0.001
0.402
<0.001
0.550
0.156
<0.001
<0.001

RR (95% CI)
1.33
0.55
3.68
1.29
1.06
1.77
2.53

(1.24,
(0.23,
(2.26,
(0.94,
(0.91,
(1.35,
(2.09,

1.42)
1.34)
5.97)
1.76)
1.24)
2.31)
3.07)

P
<0.001
0.183
<0.001
0.116
0.428
<0.001
<0.001

APH, antepartum haemorrhage; RR, relative risks; IUGR, intrauterine growth restriction.
Table 3 Birthing characteristics and complications

Labour and birth outcomes

2529 years
(n = 26 273)

3539 years
(n = 7116)

 40 years
(n = 1306)

Proportion
within age
group (%)

Proportion
within age
group (%)

Proportion
within age
group (%)

RR (95% CI)

RR (95% CI)

15.5
34.3

22.7
35.5

2.19 (2.05, 2.35)

1.12 (1.09, 1.16)

<0.001
<0.001

3.28 (2.97, 3.63)

1.27 (1.19, 1.36)

<0.001
<0.001

8.9

9.1

1.57 (1.43, 1.71)

<0.001

1.60 (1.34, 1.91)

<0.001

55.8
5.5
20.4
2.0
24.4

57.5
6.3
22.1
1.9
22.0

1.09
1.05
1.15
1.53
1.20

1.12)
1.18)
1.21)
1.86)
1.26)

<0.001
0.352
<0.001
<0.001
<0.001

1.12
1.21
1.24
1.47
1.08

1.18)
1.50)
1.38)
2.20)
1.20)

<0.001
0.089
<0.001
0.059
0.144

12.3
33.7

18.5
37.2

2.62 (2.42, 2.83)

1.49 (1.43, 1.55)

<0.001
<0.001

4.15 (3.69, 4.67)

1.77 (1.65, 1.89)

<0.001
<0.001

9.0

10.4

1.30 (1.19, 1.41)

<0.001

1.50 (1.27, 1.77)

<0.001

12.0

14.0

1.18 (1.10, 1.27)

<0.001

1.39 (1.21, 1.59)

<0.001

2.5
1.2

2.1
1.5

1.50 (1.27, 1.79)

1.69 (1.32, 2.18)

<0.001
<0.001

1.31 (0.90, 1.91)

2.14 (1.35, 3.38)

0.163
0.001

Onset of labour (Ref: spontaneous)

No labour
7.1
Induction
33.6
Presentation (Ref: cephalic)
Breech/other position
5.7
Complications (Ref: without complication)
Any complication
51.2
Postpartum haemorrhage
5.2
Fetal distress
17.8
Retained placenta
1.3
Failure to progress
20.3
Method of birth (Ref: vaginal)
Elective caesarean
5.4
Emergency caesarean
24.5
Preterm birth (Ref:  37 weeks)
<37 weeks
6.9
SGA infant (Ref: not SGA infant)
SGA
10.1
Infant outcome (Ref: normal stay in hospital)
Prolonged hospital stay >28 days
1.7
Perinatal death
0.7

 40 years

3539 years

(1.07,
(0.94,
(1.09,
(1.26,
(1.15,

(1.07,
(0.97,
(1.12,
(0.98,
(0.97,

SGA, small for gestational age; RR, relative risks.

Includes cord, shoulder and transverse lie presentations.

increased with age (RR 1.15, 95% CI 1.09, 1.21 and RR

1.24, 95% CI 1.12, 1.38, respectively).
The risk of elective caesarean increased for women
aged 3539 years (RR 2.62, 95% CI 2.42, 2.83) and
 40 years (RR 4.15, 95% CI 3.69, 4.67), as did the risk
of emergency caesarean (RR 1.49, 95% CI 1.43, 1.55 and
RR 1.77, 95% CI 1.65, 1.89, respectively). The likelihood
of having an SGA infant also significantly increased with
age (RR 1.18, 95% CI 1.10, 1.27 and RR 1.39, 95% CI
238

1.21, 1.59, respectively) as did preterm birth (RR 1.30,

95% CI 1.19, 1.41 and RR 1.50, 95% CI 1.27, 1.77,
respectively).
The results of the regression analyses revealed that
adverse pregnancy outcomes increased consistently with
age, after adjustment for known risk factors and
confounders to the outcomes of interest (Table 4).
Advanced maternal age was found to be associated with
an increased risk of SGA infants for women aged
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Advanced maternal age and pregnancy outcomes

Table 4 Relationship of advanced maternal age with selected pregnancy and infant outcomes
3539 years (n = 7116)
Outcome

AOR

Preterm birth
SGA infant
Method of birth
Elective caesarean
Emergency caesarean
Infant outcome
Perinatal death
Prolonged stay >28 days

1.26
1.26

RRR

 40 years (n = 1306)

95% CI

AOR

1.15, 1.40
1.16, 1.37

<0.001
<0.001

1.43
1.50

2.55
1.59

2.31, 2.80
1.48, 1.70

<0.001
<0.001

1.94
1.59

1.49, 2.52
1.31, 1.93

<0.001
<0.001

RRR

95% CI

1.18, 1.73
1.28, 1.77

<0.001
<0.001

4.52
2.21

3.82, 5.35
1.91, 2.55

<0.001
<0.001

2.18
1.19

1.35, 3.52
0.79, 1.80

0.001
0.405

AOR, adjusted odds ratios; SGA, small for gestational age; RRR, relative risk ratios.
Reference group was nulliparous women with singleton pregnancies aged 2529 years (n = 26 273).

3539 years (AOR 1.26, 95% CI 1.16, 1.37) and

 40 years (AOR 1.50, 95% CI 1.28, 1.77), after
adjustment for race, SES, smoking, hypertension (preexisting and pregnancy induced), anaemia and antenatal
visits. Advanced maternal age was also associated with
preterm birth for women aged 3539 years (AOR 1.26,
95% CI 1.15, 1.40) and  40 years (AOR 1.43, 95% CI
1.18, 1.73), after adjustment for smoking, hypertension
(pre-existing and pregnancy induced), anaemia, diabetes
(pre-existing and gestational) and APH (abruption,
placenta praevia and other/unknown cause).
The multinomial regression for method of birth
revealed the risk of having an elective caesarean increased
for women aged 3539 years (RRR 2.55, 95% CI 2.31,
2.80) and  40 years (RRR 4.52, 95% CI 3.82, 5.35).
The risk of an emergency caesarean also increased for
women of advanced maternal age (RRR 1.59, 95% CI
1.48, 1.70 and RRR 2.21, 95% CI 1.91, 2.55,
respectively), after adjustment for patient status, region,
race, smoking, hypertension (pre-existing and pregnancy
induced), diabetes (pre-existing and pregnancy induced),
APH (abruption and other/unknown cause), IUGR, fetal
distress and failure to progress.
Analysis of infant outcome revealed infants born to
women aged 3539 years were significantly more likely to
have a prolonged stay in hospital >28 days than those
born to women aged 2529 years, however, no significant
difference was observed for women aged  40 years.
Women aged 3539 years and  40 years were more
likely to experience a perinatal death (RRR 1.94, 95% CI
1.49, 2.52 and RRR 2.18, 95% CI 1.35, 3.52,
respectively), after adjustment for antenatal visits,
hypertension (pre-existing and pregnancy induced), preexisting diabetes, APH (abruption, placenta praevia and
other/unknown cause), suspected IUGR and failure to
progress.

Discussion
The demographic profile of the SA cohort was consistent
with previous studies and showed that women of

advanced maternal age were more likely to be nonsmokers, of higher SES and maintain private health
insurance.68 Women of advanced maternal age were also
more likely to have a pre-existing medical condition and,
in particular, pre-existing hypertension, consistent with
previous findings.6,912,18,19
The risk of having an obstetric complication, placenta
praevia, suspected IUGR and gestational diabetes
consistently increased with age.9,11,13,17,18 No relationship
between advanced maternal age and the risk of placental
abruption was observed. The characteristics of the cohort,
in addition to a lack of power in the comparison (<50%),
may partially account for this result with previous
pregnancies and multiple pregnancies risk factors for
placental abruption.23,24 Interestingly, the frequency of
pregnancy induced hypertension was consistent across the
age groups (range 11.011.7%).
Consistent with previous findings, the risk of having an
SGA infant increased with maternal age.12,17 Smoking
was found to be the largest contributing risk factor in the
regression model. A lower number of antenatal visits (06
visits) significantly contributed to the model, suggesting
that the opportunity to detect and manage restricted fetal
growth during the antenatal period may be an important
factor for this infant outcome. Anaemia was found to
have a small protective effect; however, this may be
related to attendance for antenatal care rather than a
direct physiological effect. In line with previous findings,
advanced maternal age was also significantly associated
with preterm birth12,13,16, with APH and gestational
diabetes, the largest contributors to the model.
Adverse birthing outcomes and complications were
found to be more frequent in women of advanced
maternal age. Women aged  35 years were less likely to
labour prior to birthing and were found to be at increased
risk of pre-conditions to caesarean birth, including breech
presentation.6,14 Advancing maternal age was significantly
associated with an increased risk of both elective and
emergency caesarean birth, after adjustment for known
risks factors and confounders. The effect of maternal age
was found to be additive, with the risk of elective and

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I. Ludford et al.

emergency caesarean birth higher for women aged

 40 years relative to those aged 3539 years.
In the model for infant outcome, evidence for an
association between advanced maternal age and prolonged
infant stay in hospital was mixed. The risk of perinatal
death, however, consistently increased with advancing
maternal age. Smoking was not identified as an
independent risk factor for perinatal death in the final
regression model, which may be as result of missing data
and the relatively low numbers in this group. Failure to
progress was associated with a reduced risk of perinatal
death, a finding that may be owing to these infants being
actively managed and delivered by caesarean.
This study addressed a number of methodological
limitations identified in previous Australian studies. The
generalisability of previous findings have been limited by
small sample sizes, the use of patient records, lack of
control for parity and plurality, different methodologies
used to extract data for study and reference groups, and
limited control for risk factors such as smoking. Utilising
a population cohort drawn from the SA Perinatal
Database reduced the issue of selection bias present in
previous studies.6,20 Data were extracted and analysed in
a consistent manner for both the study and reference
groups using standardised, reliably collected outcome
measures. This study also accounted for known risk
factors for adverse pregnancy and infant outcomes, such
as smoking, and controlled for plurality and parity, which
were not consistently adjusted for in a number of previous
studies.6,1820
There were, however, a number of limitations in this
study. Population-based cohort studies are retrospective
and limited in their capacity to examine clinical risk
factors outside the collected database. For example, it was
not possible to examine the effect of artificial reproductive
therapy (ART) or high body mass index (BMI), both of
which have been associated with a range of adverse
pregnancy outcomes.25,26
The findings have a number of practical implications
for clinical practice. There is a need to increase public
awareness of the potential risks that pre-existing and
pregnancy induced medical conditions pose to mother
and child, as well as the risk of adverse pregnancy
outcomes and the fertility implications of pregnancy
later in life. Pre-conception counselling can identify
these risks and assist women in making informed
decisions about their reproductive options as they age.
Clinician awareness of the risks associated with
pregnancy in the later reproductive years is crucial to
ensure that an appropriate level of surveillance is
maintained to allow for the prevention and early
detection of complications.
In conclusion, advanced maternal age was shown to be
associated with increased risk of pre-existing medical
conditions, obstetric complications, and labour and
birthing complications in nulliparous women with
singleton pregnancies. Maternal age was found to have an
independent, additive association with the risk of having
240

an SGA infant, preterm birth, elective caesarean birth,

emergency caesarean birth and perinatal death. These
findings have implications for pre-pregnancy counselling
and clinical practice in terms of the surveillance for and
management of complications in women of advanced
maternal age. Further investigation of the role of BMI and
ART is warranted.

Acknowledgements
We would like to thank all of the midwives, neonatal
nurses and other hospital staff who notified to the SA
Perinatal Database. Kind support for this study was
provided by the South Australian Department for Health
and Ageing.

Conflict of interest
The authors declare no competing interests in the
submission of this article.

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