Christina Applegate is doing it. So is Alanis Morissette. Kelly Preston and Celine Dion, too. They're all having babies after age 35.

If you're pregnant and at a similar age, there's good news.

"The majority of women over age 35 have healthy pregnancies and healthy babies," said Jim Link, an obstetrician/gynecologist with Partners in Women's Health in Louisville. "There's really not any preset age that's unsafe for any one patient to become pregnant."

But there are some things to think about.

"Pregnancy is a one-year project -- three months to get tuned up and then nine months to do the pregnancy," said Stanley A. Gall, a professor of obstetrics, gynecology and women's health at the University of Louisville.

"Consider what kind of health you're in," Gall said. "It becomes important to maintain good health because healthy moms are more likely to have healthy babies."

Schedule a pre-pregnancy visit. Some physicians recommend visiting an OB/GYN before getting pregnant. The doctor can review your medical history and "determine what things, potentially, besides age, are going to be risk factors for that pregnancy," Link said.

The doctor is likely to consider such things as, "Are your vaccinations up to date? Are you in a good body-mass-index range? Is your blood pressure normal? Is your renal function good?" said Link. Some things can be addressed "prior to conceiving and make your life a whole lot easier, not to mention the baby's," he said.

Follow your doctor's instructions. Your doctor probably will want you to take at least 400 micrograms of folic acid a day to reduce the chance of neural tube defects, such as spina bifida, and to take steps to get troublesome medical conditions, such as diabetes and high blood pressure, under control. You also might be asked to change medications.

Be aware of medical conditions that can affect older mom.

"When women conceive over the age of 40, there's a greater incidence of gestational diabetes, preeclampsia and other medical complications," said Steven Nakajima, director of reproductive endocrinology and infertility at the University of Louisville. "It's a taxing effort on your body."

Women older than 35 have a higher chance of having a child with Down syndrome than women who are younger.

Here is some specific advice for older women:

Watch your weight. Older women who are heavy tend to have problems such as diabetes, high blood pressure and asthma during pregnancy, said Stanley A. Gall, a professor at the University of Louisville.

Genetic counseling. This can help determine the risk of passing down an inherited disease. It also may provide clues to couples who've experienced recurrent miscarriages. And it can give some couples "peace of mind," said Jim Link, an obstetrician/gynecologist with Partners in Women's Health in Louisville.

Make smart choices. "It's never too late to make positive health changes," such as "stopping smoking, minimizing your stress, trying to get a regular amount of cardiovascular exercise on board, really rounding out your nutrition -- doing away with fast food, minimizing the processed foods, minimizing the high-sugar foods, minimizing your caffeine intake," Link said. "There's a lot of nutritional things that you can do."

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PregnancyWeekly.com

Conventional wisdom says that the better educated a woman is, the more likely she is to delay motherhood. But a new study suggests personality type could be a more powerful determinant.

The research found that high levels of "extroversion", "agreeableness" and "neuroticism" accelerated the desire of a woman to have a child. Conversely, high "conscientiousness" and "openness" were associated with delaying childbirth.

In the report, by the Institute of Social and Economic Research, the five personality traits were cross-referenced with the age at which more than 16,000 women had their first child.

Lara Tavares, author of the study – Who Delays Childbearing? The Relationships Between Fertility, Education and Personality Traits – used data from the British Household Panel Survey (BHPS) collected over the past five years.

There is on average a two-year gap between the mean age at first birth of women with and without higher educational qualifications.

But, said Tavares, personality traits could help to explain the maternity timing gap between women with differing levels of education. "Most studies do find evidence of a positive relationship between education and age at first birth," she said. "However, the nature of this relationship is far less clear. The difficulty in studying the relationship between education and fertility is that it might be spurious.

"First, personality traits influence both education and fertility decisions. Secondly, some highly educated women – the more 'open-minded' – severely postpone childbearing, and therefore they push up the average age at first birth within the group of more educated women, thereby creating a fertility timing gap between more and less educated women."

According to the BHPS categorizations, extroversion is mainly characterized by sociability, with extroverts tending to be talkative and assertive. Agreeableness relates to the subject's willingness to help others – to be caring, co-operative and kind.

Neuroticism indicates the subject's emotional stability, with high scorers tending to be anxious, depressed and insecure. Those who scored highly on conscientiousness tended to follow the rules, to be reliable, well-organised and self-disciplined.

"Openness" reflected an individual's tendency to unconventionality and intellect. Open-minded women tend to enjoy being unattached, free, not tied to people, places, or obligations – and may be rebellious.

"More 'open-minded' people might be less vulnerable to the social pressure for having children," said Tavares. "Because people who score high on openness usually have wide interests, they are less likely to be exclusively family-oriented. Consequently, they might value their careers more and therefore face higher psychological childbearing costs.

"Declining fertility rates are associated with a transition to an individualistic family model, characterized by self-development, individual autonomy and gender equality. In other words, the change in values that resulted in a greater weight being given to individual preferences. Or, to put it another way, to openness."

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PregnancyWeekly.com

First-time moms who are older than 30, overweight or have breastfeeding difficulties on their newborn's first day may have increased odds of a delay in their full breast milk production, a new study suggests.

After giving birth, women produce a precursor to breast milk called colostrum until their full breast milk comes in; if that shift does not happen within 72 hours, researchers consider it "delayed lactogenesis."

The concern with this is that some infants may start to become dehydrated and lose excess weight (some weight loss after birth is normal), and that some mothers, worried and frustrated, may give up on breastfeeding.

However, new moms with a delay in full milk production should not be discouraged, said Dr. Laurie A. Nommsen-Rivers of Cincinnati Children's Hospital Medical Center in Ohio, the lead researcher on the new study.

Instead, she said, they should call their pediatrician or "lactation consultant" -- a specialist in breastfeeding issues who works in some hospitals and also in private practice.

With some support, Nommsen-Rivers said, mothers with delayed breast-milk production will "do just fine." She noted that nearly all new moms -- 98 percent -- have their milk come in within a week.

For the current study, published in the American Journal of Clinical Nutrition, Nommsen-Rivers and her colleagues looked at the factors associated with delayed lactation among 431 first-time mothers who gave birth at one California medical center.

The researchers focused on first-time mothers because they are significantly more likely than women who've given birth before to have a delay in their breast milk coming in.

Overall, the study found, 44 percent of the women took longer than 72 hours to have their milk come in -- which was assessed by asking the study participants whether their breasts felt "noticeably fuller" three days after giving birth.

Women who were overweight or obese were more likely than thinner women to have a delay; 45 percent and 54 percent, respectively, compared with 31 percent of normal-weight women. Age also appeared to be a factor, as 58 percent of women age 30 and older had a delay in their breast milk coming in, versus 39 percent of younger women.

In addition, mothers who said they had "breastfed well" at least twice during the first 24 hours of their newborn's life -- when colostrum is produced -- were less likely to have a delay in their milk coming in: 39 percent to 43 percent of these women had a delay, compared with 65 percent of mothers who reported only one or no instance of breastfeeding "well" in the first 24 hours.

Another factor related to delayed milk production was nipple soreness. Women who had more than mild soreness in the first few days after giving birth were less likely to have a delay than other women.

That soreness, the researchers note, may be an indicator of more-effective early breastfeeding, which would encourage full milk production.

It is not clear why relatively older age and heavier weight in the mother would be associated with a higher risk of delayed lactation, according to Nommsen-Rivers.

But both, she and her colleagues note, are related to greater odds of carbohydrate "intolerance" during pregnancy. Problems in sugar metabolism could be a factor in the higher risk of delays in full breast-milk production, they speculate.

Whatever the underlying mechanisms for the findings, Nommsen-Rivers said that the bottom line for women is to seek help for any early breastfeeding difficulties.

She suggested that during pregnancy, women try to see a provider who has an affiliation with a lactation consultant. A home visit from the consultant in the first couple days after a woman gives birth can help identify and address any breastfeeding difficulties.

Women who feel their milk has not come in within 72 hours should call their pediatrician, Nommsen-Rivers said. The doctor can weigh and assess the baby, and watch the mother breastfeed to help spot any problems.

To help support early breastfeeding success, the American Academy of Pediatrics recommends that women ask to have their newborn placed in skin-to-skin contact with them immediately after birth so that they can breastfeed.

Frequent feedings in the early days are also important, Nommsen-Rivers said. It is often recommended that women breastfeed every two hours, but she suggested that new moms try to breastfeed whenever their newborn "shows an interest," with cues such as "smacking" his or her lips.

The rate of delayed milk production in this study -- 44 percent -- is significant, according to Nommsen-Rivers. Past studies have shown that compared with U.S. women, those in less-developed nations, such as Peru and Guatemala, tend to have their milk come in more quickly.

Pinning down the reasons for that difference -- including the facets of modern maternity care that may be involved -- will be important, Nommsen-Rivers said.

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PregnancyWeekly.com

Women who had gestational diabetes in their first and second pregnancies are at greatly increased risk for the condition in future pregnancies, a new study finds.

Gestational diabetes can lead to early delivery, cesarean section and type 2 diabetes in the mother, and may increase a child's risk of developing diabetes and obesity later in life.

"Because of the silent nature of gestational diabetes, it is important to identify early those who are at risk and watch them closely during their prenatal care," lead author Dr. Darios Getahun, a research scientist/epidemiologist in the research and evaluation department at Kaiser Permanente Southern California, said in a Kaiser news release.

In this study, researchers analyzed the medical history of more than 65,000 women who delivered babies at a Kaiser Permanente Southern California medical center between 1991 and 2008.

Compared to women who didn't have gestational diabetes in their first and second pregnancies, those who had the condition in their first but not second pregnancies were more than six times as likely to develop it in their third pregnancy. Women who had gestational diabetes in their first and second pregnancies were almost 26 times more likely to have it during their third pregnancy, the team report.

The risk of gestational diabetes recurrence was higher in Hispanics and Asian/Pacific Islanders than in whites. Recurrence was also more common in women 30 and older and in those with a longer period of time between any two of their successive pregnancies.

The findings, published online in the American Journal of Obstetrics and Gynecology, highlight the importance of educating and counseling pregnant women who developed gestational diabetes in a previous pregnancy, said the researchers.

"Clinicians should be aware and counsel potential pregnant women about their increased risk and that early detection and initiation of treatment is important, because unrecognized or untreated gestational diabetes is likely to lead to adverse maternal and fetal outcomes," Getahun said.

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Lee Robinson wasn't all that excited about having a baby, It's not that she didn't want one, it's just that she and her husband, Claude, were happy with their busy lives in Thomson, Georgia, where she's a high school teacher and he's a caterer.

Life rolled merrily along until one day, at age 44, Robinson discovered to her great shock that she was pregnant. When not one but two pregnancy tests confirmed the news, she plastered herself to the internet to figure out how risky this pregnancy was for her and her baby.

What she found online wasn't comforting. A slew of statistics about the high risks of birth defects for the baby and pregnancy-related diseases for her scared the wits out of her.

"I'd be less than normal if I didn't think this was pretty severe, life-threatening stuff," Robinson says. "All kinds of things run through your mind."

These days, more women are finding themselves in Robinson's situation. The birth rate for women age 40-44 increased 4 percent in 2008 from 2007, according to the Centers for Disease Control and Prevention. Contrast that to the birth rate for women below age 40, which went down as much as 3 percent from 2007 to 2008.

"Whatever can go wrong goes wrong at an increased rate for a woman who is older starting pregnancy," says Dr. Alan Fleischman, medical director for the March of Dimes.

So just how scary is it for a woman over 40 to have a baby? We asked physicians at the March of Dimes and the American College of Obstetrics and Gynecologists to set the numbers out for us.

Higher risk of miscarriage

• At age 20: 1 in 10 women
• At age 35: 1 in 5 women
• At age 40: 1 in 3 women
• At age 45: 1 in 2 women

Noncancerous tumors called fibroids and endometriosis, the abnormal growth of the lining of a woman's uterus, can lead to a miscarriage.

Higher risk of any chromosomal disorder

• At age 20: 1 in 526 births
• At age 30: 1 in 385 births
• At age 40: 1 in 66 births
• At age 45: 1 in 21 births

Women are born with all the eggs they'll ever have. As a woman ages, her eggs also age.

Higher risk of Down syndrome

• At age 25: 1 in 1,250 births
• At age 30: 1 in 1,000 births
• At age 35: 1 in 400 births
• At age 40: 1 in 100 births
• At age 45: 1 in 30 births
• At age 49: 1 in 10 births

As a woman ages, the risk of delivering a baby with Down syndrome increases. Down syndrome is a genetic disorder often caused by an error in cell division. There are multiple types of Down syndrome, and the exact cause is not known.

Higher risk of gestational diabetes

• At age 20: 22 in 1,000 women
• At age 25: 36 in 1,000 women
• At age 30: 51 in 1,000 women
• At age 35: 67 in 1,000 women
• At age 40: 84 in 1,000 women

Pregnancy stresses the body, requiring the pancreas to produce more insulin. In older women, having a baby can trigger diabetes during pregnancy.

Higher risk of preeclampsia

• At age 20: 38 in 1,000 women
• At age 25: 37 in 1,000 women
• At age 30: 36 in 1,000 women
• At age 35: 39 in 1,000 women
• At age 40: 48 in 1,000 women

"Women as they get into their 40s may also have some hypertension already," Fleischman says. "And if they do, they have a higher risk of that being exacerbated during pregnancy."

Advantages of being an older mom

Working women who have children later in life are often able to spend more time with their families because they're in a better position to negotiate flexible schedules, according to research by Elizabeth Gregory, author of the book, "Ready: Why Women Are Embracing the New Later Motherhood," and director of the Women's Studies Program at the University of Houston.

"Women report that the clout they've established at work in the years before they have kids gives them a bargaining chip that they wouldn't have had" at an earlier stage of their career, Gregory says.

Plus, women who wait to have children make more money and are better able to provide for their families, according to Gregory's analysis of 2000 census data.

Gregory looked at women in their early 40s and found sizable salary differences based on when they'd had their children. She found that those who'd had babies in their mid-20s had salaries in the mid-$40,000 range, but those who waited to have babies until their mid- to late-30s had salaries that averaged in the $70,000 range.

The reason, she says, is simple. "Once kids arrive, it's much harder for women to continue to climb the career ladder, so if they start having babies earlier, they tend to get stuck down on the ladder," she says.

Last week, Robinson gave birth to a healthy boy named Price, and now she and her husband are thinking about having another child, even though she's 44 years old.

"It's really overwhelming to think I never thought I was going to be a mom," Robinson says. "We're both just absolutely in love with this little baby."

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PregnancyWeekly.com

Just when to have the first child is more than just a family decision for the couple; it may have longer-term repercussions that affect a woman's lifelong earnings, according to a preliminary study presented Thursday at a session of the Population Association of America meeting.

Researchers at the University of Maryland in College Park and the University of California at Los Angeles reviewed 35 years of data from some 2,200 women born between 1944 and 1954, and found that women who had kids in the early- to mid-20s or even younger didn't fare as well economically as those who delayed.

Research has found that women who are childless tend to have greater earnings and those with kids have what some have referred to as a "motherhood penalty," that is, lower wages for working mothers.

But this new study, presented by co-author Joan Kahn, a sociologist at the University of Maryland in College Park, finds women who got more education and job training before having children don't experience that so-called "penalty."

"Women who delay childbearing end up as successful economically as women who didn't have children, and we look at it basically throughout their adult years — well into their 50s," she says.

Although the study used age 26 as the age for these later births, Kahn says there's nothing magical about it. She says they picked it for the analysis because 20% of those studied had had their first-born at 26.

The point, she says, is that women who are younger when they have kids and attempt to get back into the workforce later may not have that up-front investment in education and training, which those who have kids later benefit from. They earned equivalent wages and had higher status occupations just like women who were childless.

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PregnancyWeekly.com

While birth rates in 2008 dropped among women in their teens, twenties, and thirties, the 40-to-44 age bracket saw a 4 percent increase in birth rate, according to a report released Tuesday by the Centers for Disease Control and Prevention.

Birth rates increased for mothers over 45 as well, with the number of births among these women increasing by 4 percent in the past year. What's more, women over 40 were also more likely to be first-time mothers than in past years, the report found. "This increase is part of a general trend that we've seen over the past few decades," says Brady Hamilton, lead author on the study and researcher for the CDC's National Center for Health Statistics. "A rise in reproductive technology gives women more options and more women are choosing to postpone childbirth or have a second or third child later in life," he says.

This doesn't mean it's easy to conceive in mid-life, however, warns Dr. Marjorie Greenfield, author of "The Working Woman Pregnancy Book" and director of general obstetrics and gynecology at University Hospitals Case Medical Center.

"Statistics like this encourage putting off pregnancy even more. It gives women the illusion that the biological clock doesn't really start ticking until later," she says, "but most births over 45 are from egg donors. The chance of getting pregnant without assisted reproductive therapy after age 40 is only 10 percent," she says.

"Assisted reproduction therapy and fertility treatments are feeding this trend," says Dr. Richard Paulson, chief of the division of reproductive endocrinology at the University of Southern California, "but it would be hard to tell how many people are actively waiting to have children [because they can use this technology] and how many are older women wanting to have children that now can because of an increasing social acceptance of being an older mother and this technology."

"There are a variety of things about our society that push both men and women to delay childbearing -- professional achievement, becoming financially secure, what-have-you," says Paulson.

"What ART has done for women is to increase reproductive options and level the playing field a bit. That doesn't mean you should wait until 50 to be a mom, but if your life plays out in such a way that motherhood at an advanced age makes sense, it's nice to know that that option now exists."

It's important to know, however, that this option can also come at a price.

By postponing pregnancy until middle age, women are at greater risk for gestational and birth complications that can affect both mother and child, notes Greenfield.

"By the time you're in your forties, you're more likely to go into the pregnancy with medical problems such as diabetes or hypertension, which can complicate the pregnancy. You are also at higher risk for getting gestational diabetes or hypertension during your pregnancy," she says.

Risk of genetic conditions like Down syndrome increase throughout the forties as well, but the most common issue women face when they try to conceive later -- one they often aren't expecting -- is miscarriage and infertility.

ART can help battle dwindling fertility but the therapy doesn't always work and can itself complicate pregnancies because it makes women more likely to have multiple births.

"Twins confer more risks to pregnancy than any other thing we think of as high risk factors," Greenfield says, "and that's just twins, not triplets or other multiple births."

"Women's lives are complicated, and for some women it's just not feasible to have their children in their early thirties, when fertility is higher," Greenfield says.

Women are taking better care of themselves -- "Forty today doesn't look the same as 40 twenty years ago," she adds, "but that doesn't have anything to do with fertility."

Being young for your age "may affect how active you can be as a parent, but it doesn't help your fertility."

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PregnancyWeekly.com

A new study confirms that women who have incontinence during pregnancy are more likely than other women to have the problem after giving birth as well. The good news, researchers say, is that there are ways for women to reduce their risk.

In a study of more than 1,100 first-time mothers, Spanish researchers found that 39 percent reported urinary incontinence, or urine leakage, at some point during pregnancy. Another 10 percent said they had anal incontinence, which included uncontrolled passage of gas or stool.

These women were more likely than those without incontinence during pregnancy to have symptoms seven weeks after giving birth.

Overall, 16 percent of women in the study had urinary incontinence seven weeks after giving birth, while 7 percent had anal incontinence.

The risks for women who'd had those problems during pregnancy were three and six times greater, respectively, compared with women who had remained continent during pregnancy.

The study, reported in the journal Obstetrics & Gynecology, also confirmed that vaginal childbirth carries greater risks compared with cesarean section. Women who had a vaginal delivery were three times more likely than those who had a C-section to have urinary or anal incontinence after childbirth.

Of 692 women who had a vaginal delivery and responded to questionnaires seven weeks after childbirth, 139 reported symptoms of urinary incontinence and 57 reported anal incontinence.

They also highlight potential ways to reduce the risk.

For example, studies have tied excess weight gain to an increased risk of incontinence during pregnancy. (In this study, it was linked to anal incontinence only.) So gaining only the recommended number of pregnancy pounds may help prevent incontinence both during and after pregnancy.

In addition, exercises that strengthen the pelvic floor muscles, known as Kegel exercises, have been shown to lower the risk of pregnancy-related incontinence.

In cases where a woman already has risk factors for post-childbirth incontinence -- such as being older than 35 or having a family history of incontinence -- doctors might want to avoid using forceps or other instruments during vaginal delivery, or doing an episiotomy -- an incision made to enlarge the vaginal opening during delivery.

Past studies have linked instrument-assisted deliveries, particularly in conjunction with episiotomy, to an increased risk of incontinence.

Because the current study followed-up with women only seven weeks after they gave birth, it is unclear how many women had long-term symptoms. Past research has suggested that for most women, incontinence goes away within a few months of giving birth, though for some it may become a persistent problem.

Treatments for persistent incontinence include Kegel exercises, behavioral changes (like scheduled bathroom trips), medications and, in more severe cases, surgery.

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PregnancyWeekly.com

Over the past decade, the U.S. maternal mortality rate has nearly doubled, with about 500 women dying of pregnancy-related complications each year. That's a tiny percentage of the 4 million American women who give birth annually. But what's shocking is that among industrialized countries, the U.S. ranks an abysmal 41st on the World Health Organization's list of maternal death rates, behind South Korea and Bosnia-yet we spend more money on maternity care than any other nation.

Amnesty International has designated the U.S. maternal mortality rate a human-rights concern. This month, the organization called on President Barack Obama to address the crisis, noting that two to three women die of pregnancy-related complications in this country every day, as we move further away from the government’s goal of 3.3 deaths per 100,000 live births. The health-care reform bill signed into law by Obama Tuesday could help, as it requires insurance companies, for the first time, to cover prenatal care and some childbirth costs.

Skeptics attribute the rise in the maternal mortality rate to better reporting of maternal deaths—and it’s true that over the past decade, states have revised death certificates to better flag pregnancy-related mortalities. Yet review committees estimate that better reporting only accounts for about 30 to 40 percent of the rise.

More likely, the maternal death rate is going up due to a complex cocktail of factors—causes that reflect a changing population, disparities in poor women’s access to health care, and even Americans’ reliance on cutting-edge medicine. Here are seven explanations for the unsettling rise:

1. A Skyrocketing Caesarean Rate

   Before C-sections became as safe and standard as they are today, pregnant women had few options if they found themselves in an emergency situation; aside from metal forceps, doctors lacked tools to get babies out quickly, which often led to tragedy.

   Yet as lifesaving as C-sections can be, an astounding one in three American women now give birth surgically, up from one in five a decade ago. Healthy women who give birth surgically are 80 percent more likely to be re-hospitalized than healthy women who give birth vaginally; they’re also four times more likely to die. Hemorrhage, infection, and pulmonary embolism are all more common following a surgical birth.

2. More Obese Moms

   As the obesity epidemic swept the country, more overweight women have gotten pregnant and given birth, despite serious risks. One in five women in the U.S. are now obese at the beginning of their pregnancy, according to the Centers for Disease Control. Obese women are more likely to develop hypertension, high blood pressure, and diabetes during pregnancy, which can lead to preeclampsia and other fatal conditions. Preeclampsia is responsible for about 18 percent of maternal deaths in the U.S., and over the past decade, the incidence of the condition rose by 40 percent.

   Labor can also be more difficult for obese women, as soft tissue can impede delivery. Obese women are also at greater risk for delivering bigger babies, needing C-sections, and developing postpartum infections and heart problems.

3. Disparities in Access to Care

   As economic disparities in the U.S. health-care system grew wider over the past several decades, fewer women got the family planning, prenatal, and postpartum care they needed. Currently, one in five women of childbearing age are uninsured, Amnesty International reports. In most states, poor women do qualify for Medicaid once they become pregnant; the problem is, six weeks after giving birth, most of these women are dropped.

   From there, a dangerous cycle can begin: If a woman has risk factors going into her first pregnancy—say, diabetes or hypertension—the conditions often get worse through the process. She can’t afford the medical care to treat her conditions. Nor can she afford contraceptives, so she often ends up getting pregnant again, this time facing even greater risks. By the time she’s back on Medicaid for her next pregnancy, she’s in big trouble.

   The good news is that the new health-care reform legislation will expand access to Medicaid for about 15 million people, and will include prenatal and maternal care in the basic package of services private insurers must cover.

4. Unnecessary Medical Interventions

   Like C-sections, medical innovations such as drugs to induce labor and devices to monitor fetal heart rates can be lifesaving, but they can also lead to complications in healthy women. When an intervention is unnecessary—performed out of convenience or protocol—the harms can outweigh the benefits.

   In many developed countries, induction is used as a last resort, but in the U.S., hospitals induce or accelerate roughly 40 percent of labors. These drugs, in turn, can create more aggressive contractions, which increase the risk of uterine rupture. A woman who is induced is also more likely to end up needing a C-section.

5. Older Moms

   As the rate of childbearing women over 40 has risen, so has the maternal mortality rate. Moms over 35 are more likely to develop gestational diabetes and other complications; they’re also more likely to have twins or other multiples, thanks both to biology and the wonders of fertility treatment—and multiple births are far riskier than single births, for both mother and babies.

   But Elliott Main, a San Francisco-based OB/GYN and principal investigator of the California Maternal Quality Care Collaborative, says that most American women who die in childbirth are in their twenties or thirties.

6. Poor Birth Education

   Maternity-care advocates stress that as birth has become increasingly medicalized, American women have become surprisingly uneducated on the topic.

   In particular, low-income women with limited access to health care may not be aware of the risks of taking certain medications or engaging in certain behaviors during pregnancy. Similarly, advocates point out that with C-sections and interventions on the rise, women feel less empowered to take control of their birth experience—they don’t always know their options or trust their instincts. They must rely completely on hospital staff, who are often overworked, exhausted, and juggling many births at once.

7. Complacency

   Despite the rising maternal mortality rate, pregnancy-related deaths in this country are still rare. Most doctors and nurses will go their entire career without encountering one. Yet as a result, many hospitals have become complacent that mothers just don’t die anymore. Hospitals need to act proactively, paying closer attention to changes in women’s vital signs.

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