by Dr. Marvel Ver
It took many years of schooling and training to achieve success in my current career as a general surgeon.
Additionally, many years of real-life community experience have helped me excel as past President of the Philippine Medical Association (PMAH), as well as attain other leadership positions at my hospital.
I married “late” at 38 years old. Then, I embarked on a new challenging journey –having my first child at the age of 40.
I was excited and scared, but more scared to be honest. I was very grateful for the blessing, but as a medical provider, had some knowledge about the risks of having a child as an advanced maternal age (AMA) mother-to-be.
AMA is defined as having a pregnancy when a woman is over 35 years old.
Being pregnant over this age increases the risk of complications like miscarriage, congenital disorders, and overall maternal health risks like high blood pressure and others. Furthermore, as age increases, infertility also rises. Referrals to fertility and reproductive specialists have increased significantly over the last few years.
Reproductive medicine is a booming specialty of gynecology.
Care involves many appointments, different types of invasive and non-invasive testing, hormonal medications, and even costly reproductive procedures involving patient and partner.
Common treatments include intrauterine inseminations (IUI) and in vitro fertilization (IVF). Egg and sperm donation and freezing, and surrogacy may also be discussed.
I was one of those who sadly underwent the pain of loss with a miscarriage. I was subsequently referred to a reproductive specialist given the challenge of age and time. I also felt guilt and shame since I thought that I did something wrong.
During this leg of my journey, I thought I was alone and one of the few AMA women, but as I learned more and spoke to more people, miscarriages and the use of reproductive medicine is more common than we might think.
But because it’s such a personal and traumatic topic of conversation, it is not always talked about freely.
My ObGyn (Obstetrics-Gynecology) colleagues state the miscarriage rate at 35 years old is approximately 15-20%. At 40 years old, it is between 30-40%, and at 45 years old it approaches 50-80%.
Miscarriages are most often due to chromosomal genetic abnormalities, which increase with age.
Although advances in reproductive technology have resulted in successful pregnancies for many, I did not get pregnant after a significant amount of time and money invested in this emotional rollercoaster.
Afterward, I gave myself time to reset and try to get back to my normal busy schedule. To our delightful surprise, we were blessed with a natural pregnancy several months later.
My ObGyn colleagues share with me that the percentage of AMA patients can be demographically dependent.
There are more AMA pregnancies in countries with higher availability of socioeconomic resources. The decision for family life is also patient-dependent; if a patient embraces the idea of having a large family, then she may start having children early in life well into AMA.
In Hawaii, it is also location and race distribution dependent. Culture plays a role in the acceptance of early versus late childbearing.
For instance, ObGyn Dr. Lisa Natavio shares that in her previous practice in Wahiawa, with a high population of Filipinos and Polynesian-mix patients, there were less AMA first pregnancy mothers compared to her current Ewa Beach practice, where there is a more variable patient population (ie Hawaii locals, military, new Hawaii residents from mainland, etc).
In Ewa Beach, her rate of AMA first moms is about one in five patients compared to her patient population in Wahiawa.
AMA patients are often sent to a Maternal Fetal Medicine (MFM) specialist to discuss genetics testing and risks, complications, and prenatal management.
MFM specialists do not just take care of AMA patients, but also those women with higher risks due to medical problems like diabetes, hypertension, and obesity.
Dr. Corrie Miller is an MFM specialist in Honolulu and takes care of high-risk pregnancies. Her practice is about 40% AMA.
She shares that anecdotally Hawaii has a lower incidence of AMA pregnancies compared to her previous hospital in Connecticut where there is a significant percentage of highly educated white women.
Genetic testing may provide a path to decision-making. Some chromosomal abnormalities are incompatible with life. Others can produce a viable baby but possibly with birth defects.
MFM specialists help guide patients when difficult decisions may need to be considered. The ObGyn guidelines recommend referral to a specialist after three miscarriages. Many ObGyns start referring at two miscarriages especially since emotions, time, and age are factors.
I was under the care of MFM and ObGyn colleagues who provided excellent personalized guidance and management during my pregnancy journey.
Fortunately, I am healthy without baseline medical issues. My colleagues share that in AMA, the amount of prenatal visits is not necessarily increased but does so depending on risks and complications found. They also share that prenatal counseling is not significantly different in younger and older pregnant patients.
However, the majority of older patients already have some idea of the risks and expectations of pregnancy. Therefore, maintaining a healthy pre-pregnancy lifestyle is even more important.
My genetics testing was negative, but I was monitored closely for placenta previa (placenta blocking the delivery canal). I tried to be as healthy as I could during my pregnancy within the limits of my busy life as a working surgeon.
I am very grateful to my husband, professional colleagues, and family who really stepped up to be there for me. I safely delivered my beautiful son on November 10, 2021, via cesarean section.
Being at the top of my game in my medical field is a stark difference from my life as a rookie new mom, where I often feel lost and sometimes helpless. I didn’t grow up taking care of babies or kids, therefore taking care of my own newborn was a brand new “skill set” I had to learn.
Despite advice from many seasoned moms, articles, books, and phone apps, nothing gets you ready for the real thing until the real deal.
Being the senior and the leader in my office, I felt somewhat embarrassed asking my younger counterparts for mom advice and hacks.
Personally, all my AMA first baby colleagues have since shared that they felt this very same way. At the end of the day, I finally gave in and stubbornly accepted the help that was offered, especially because I really need it for my own health and sanity.
I did not train in a generation where motherhood was graciously welcomed in medicine, especially within the surgical field. Therefore, the amount of joy and support for me from my colleagues was refreshing.
With more women in medicine and law, leadership positions, and traditionally male-dominated fields, motherhood for the working professional is slowly gaining wider acceptance and is more celebrated, compared to the past. There are ongoing movements for gender equality in many fields in this country and others.
The ‘work-life balance’ is an ongoing challenge.
I had to cut down drastically on my workload pre and post-pregnancy. I had to make physical adjustments to safely work in the operating room.
I honestly felt guilty about not being able to service my patients or delegating their care to another provider. Many of my patients have been under my care for years.
Again, to my surprise, my patients celebrated my pregnancy with me, and were happy that I was actually “taking time for me”,” because I’ve done so much for them.”
Perhaps it’s just my luck having such nice patients or the fact that in Hawaii, the concept of family is so highly regarded.
As I am back at work again, ramping up to almost pre-pregnancy productivity, I am forced to adjust my schedule and be more efficient, as it’s not just about me anymore.
My workdays start later and end earlier so I can pick up my baby son from childcare. Of note, we were lucky to get into daycare, as it was news to us that there are waiting lists for daycares and schools. It is not easy to find vetted caregivers.
It is not easy to find an old-school yaya in the United States. I do not live in a multigenerational home.
The concept of my husband or I staying home was considered, but really not feasible in practice given the existing shortage of specialists in both of our fields. Moreover, we help to financially support our parents through our work.
I’m still struggling with the idea that work should stay at work. While at home, my energies are to be mom and wife.
I’m working on being less stubborn to improve my partnership with my husband as new parents which can be difficult. My husband is probably experiencing similar feelings being an older new dad.
Instead of reading about new surgery robots, hernia meshes, and the latest operative techniques, I am now researching strollers, child-proofing devices, and school tuitions.
The concept of “mom brain” is real. The tired mom is a whole new different type of tired.
I try not to think about the expectant challenges of being that older parent when my child graduates high school and transitions into adulthood.
I try not to compare myself to my younger counterparts who seem to physically and mentally bounce back so quickly.
I am very grateful to my parents, who are also deemed ‘older’ Lola and Lolo, for helping to care for their first apo given their physical limits.
My reality is now the challenge of taking care of my new baby in addition to taking care of our aging parents.
For new mom care, mental health screening and monitoring for postpartum blues and depression are very important.
The CDC reports about 1 in 8 moms experiences postpartum depression. Interestingly they also report that 1 in 10 new fathers report depressive symptoms.
My ObGyn colleagues share that their screening does not differ between young and older patients. However, they do acknowledge that older patients may have a different set of stressors and challenges as compared to younger ones.
Despite my candidly honest thinking and perspectives about motherhood, when my son smiles back at me with a face that mirrors mine, it is all worth it. My life has indeed changed. So, this is what parenthood is.
The rites of passage and the joy of a little person made from both of you is a gift, but only a woman can bring life into the world. Like my dedication to being the best surgeon leader I can be, I’m going to be the best mom I can possibly be.
I am fortunate to have the personal support of various friends and colleagues to help me do so. But even more importantly, I have the unwavering support and love of my own parents to guide me in this journey.
I was always encouraged by my parents to further my career path, with a focus on long-term financial stability. Therefore, starting a family early was not a priority for me.
It is not uncommon now that women start family life late when their careers, relationships, and finances are more stable. There are also older women who are still single or those in repeat marriages or relationships. This is in contrast to the general Filipino culture that pushes you to settle with a good job and have a family early.
As a mentor to a handful of young Filipinos, this pressure is very real. I have students who struggle with the notion of supporting their families as soon as possible versus following their dreams. Perhaps this sentiment contributes to the scarcity of Filipinos with advanced academic degrees and a decreased presence in higher leadership and executive positions.
This article is a personal one to me and may strike a chord with many. I do wholeheartedly believe that we are all born with potential, in a life that is a series of choices.
I chose to push towards my potential which delayed motherhood and accepted the risks and unmeasurable joy that comes with it. Until society completely acknowledges, accepts, and adjusts to the journey of motherhood, professional women will often find themselves at a crossroads.
Lastly, if you are a young woman who is considering a longer career path, or you are a parent with a daughter who wants to go further, please know that it’s okay. The “biological clock” does exist, but “there is no perfect time to get pregnant” is often said in late path individuals.
Know that you are not alone. Know that all of your dreams, even of motherhood, can be possible. And it’s all worth it.
I would like to thank and acknowledge my PMAH colleagues, especially Lisa Natavio, MD (ObGyn) and Corrie Miller, DO (MFM) who contributed their expertise to this article.
DR. MAREL VER is a general surgeon in West Oahu and a recent past president of PMAH.
by Dr. Marvel Ver