The article was published in partnership with USA Today.

Sara Toups thought it was early signs of menopause. 

Her breasts were sore, her belly bloated with discomfort. She started to wonder if she had missed her period. Shouldn’t she have gotten it weeks ago? 

Toups was 44 — old enough, she figured, that any chance of pregnancy was long behind her. She had made peace with it. A former special education teacher, Toups had never made enough money, had never been in quite the right relationship to feel secure having a child. 

And yet, after arriving back home in New Orleans after a cruise in May, she found herself taking pregnancy tests. The results were the same on all five: two lines on the strip, positive. Toups couldn’t believe it: In her experience, 44-year-olds were close to becoming grandmothers, not first-time parents. 

A doctor’s appointment in early June confirmed she was about eight weeks pregnant, due in January 2024. It felt like cosmic intervention. Toups had recently met her partner, the first person she could see herself parenting with. When he told her he wanted children, she was honest: She didn’t think she could become pregnant.

Her joy was unequivocal.

“It just felt right. It was like a complete, immediate 180, just like that,” Toups said. “There was no question about whether or not I wanted to do it. It was bizarre. It still feels a little bizarre.”

A growing share of Americans are opting to start parenthood later in life, having their first children in their late 20s, 30s and even 40s. 

Federal data shows steady growth of the number of older first-time parents over at least the past two decades. By 2021, the mean age for first birth hit 27.3, a record high. The share of people in their 30s and 40s giving birth has continually increased since 2000. Data from the Centers for Disease Control and Prevention shows that in 2021, close to 1 in 5 pregnancies in America were among people 35 and older, along with almost 12 percent of first pregnancies. In 2000, by contrast, people 35 and older made up about 7.4 percent of first births. 

The trend is visible across racial groups, though White and Asian Americans were most likely to start giving birth at or close to age 30. In 2021, about 12.8 percent of first pregnancies for White Americans, like Toups, were among people 35 and older, with 22.5 percent for Asian Americans. (Among Black, Latinx, American Indian/Alaska Native and Native Hawaiian/Pacific Island people, the rates were about 9, 8.1, 5.3 and 7.1 percent, respectively.) 

The shift is emblematic of other lifestyle changes. Americans are marrying later, with many waiting until then to have children. Per the U.S. Census Bureau, women in 2022 were about 28 on average when they first got married. In 2000, the median age for a woman’s first marriage was 25. Men in 2022 had a median first marriage age around 30, compared to between 26 and 27 in 2000. 

Women are increasingly choosing to prioritize their careers, multiple economists and demographics researchers told The 19th, wanting to establish themselves professionally and financially before having a child. And in general people now want to hit certain milestones — owning a home, earning a certain amount of money, paying off outstanding debts — before pursuing parenthood. 

“There’s been a huge societal shift in people’s ideas about when is an ideal time to have kids,” said Alison Gemmill, a demographer at Johns Hopkins University who studies family and reproductive health. “There’s a lot more emphasis, especially in one’s 20s, to engage in activities that are developing what we can call human capital: going to school, getting a career established.”

These changes indicate strides toward greater gender equity, experts said. But health care  hasn’t necessarily kept up. 

Pregnancies after age 35 present challenges in a medical system that was already besieged by poor health outcomes for pregnant people. And the disappearance of federal abortion protections has added a new layer of complexity for Americans getting pregnant at any age, but especially for those pursuing parenthood later in life, researchers said. 

From that first positive test, Toups felt like her age caused added anxiety — for her and her doctors. Pregnant people over 35 face higher chances of miscarriage and stillbirth, as well as greater risks of complications that could threaten the health of the pregnant person or fetus. 

“Miscarriages are pretty common for women, and I knew it was more common for me. I wouldn’t say I was working myself up into a frenzy, but I was very aware that at any time, I might miscarry,” Toups said. 

Even amid her joy, Toups’ fears underscored a broader tension: As pregnant people age, it’s unclear that the United States is prepared to care for its growing cohort of older first-time parents. 

“The fact that it’s more possible for women to have births when they want to have births seems to me to be an unambiguously good shift,” said Lucie Schmidt, an economist at Smith College who focuses on economics of the family. “But there are implications we haven’t grappled with as a society.” 

---

Toups and her doctor both were proactive: About two weeks after learning she was pregnant, Toups underwent noninvasive prenatal testing, which was recommended by her doctor and covered by health insurance since her age put the fetus at a greater risk for genetic anomalies and her at risk for other complications. She also would receive regular care from both her OB-GYN and a maternal-fetal medicine specialist. 

She passed milestone after milestone without incident, but it felt like her doctors couldn’t stop emphasizing her age and the risks it brought. Doctors constantly suggested that gestational diabetes and preeclampsia, a dangerous high blood pressure condition that develops in the second trimester, were “right around the corner.” Such conditions are more common in older pregnant people — in part because of age, but also in part because those patients are more likely than younger ones to have other risk factors as well, such as high blood pressure, diabetes or obesity.

“They’re causing me to have a lot of fear that I wouldn’t normally have,” she said. “They’ve made me feel — and society as a whole has made me feel — like I am too old to do this.”

It’s difficult to find medical care attuned to the risks for pregnant people in their late 30s and 40s, but also sensitive to the idea that age in and of itself doesn’t mean a complex or dangerous birth.

People like Toups — who live in cities with large hospitals and research institutions — have an advantage in finding appropriate pregnancy-related medical care, noted Karen Guzzo, a sociologist at the University of North Carolina who studies family formation and birth patterns. OB-GYN care is already difficult to find in large swaths of the country, particularly more rural areas. And then there’s finding a physician comfortable caring for older patients, and who can make sure those patients feel adequately treated.

“In cities, people will understand — doctors will understand. In smaller towns, particularly the ones that don’t get a refresh of doctors, so to speak, they might not be aware,” Guzzo said. In smaller towns, she added, “you might have to travel further to find a doctor who’s comfortable and able to treat you if you have any particular needs.”

There are efforts underway to shift physicians’ understanding of older pregnancies. In a 2022 position paper, the American College for Obstetricians and Gynecologists suggested that using terms such as “advanced maternal age” — a descriptor used to characterize pregnant people older than 35 — could lead to substandard care by suggesting there are only two groups of pregnant patients.

Instead, the organization has recently argued, pregnancy care providers should assess age on a continuum. That means acknowledging a progressive increase in risk as patients get older and counseling patients accordingly. But it also means emphasizing that age alone will not determine a pregnancy’s outcome. 

“The majority of women aged 35 or older have a healthy, uncomplicated pregnancy,” said Dr. Mark Turrentine, chair of the college’s Clinical Consensus Committee for Obstetrics. “No obstetric health care professional should ‘shame’ a pregnant individual regarding age.”

Toups believes the constant reminders about her age in medical settings might actually have made her health worse.

Early in her pregnancy, her physicians asked her to monitor her blood pressure at home, a preventive measure after some high levels she recorded in her first checkups. As things progressed, her blood pressure at home stayed normal, data she uploaded for her doctors to monitor. But whenever Toups went in for a checkup, her blood pressure spiked. 

It was a pattern she couldn’t ignore. The phenomenon, called “white coat hypertension,” offered what she believed was a quantifiable result of how stressful each checkup had become. 

“They’re treating me like I’m old. As a woman who’s 44, I’m too old,” she said. “That’s just the default response. But I think what they need to recognize is that a healthy pregnancy is a healthy pregnancy.”

Still, the medicine is complicated, as is deciding the appropriate treatment. After regular checkups continually showing high blood pressure — a pattern Toups continued to attribute to the anxiety associated with those doctors’ visits — she finally agreed to start taking medication at the advice of her midwife. No matter the cause of her numbers, she didn’t want to risk anything that might hurt her baby.

“I didn’t want to take any chances,” she said. 

Toups knew her age put her at greater risk for something to go wrong during her pregnancy — a fetal anomaly, a complication that could threaten her health or the baby’s. She read countless stories about people who discovered problems later in their pregnancy who, because of abortion bans, couldn’t access medical care. She feared that if she discovered any complications, no doctor in Louisiana would be able to help her.

The post-Roe v. Wade reality will continue to have acute implications for pregnant people Toups’ age, said Sonia Suter, a legal professor and bioethicist at George Washington University. Access to legal abortion is far more salient for pregnant people 35 and older, given the higher risks of complications, including fetal anomalies.

“Very few [abortion bans] have exceptions for fetal anomalies, and those that do limit it to lethal, defined in the vaguest terms,” she said. 

Pregnancy in Louisiana — home to some of the highest rates of pregnancy-related deaths in the country, particularly for Black people — was already dangerous, and after abortion was outlawed in the state, the risks became even greater. If there was a risk to Toups’ health or a fatal fetal anomaly, she would be unable to get an abortion under the state ban’s very narrow exceptions.

She made contingency plans, deciding she’d stay with her mother in Michigan if she needed care. 

“I don’t want to die in the parking lot at some hospital,” she said. “I was mentally preparing for the possibility that an abortion was still something that might be on the horizon.” 

---

In their 20s and early 30s, 1 in 4 women will get pregnant within a given menstrual cycle, per the American College of Obstetricians and Gynecologists. The chances decline to 1 in 10 for people in their 40s. 

Toups was able to conceive without fertility treatment. But many people her age require those services — including intrauterine insemination and in vitro fertilization (IVF) — to become pregnant. Those treatments can cost thousands or even tens of thousands of dollars. They are rarely covered by insurance, especially for people who receive Medicaid, the federal-state insurance program for low-income Americans.

For most of her life, Andrea Edwards didn’t think she wanted kids — she was never in the right relationship, and motherhood never felt like a role she could see for herself. But things changed when she met Jon. They were both teachers in a school district just outside of Philadelphia. When they began dating, she watched the way he worked with his students: He would be an incredible dad, she thought.

After half a year of trying to conceive, Edwards, then 36, went to a specialty clinic where the staff ran a full panel of tests. She learned that there was little chance she could get pregnant without fertility care. 

The couple was told that if they wanted two rounds of IVF, it would cost them more than $20,000 in total. For Edwards, the odds of success were slim; realistically, if she wanted to get pregnant, they would likely need to use eggs from a donor. Still, the couple gave it a shot, only to learn that Edwards’ eggs couldn’t even be retrieved from her body to fertilize. They tried again, with the same result. That was $14,000 sunk. And still, they were no closer to being pregnant.

Finally, the couple decided they would still try to get pregnant using IVF using eggs from a donor — an additional $10,000. Along with the cost of fertilizing the eggs, implanting embryos, medications and doctors’ visits, Edwards estimated that they would ultimately spend upwards of $50,000 trying to get pregnant.

The couple knew they wanted a baby, but with the costs ramping up, they started looking into other options. Maybe they would take out medical loans. If Edwards worked a few months part-time at Starbucks, maybe she would qualify for the company’s fertility benefits, which included covering the cost of IVF. 

Finally, they settled on a solution: Edwards’ mom, also a former teacher, loaned them some of the money, withdrawing it from her retirement savings. Jon’s mother gave them more money to use for the donor eggs. They planned to pay Edwards’ mom back over time, $500 per month, no interest. The $14,000 they already spent would go on credit cards. They knew they’d have to put other dreams, like owning a home, on hold as they paid off their debts.

They cultivated four embryos, planning to try one by one to implant them in Edwards’ uterus. The first transfer failed, but the second worked. She found out she was pregnant on November 1, 2022.

“I realize how lucky we are to be able to afford this,” she said. “It was worth it — every bit of it.” 

The heavy cost of IVF isn’t new, though it is a burden that has become more significant as a larger share of Americans pursue pregnancy later in life. 

“If you know anyone who’s gone through this, it’s exorbitantly expensive, and we don’t have enough care facilities. We don’t have enough doctors who do medically assisted reproduction,” Guzzo said. “Lots of women we see, they would like to have more children. But they don’t have access to the services they would need. They’re not affordable, or they don’t exist.”

But the strain of fertility care has been amplified in the post-Roe landscape, which has introduced new threats on top of financial concerns. In the early days of her pregnancy, Edwards worried about just how long treatment like hers would remain not only within even remote financial reach — but simply legally available. 

IVF, and in particular its reliance on embryo cultivation, has emerged as a potential target in some anti-abortion spaces, particularly among those who embrace the idea that embryos should be treated as people. Under that theory, discarding frozen embryos — a common practice in IVF to ensure a healthy pregnancy — could be a crime. 

Edwards discovered her pregnancy only days before Pennsylvania’s 2022 elections, in which the Republican candidate for governor, Doug Mastriano, had argued that life begins at conception. Mastriano never mentioned the implications for IVF specifically, but still, Edwards couldn’t stop thinking about what that belief meant — for her, and for the other embryos she and Jon still have frozen to this day. When Mastriano lost, a defeat political observers attributed in part to his views on abortion, she heaved a sigh of relief.

“He could basically say I would be a murderer if we didn’t have those embryos,” she said. “It just really brought home how much everybody will be affected.”

No state has yet enforced a fetal personhood law that could be used to criminalize IVF. Only one state, Louisiana, currently bans the destruction of frozen embryos under a law enacted in 1986. That law, which pre-dated Roe’s overturn, hasn’t stopped physicians from offering the treatment, noted Hank Greely, a law professor at Stanford University and director of its Center for Law and the Biosciences. But heightened hostility toward the procedure could still deter people from providing it, especially if multiple states eventually outlaw the destruction of unused embryos — an outcome more likely after the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization eliminated federal abortion protections. 

“Even before Dobbs, there was debate among scholars about whether the right to abortion led to a corollary right to access IVF,” Suter, the George Washington University professor, said. “Whatever uncertainty existed before, Dobbs has made infinitely clear there is no constitutional right to things like IVF.” Suter said she anticipates IVF to remain a target in the years to come.

Efforts to pass a law that could have criminalized IVF failed this year in Arkansas, and in states with strict abortion bans, lawmakers have largely sought to clarify that their abortion bans do not prohibit IVF. Still, Students for Life, an influential anti-abortion group, has criticized IVF, honing in on the likelihood that people who undergo the treatment will ultimately discard some embryos. 

All of that has and continues to put heightened pressure on a medical service already difficult to come by.

If and as the battle over fertility care continues, Edwards and her family will be fine — for now. At age 38, she gave birth to a healthy son July 1, almost exactly a year after her first failed IVF treatment. A month later, she and Jon got married at a wildflower preserve. 

The couple have talked about having another child. They still have more embryos frozen, and it would be an opportunity to give their son a sibling. But the risks — financially, physically, legally, psychologically — are daunting. 

“It was just so scary and took so much out of me,” she said. “I look back on who I was a year ago, and I wasn’t the same person.”