MIDIRS Essence > February 2010 > Informed Choice

Delayed motherhood: Crisis or confidence?

Originally posted on Feb 2010

For this month’s column I’ve made a very transparent move away from reflecting on a specific Informed Choice leaflet. Instead, I will be considering informed choice from a much wider perspective, not necessarily focusing on the clinical aspects of practice, but more on the wider policy, organisational and strategic considerations as they relate to choice for women and their partners, practitioners and service providers.

For this column, I’ve chosen a topic that is currently being hotly discussed within maternity services, as well as by the wider media: the growing trend for women to decide to delay motherhood until later in their reproductive life.

Having their first baby and becoming a mother later in life has become an increasingly popular choice for many women in the UK and many other developed countries (Delpisheh et al2008, Office for National Statistics 2009). More and more women are now making an informed decision to delay their fertility, instead choosing to pursue successful careers, achieve financial security, and settle into stable relationships before embarking on pregnancy and motherhood (RCOG 2009). Whereas, back in the 1970s and 1980s women often had their first baby while in their mid-twenties, figures released from the Office for National Statistics show that this trend has now shifted and the numbers of women having a live first birth when aged 40 or over has doubled over the past decade (Office for National Statistics 2009). In fact, in 2006, 25,400 women became mothers at the age of 40 or above; this was a notable six per cent increase on the previous year and accounted for 12.6% of all live births (Office for National Statistics 2009). Assisted reproduction techniques, which include egg donation, have also made it more possible for women to choose to delay motherhood (Aref-Adib et al 2008). This demonstrates that increasingly, the time frame for first time motherhood now covers the very early ‘teenage’ years and extends over a much longer period, arguably into ‘middle age’.

However, while the trend to delay motherhood may be growing in popularity with women and their partners, this is causing a growing concern amongst obstetricians and gynaecologists who cite the hazards of entering pregnancy in later ‘reproductive’ life. Research shows that with increasing maternal age there is a greater risk of age-related infertility (ACOG 2008) and that many women don’t realise how rapidly their fertility decreases after 35 years (RCOG 2009). Increased maternal age also raises the chance of having a baby with congenital abnormalities (Cleary-Goldman et al 2005), such as Down’s syndrome, and women are at increased risk of developing medical conditions such as hypertension, gestational diabetes, and other pregnancy-related complications, including fetal death and ectopic pregnancy (Ankum 2001, Khoshnood et al 2008). A strong association has also been found between increased maternal age at birth and the risk of diabetes in the child (Bingley et al 2000), and there are links with increased rates of miscarriage or early fetal death where the paternal age is over 45 years (Nybo Anderson et al 2004, Slama et al 2005).

I am not going to discuss these clinical concerns further, but as many of you will know, there are now specific antenatal screening tests and clinical observations to alert practitioners to the possibility of a deviation from the norm; however, being older does not necessarily mean this is an inevitability. The MIDIRS Informed Choice leaflets cover a range of topics relating to these tests, which have been discussed over the last couple of years and further information is available at: www.infochoice.org.

However, while the research evidence shows us that women who become pregnant in their forties are at increased risk of developing the conditions previously mentioned, this needs to be put into context, because it is also widely recognised that pregnancy can be a risk to women at any age. Therefore, for many women aged 40 and over, pregnancy and childbirth will follow an uneventful pathway and both the mother and neonate will be well throughout the pregnancy and afterwards. What appears to be of more importance is that regardless of their age, women who are pregnant or of childbearing age, follow a healthy lifestyle and are not involved in health risk-taking behaviours, such as alcohol drinking, smoking and substance misuse, all of which can jeopardise a successful pregnancy and birth outcome (Crafter 1997, Dunkley 2000).

There are concerns about the outcomes associated with delaying pregnancy and parenthood beyond what is seen as the ‘optimum’ time, during a woman’s late twenties and into their thirties, and whether by waiting beyond this, women are knowingly putting their babies at increased risk of congenital abnormalities and problematic births.

However, even where women at 40 or over are more likely to have pregnancies affected by Down's syndrome, these women still have a 99 in 100 chance of having a perfectly healthy baby. Similarly, many women over 40 demonstrate that they have entered motherhood with their ‘eyes wide open’ and are in no way delusional about the physical and emotional challenges that lie ahead of them. Undoubtedly, older mothers will be very aware of their age as it relates to their child’s growth and development, and appreciate that when their child starts secondary school they will be entering their fifties. However, there arguably remain distinct emotional and financial benefits to delayed motherhood, which also need to be considered within the context of the small absolute numbers of obstetric and perinatal complications (Aref-Adib et al 2008).

Women in their forties have often had the time and the life experiences to help them better cope with the emotional and social aspects of becoming a mother. They are more likely to have completed all their travelling in their twenties and thirties and by the time they become a mum, tend to be homeowners who are living in a stable relationship with a supportive partner and a strong network of friends and family for additional support. The life events and experiences that women have lived and witnessed through their former years will have helped to build their self-confidence, wisdom and self-esteem. This often means that when they enter motherhood, they can provide their newborn baby with a genuinely deep sense of security, because they have already had the years to develop and cultivate responsibility, patience, tolerance and understanding. Because they have often planned the timing of their pregnancy, mums in their forties also tend to be a lot more prepared to devote more of their time and energy solely to their baby’s care needs. Because they will have probably embarked on maternity leave from long-term employment or an established career, they are also more likely to have increased financial security. This means that the financial implications of motherhood often tend to be of less concern to them.

Increasingly, we need to respect that whether there has been a conscious, informed decision to delay starting a family to mid-life, or it has happened as a result of unplanned circumstances, women and their partners need relevant information and support to help them, should pregnancy become more complicated than anticipated. So while advances in maternity services means the NHS is better able to cope with this demographic trend, concern will remain about this phenomenon and its longer-term implications. Increased midwifery involvement in health promotion is therefore particularly important for women embarking on their first pregnancy in late reproductive life. This input helps to ensure that these women and their partners are more aware of the potential for adverse pregnancy and birth outcomes. Contemporary maternity services will, however, need to respond accordingly with health professionals continuing to offer each woman the individualised care that she, her partner and their baby require.


References

American College of Obstetricians and Gynecologists (2008). Age-related fertility decline: a committee opinion. Fertility and Sterility 90(3):486-7.

Ankum WM (2001). Higher maternal age was associated with increased risks for fetal death and ectopic pregnancy. Evidence Based Medicine 6(1):28.

Aref-Adib M, Freeman-Wang T, Ataullah I (2008). The older obstetric patient. Obstetrics, Gynaecology and Reproductive Medicine 18(2):43-8.

Bingley PJ, Douek IF, Rogers CA et al (2000). Influence of maternal age at delivery and birth order on the risk of type 1 diabetes in childhood: prospective population based family study. BMJ 321(7258):420-4.

Cleary-Goldman J, Malone FD, Vidaver J et al. (2005). Impact of maternal age on obstetric outcome. Obstetrics and Gynecology105(5pt1):983-90.

Crafter H (1997). Health promotion in midwifery: principles and practice. London: Arnold.

Delpisheh A, Brabin L, Attia E et al (2008). Pregnancy late in life: a hospital-based study of birth outcomes. Journal of Women’s Health 17(6):965-70.

Dunkley J (2000). Health promotion in midwifery practice: a resource for health professionals. Edinburgh: Bailliere Tindall.

Khoshnood B, Bouvier-Colle MH, Leridon H et al (2008). Impact of advanced maternal age on fecundity and women’s and children’s health. Journal de Gynécologie, Obstétrique et Biologie de la Reproduction 37(8):733-47. [Article in French].

Nybo Andersen AM, Hansen KD, Andersen PK et al (2004). Advanced paternal age and risk of fetal death: a cohort study. Am J Epidemiol 160(12):1214-22.

Office for National Statistics (2009) Birth Statistics 2008 Statistical Bulletin http://www.statistics.gov.uk/pdfdir/births1209.pdf

Royal College of Obstetricians and Gynaecologists (2009). RCOG statement on later maternal age. London: RCOG.

Slama R, Bouyyer J, Windham G et al (2005). Influence of paternal age on the risk of spontaneous abortion. Am J Epidemiol 161(9):816-23.

Vicky Carne | Head of Midwifery | MIDIRS | Photo credit: © nyul

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