By Schardt, Dana
ABSTRACT
Delayed childbearing is, for various reasons, a current societal trend, Literature reports the physical risk to women thirty-five and older is higher than for their younger counterparts. Typically psychological responses to pregnancy have been focused on women under age thirty-five. Several psychological issues are identified in women choosing to delay childbearing. Women over thirty-five years of age are often underestimated in consideration of their psychological needs. The dynamics of infertility, perinatal loss, or high-risk pregnancy may create psychological distress, resulting in disappointment, guilt, anger, and jealousy, and often doubt as to one’s own abilities. This paper will explore the psychological impact of delayed childbearing and implications for childbirth educators and health professionals.
At age 47, I had almost run out of time. For the two weeks after insemination, I tried not to let my Imagination run away with me. Again and again I reminded myself it would not work. We began another round of fertility… A few weeks later, on the 3 Jsi day of my cycle, I hadn’t started my period yet – but I’d been fooled before, many times, and I no longer trusted my body. The pregnancy test is positive. I could hardly believe it and I was thrilled.
I was lying on the examination table in the ultrasound room. I had been there forty minutes now. Now it came: words that both surprised me and yet seem familiar, as if I’d already heard them. “Do you want me to give it to you straight?” he asked, and with these words, he already had. “Of course I do,” I said in a firm voice. So he said it: “I don’t believe the pregnancy is viable.”
Now I become the sad receptacle of miscarriage stories. Women bring them to me, in sympathy and comfort, like flowers.
In a few weeks we met with the geneticist. I want to know what has gone wrong and if it is age-related. She tells us the egg would have been defective all along. She talks on and on, but I come to when she refers to “her.” Her? I think. Who? That’s right, she says. Of course there was no fetus yet – the tissue – had 2 χ chromosomes. It would have been a girl.
Excerpt from Crossing the Moon: A Journey Through Infertility,
Paulette Bates Alden
INTRODUCTION
Today an increasing number of women are choosing to have their first baby after age 35. The number of first births per 1000 women 35-39 years of age has increased by 36% between 1991 and 2002, and the rate among women 40-44 years of age has increased by a remarkable 70% (Heffner 2004). In recent years, the trend of conceiving at an older age continues to increase.
Many factors contribute to this trend, including effective birth control methods, expanded career options, increasing number of women with advanced education, later marriages, high cost of living, delaying childbearing until financially stable, and increased availability of specialized fertility procedures which offer opportunities for infertile couples (Heffner 2004).
Interestingly, other factors that contribute to delayed childbearing are the “celebrity and media factor.” Couples’ expectations of delaying childbearing have been altered due to the heightened public awareness from media exposure (Burrage 1998) and the reported rate and ease of celebrities having healthy babies at a later age. Media attention paid to older childbearing women has been favorable and inspiring (Heffner 2004). In 2003, most media reports were on successful pregnancies in women between the ages 50-54 (Burrage 1998). While strong media attention is being given to the successful pregnancies, and inspiring women to share their stories of success, what are the implications for the general population regarding delaying childbearing?
It is often assumed that women over 35 years old have made a conscious decision, have planned the pregnancy, and will enjoy the benefits of a good support system. At least half these women experience various difficulties emotionally, physiologically, psychologically, and socially. Although childbearing at an older age is widely socially accepted, it does present with many psychological factors and conflicting emotions (Sheiner, et al. 2001). If problems occur within the pregnancy, emotions such as guilt, anger, sadness, resentment, helplessness, and fear may develop (Burrage 1998).
The purpose of this paper is to provide information to childbirth educators and health professionals on current knowledge about the psychological impact of pregnancy and its outcomes in women over 35 years of age. While the scope of this paper is limited to psychological implications, it should be noted that there are biophysiological risks of childbearing in women over 35, along with advantages of pregnancy at a later age that will not be discussed.
DEFINITION OF ADVANCED MATERNAL AGE
Advanced Maternal Age (AMA) is defined as the childbearing woman over the age of 35. This has been considered in the literature as relatively more hazardous from both maternal and fetal perspectives. Although AMA is traditionally defined as age greater than 35 years at time of delivery, new definitions such as Very Advanced Maternal Age (VAMA) is reported as age greater than or equal to 45 years of age at delivery (Dildy, et al. 1996). AMA designation suggests that a woman’s fertility rapidly declines after the age of 35. Approximately one-third of women who delay pregnancy until their mid- thirties and beyond will find it difficult to conceive (Burrage 1998), or have physical maternal or fetal complications. These women may experience an increased incidence of miscarriage or stillbirth resulting in significant emotional and psychological trauma (Burrage 1998).
AMA RISKS: A REVIEW OF THE LITERATURE
For most women, pregnancy is a period of intense emotion that ranges from excitement, anticipation, and fulfillment of their life, to disappointment and fear (Blickstein 2003). AMA women share the same concerns of younger women; and they may experience additional stress, believing they have placed their own and their baby’s health at risk because of their age (Kee, Jung, and Lee 2000). Professional recognition of mothers’ fear of childbearing in later life has been reported as early as 1929. Schulze, a physician in the early 1920s, reported that her older primiparous patients had a “fear of labor.” This fear came from beliefs among the lay population that older childbearing women are prone to more difficulties. In the 1930s many women avoided childbearing, fearing they were too old to have children due to anticipated dangers. In 1949, physicians Randal and Taylor (Katwijk and Peeters 1998) reported that elderly primiparous women presented with a “different mental attitude.” In the 1950s it was recognized that AMA women’s worries required extra support and supervision during pregnancy (Blickstein 2003).
The effects of both maternal age and outcome of pregnancy may be assessed by examining specific factors that can negatively affect pregnancy outcome. These factors include increased infertility rate, miscarriage, chromosomal anomalies, and physical complications to mother, such as hypertension and stillbirth (Heffner 2004). Maternal death, although rare, does increase with maternal age (Heffner 2004). These outcomes carry psychological implications which can negatively affect the woman’s emotional health. A woman with a history of infertility or perinatal loss may have unresolved grief, guilt, or uncertainty about becoming a mother (Levy-Schiff, et al. 2002), especially with advancing age and limitations of conceiving.
IDENTIFIABLE STRESSORS: INFERTILITY, PERINATAL LOSS, AND THE CONTEXT OF CULTURE
Infertility has been considered a potent source of stress for most AMA couples (Kee, Jung, and Lee 2000). The diagnosis of infertility can seriously undermine self-esteem and may reveal underlying marital or psychosexual problems (Burrage 1998). Although recent fertility methods are available with new opportunities for couples, this can also prolong the agony of disappointment if conception does not occur (Kee, Jung, and Lee 2000). Some couples are not willing to exhaust all their available treatment options, for various reasons; this may lead to additional emotional conflict between the couple and stress related to their decisions. For other couples, the difficult decision-making process of discontinuing active treatment may also contribute to additional stress and conflict in the couple’s relationship (Burrage 1998).
Distress may be exaggerated by prolonged infertility workup and treatment. Women who were evaluated or treated for psychological causes related to infertility reported the highest amount of distress affecting their daily living (Kee, Jung, and Lee 2000; Sjogren and Uddenberg 1990). Distress and decision conflict occurs with risky or uncertain situations such as diagnostic testing recommended for the AMA couple. Research indicates that women in this group experience increased anxiety at several points in the process of prenatal testing (Kaiser, et al. 2004). In addition, acute stress reaction occurs with the initial diagnosis of infertility; then chronic strain and tension develops with infertility treatment superimposed on work, family, and social life. Thus, both negative physiological and psychological responses escalate with longer treatment (Kee, Jung, and Lee 2000).
The literature reports tha\t couples perceived that the most stressful experiences were at various times in the treatment process (Goacher 1995) and when family issues were raised (Burrage 1998). During treatment couples have little control, such as whether fertilization has occurred and waiting for a positive pregnancy test (Goacher 1995). Couples who decide to have fertility treatment fear stigma and ridicule from their family or close relatives. The couple may choose to keep it a secret, which can be destructive and place considerable strain on their own relationship as well as with their families (Burrage 1998).
One study reported an increased risk of fetal loss with increasing maternal age over 30 years (Andersen, et al. 2000). At age 42, more than half of all pregnancies resulted in spontaneous abortion or stillbirth. case reports regarding AMA women with fetal loss describe experiences of unresolved grief, guilt, or uncertainty about their ability to become a mother. These dynamics create psychological distress resulting in disappointment, guilt, anger, and jealousy (Levy-Shiff, et al. 2002). In attempting to conceive, women experience diminished confidence, hope, eagerness, exhilaration, and pleasure (Levy-Shiff, et al. 2002). The incidence of multiple pregnancy is significantly increased in women who do become pregnant through fertility treatment. Multiple pregnancy and its associated risks often expose the woman and couple to further stress due to physical factors and difficult decisions, even ethical dilemmas, at a time when they want to feel joy that they have conceived (Heffner 2004).
Although this paper focuses on women in the United States, it is noteworthy to examine a cross- section of infertile women in other cultures. For example, traditionally if Korean women were infertile it was regarded as one of the “seven largest sins.” These women were subjected to mistreatment by family. The emotional response has been characterized as grief, feelings of anxiety, anger, alienation, guilt, and depression (Kee, Jung, and Lee 2000). Further research is needed in cross-cultural advanced maternal age to understand similarities and differences in psychosocial stressors and coping.
COPING STRATEGIES AND COUNSELING
Coping is defined “as the cognitive and behavioral efforts used to manage specific external and or internal demands that are appraised as taxing or exceeding a person’s resources” (Levy-Shiff, et al. 2002). Two main strategies of coping in couples have been identified. The first, problem-focused coping strategies, attempts to confront the source of the stress. The second, emotion-focused coping strategies, attempts to regulate emotion by suppression, venting, or directing negative feelings (LevyShiff, et al. 2002). In problem-focused coping strategies, couples develop strategies to help them through the infertility diagnostic and treatment processes. The emotional-focused coping strategies in AMA couples exposed to prolonged stressors can cause the couple to become desensitized to the distress, and actually result in them perceiving less distress as a means of coping with long-term exposure to emotional stress (Kee, Jung, and Lee 2000). The outcomes of these coping methods in AMA couples is not well-documented in the literature.
When AMA women were asked about their coping strategies for unsuccessful fertility treatment, the majority (93%) said they would continue to pursue treatment or pursue other options; 26% considered adoption; 26% were not sure how they would cope. None of these respondents considered remaining childless as an option, although they did express that taking a holiday from continued fertility treatment would help them cope (Goacher 1995). For those with VAMA, taking time away from fertility treatment may not be a reasonable option, secondary to age. Thus these couples are denied a break and the opportunity to refresh or renew their coping skills in facing the emotional and physical stressors (Heffner 2004).
Research clearly indicates the beneficial nature of counseling for AMA couples (Burrage 1998). Additional social support resources are thought to moderate the effects of stress as well as increase effective coping methods of the couples. Studies indicate that access to social support and counseling can increase the sense of wellbeing in the expectant mother and reduce distress symptoms such as depression, anxiety, or burnout caused by infertility or pregnancy loss (Levy-Shiff, et al. 2002). Professional support is a key intervention in the psychological management of AMA women. Since the women are at risk for iatrogenic stress, reassurance by providers can improve their emotional state by reducing excess worry. Providers must be realistic in their assessment of the patients’ concerns and give them an opportunity to express their concerns. The health care professional can provide accurate, personally-focused information, creating a positive perception of the process and/or the pregnancy (Heffner 2004).
ATTITUDES AND IMPLICATIONS OF HEALTH PROFESSIONALS
It can be difficult for health educators and professionals to remain impartial or non-judgmental if it conflicts with their personal beliefs and values. In an overcrowded world, some believe that infertility treatment should not be offered to anyone, regardless of age or circumstance. The medical profession and society in general favor younger women and pregnancy even with serious medical issues versus the AMA woman (Burrage 1998). This judgment may have psychological implication on the couple in regards to working with health professionals. To effectively work with AMA couples, the individual educator must assess their own values and morals and needs to be comfortable in working with this specialty. The American Society for Reproductive Medicine has begun an effort to educate the public on risks of delaying childbearing. Generally speaking, the decade between 25-35 years of age seems ideal. For women between 3545 years of age, where historically childbearing was not an option, it appears to remain safe enough and should not be considered a contraindication for childbearing (Heffner 2004). Information to professionals is vital to be effective in treatment with the AMA couple.
The majority of couples feel the provisions of information regarding medical procedures and treatment options are excellent (Goacher 1995). Such extensive preparation is viewed by some physicians as undesirable because it provides too much information to the couple and is apt to heighten their stress considerably. This fearful burden detracts from the pregnancy experience. Information regarding psychological and emotional aspects of infertility and the risk of perinatal loss have been reported to be limited. This indicates a clear opportunity for health educators to develop and implement additional instruction (Goacher 1995). Education and interventions regarding psychological and emotional aspects of the AMA couple may make a difference in the choices couples make, the standards of client care, and perhaps ease the psychological burden associated with AMA.
CHILDBIRTH EDUCATION
Childbirth education classes are important during pregnancy for couples of any age. Older couples’ needs may be unique, requiring a change in childbirth education. Although AMA couples are still in the minority, these couples may feel uncomfortable in classes where participants are younger. The older couple’s special psychological needs and concerns may not be met in the class. Educators should try to anticipate the informational needs for the older couple, while at the same time not drawing attention to or making them uncomfortable. As the number of AMA couples increases, class accommodations must be met for the specific needs of the older couple. Research indicates that individualized, personally focused information provides a positive influence on a women’s perception of the pregnancy, her “pregnancy lens.” Also apparent in the literature is the compelling evidence for childbirth educators to take an active role in the psychological education of AMA women as well as educating younger women who are contemplating delaying childbearing.
CONCLUSION
What significance can we derive from insights of the AMA client? First, we can confirm from research literature that later childbearing is associated with a number of physical, psychological, and emotional complications. This does not mean that an AMA pregnancy is not in the best interest of the couple. Many of these identifiable complications can be treated during pregnancy. Cross- cultural AMA is limited in the literature, making it difficult for a provider and educator to understand similarities and differences in psychosocial stressors. AMA is a specialty requiring alternative options to women, including professional emotional and psychological support along with identifying coping strategies. Emphasis should be placed on counseling AMA couples about the physical, psychological, and financial implications of treatment. Childbirth education trends may require additional accommodations for the needs of the AMA couple. It is clear that additional resources are needed to support the AMA specialty.
References
Andersen, A., J. Wohlfahrt, P. Christens, J. Olsen, and M. Melbye. 2000. Maternal age and fetal loss: Population based register linkage study. British Medical Journal Vol. 320 (7251): 1708-1712.
Blickstein, I. 2003. Motherhood at or beyond the edge of reproductive age. Int J Fertil Womens Med Jan-Feb, 48 (1): 17-24.
Burrage, J. 1998. Infertility treatment in women aged over 40 years. Nursing Standard 13 (5): 43-45.
Dildy, G., G. Jackson, G. Powers, B. Oshiro, M. Varner, and S. Clark. 1996. Obstetrics: Very advanced maternal age: Pregnancy after age 45. American Journal of Obstetrics and Gynecology 175 (3): 668- 674.
Goacher, L. 1995. In vitro fertilization: A study of clients waiting for pregnancy test results. Nursing Sta\ndard 10 (2): 31- 34.
Heffner, L. 2004. Advanced maternal age – How old is too old? The New England Journal of Medicine 351 (19): 1927-1929.
Heffner, L. 2004. Advanced maternal age – How old is too old? The New England Journal of Medicine 351 (19): 1927.
Kaiser, A., L. Ferris, R. Katz, A. Pastuszak, H. Llewellyn- Thomas, J. Johnson, and B. Shaw. 2004. Psychological responses to prenatal NTS counseling and the update of invasive testing in women of advanced maternal age. Patient Education and Counseling 54 (1): 45-53.
Kee, B., B. Jung, and S. Lee. 2000. A study on psychological strain in IVF patients. Journal of Assisted Reproduction and Genetics 17 (8).
Levy-Schiff, R., M. Lerman, D. Har-Even, and M. Hod. 2002. Maternal adjustment and infant outcome in medically defined high- risk pregnancy. Developmental Psychology 38 (1): 93-103.
Porreco, R., L. Harden, M. Gambotto, and H. Shapiro. 2005. Expectation of pregnancy outcome among mature women. American Journal of Obstetrics and Gynecology 192 (1).
Sheiner, E., I. Shoham-Vardi, R. Hershkovitz, M. Katz, and M. Mazor. 2001. Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. American Journal of Obstetrics and Gynecology 185 (4): 888-892.
Sjogren, B., and N. Uddenberg. 1990. Prenatal diagnosis for psychological reasons: Comparison with other indications, advanced maternal age and known genetic risk. Prenat Diagn, Feb; 10 (2): 111- 20.
Van Katwijk, C., and L. Peeters. 1998. Clinical aspects of pregnancy after the age of 35 years: A review of the literature. Human Reproduction Update 4 (2): 185-194.
* Dana Schardt, MS, WHNP, ICCE, is a Nursing instructor and Women’s Health Nurse Practitioner specializing in obstetrics and complementary and alternative therapies. She has served as faculty for ICEA Basic Teacher Workshops and Conventions. She is the author and producer of Pregnancy Relaxation: A Guide to Peaceful Beginnings, available through the ICEA Bookcenter. Dana is the owner of Childbirth Celebrations, a consulting firm.
Copyright INTERNATIONAL CHILDBIRTH EDUCATION ASSOCIATION Sep 2005
Comments