‘It's now or never’—nulliparous women's experiences of pregnancy at advanced maternal age: A grounded theory study

BackgroundDelayed pregnancy is increasingly common in many countries including the UK. There has been international interest in providing maternity care which aims to improve outcomes for mothers and babies when pregnancy occurs after the age of 35. Despite this, there is a lack of understanding of the experience of pregnancy at advanced maternal age from the woman's perspective.ObjectivesTo explore the experience of uncomplicated pregnancy for nulliparous women aged 35 and over and determine key processes involved in their pregnancy journey.DesignA two phase constructivist grounded theory study.SettingSouth West of England, United Kingdom.Participants15 nulliparous women aged 35 and over, in their third trimester of pregnancy.MethodsData were collected through semi-structured, in depth interviews which were transcribed and analysed using coding, constant comparison and memo-writing.ResultsThe core category ‘It's now or never’ reflects how women may experience their pregnancy. This appears to influence feelings of readiness to become a mother, anxieties about the pregnancy and their care choices. This was felt more acutely as maternal age advances towards 40 years and beyond.ConclusionsWomen's understanding that their future chances to have a baby may be limited can impact upon the way pregnancy is experienced. Despite having an uncomplicated pregnancy, older pregnant women may experience considerable worry throughout their pregnancy. Further research is required on how health care providers can better support women in early pregnancy and in making decisions regarding childbirth choices which are related to age.     

Primiparity at very advanced maternal age (≥ 45 years)

This study describes maternal and birth outcomes of primiparae aged ≥ 45. High rates of pregnancy complications and poor birth outcomes were found, stressing that the personal risks and ramifications to the health system should be taken into account in establishing obstetric health policy regarding primiparity at advanced maternal age.     

Is routine amniocentesis for advanced maternal age still indicated?

OBJECTIVE: To evaluate a policy of selective rather than routine use of amniocentesis for advanced maternal age. METHOD: A consecutive series of 359 pregnant women aged 38-47 underwent nuchal translucency measurement (NTM) at 10-14 weeks, maternal serum screening (MSS) by alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) at 15-17 weeks, and second trimester ultrasound at 21-23 weeks. Women with NTM <3 mm, MSS-derived risk <1/250, and a normal second trimester sonography were considered at low risk and were suggested not to have an amniocentesis. RESULTS: Either the NTM or MSS test was positive in 130 women; 105 (81%) of them elected to have an amniocentesis, versus 122 (53%) of 229 in whom both tests were negative (p < 0.001). Nineteen (5%) of 359 patients had NTM > or =3 mm; all 7 cases of Down's syndrome were in this group; 122 (34%) of 359 patients had a MSS-derived risk > or =1/250; 6 of the 7 cases of Down's syndrome were in this group: Ten patients had an abnormal second trimester ultrasound, 1 of which had trisomy 18. Of the 219 patients with MSS-derived risk <1/250, a NTM <3 mm, and a normal second trimester ultrasound, none had a baby with a chromosomal abnormality (95% confidence interval: 0-1.4%). CONCLUSION: Amniocentesis may be offered on a selective rather than routine basis in women over 38, based upon the results of noninvasive screening tests.     

First-time fathers’ experiences of parenting during the first year

Objective: The objective of this study was to explore the experiences of fathers during their first year as parents to fully capture their experiences and transition to parenthood. Background: Becoming a parent for the first time has a life-changing impact for both the mother and the father, yet the factors implicated in the transition to fatherhood have been under-researched. Methods: In this qualitative study using an interpretative phenomenological approach (IPA), 10 first-time fathers were interviewed 7–12 months after the birth of their baby. Results: Two super-ordinate themes were uncovered: experiences during pregnancy and fatherhood – the early days, which are supported by six sub-ordinate themes. Fathers’ narratives can be understood within the theoretical framework of Draper’s Transition Theory; early fatherhood represents the continuation of a man’s transitory journey, which starts during pregnancy. Conclusion: Despite increasing public awareness and socio-political changes affecting paternal parenting culture, fathers still seem to feel undervalued and unsupported when it comes to antenatal support. The antenatal period is a critical time in which to engage with and support motivated expectant fathers; antenatal psycho-education classes can be adapted to accommodate the needs of men. The mental health of the man has an impact on the woman in the antenatal and post-natal periods; addressing the needs of men during pregnancy can function as an early intervention for his family system and could reduce the financial cost to health services in the long term.     

Is primiparity a risk factor for advanced maternal age pregnancies?

Objective: Currently, more women are delaying childbearing until their 40s.This study compared the pregnancy and maternal features, pregnancy and foetal outcomes between multiparous and primiparous patients. We compared the same factors between assisted reproductive technology (ART) and non-ART primiparous patients because of the high proportion of ART used in the primiparous patients.

Methods: The study retrospectively examined 1680 patients, 35 years of age and older, between March 2008 and February 2015.

Results: Comparing the features of these two groups, there was an increased incidence of employment and the use of ART in primiparous patients, while birthweight tended to be higher in the multiparous group. There were no significant differences in pregnancy complications other than hypertension disorders, such as pre-eclampsia and HELLP syndrome, which were significantly more frequent in primiparous patients. The rates of foetal growth retardation and perinatal death were significantly higher in primiparous women. Comparison of the data between ART and non-ART primiparous patients indicated that the ART group had a higher initial body mass index and a lower smoking rate. No significant differences in pregnancy complications or foetal outcome were observed between these two groups.

Conclusion: Primiparity is associated with increased pregnancy and foetal complications in advanced age pregnancies. However, the use of ART in this age group does not seem to be an additional risk factor.     

Is advanced maternal age an independent risk factor for uteroplacental insufficiency?

OBJECTIVE: To determine whether maternal age 35 years or older is an independent risk factor for uteroplacental insufficiency and thus an independent indication for antepartum testing. STUDY DESIGN: A retrospective cohort analysis was performed of all deliveries at Los Angeles County-University of Southern California Women's and Children's Hospital between August 1, 1995, and September 1, 2003. Women with documented indications for antepartum testing, fetal anomalies, or delivery prior to 34 weeks were excluded from analysis. Markers of uteroplacental insufficiency included stillbirth, birth weight less than the 10th percentile, fetal distress, cesarean section for fetal distress, oligohydramnios, meconium passage, and 5-minute Apgar score less than 7. RESULTS: Indications for antepartum testing were significantly more common in women 35 years or older (33.2% versus 27.0%). After excluding women with indications for antepartum testing, anomalous fetuses, and women delivering prior to 34 weeks, stillbirth was twice as common in women 35 years and older. However, among stillbirths, growth restriction occurred with similar frequency in the older (28.6%) and younger (25.0%) cohorts. Among live births, 2 markers of uteroplacental insufficiency, intrapartum fetal distress (5.7% versus 4.1%) and cesarean delivery for fetal distress (4.0% versus 2.4%) were significantly more common in the older cohort. All other markers of uteroplacental insufficiency were observed with similar frequency in the 2 groups. CONCLUSIONS: After excluding women with other indications for antepartum testing, fetal anomalies, and delivery prior to 34 weeks, stillbirth was twice as common in women 35 years of age or older as in those younger than 35 years. The increased rate of stillbirth does not appear to be explained by a higher rate of uteroplacental insufficiency.     

Communicating choice: an exploration of mothers’ experiences of birth

Objective: This article gives an in-depth insight into the ways in which communication between midwives and the birthing woman shape the birth experience. Background: Birth is a significant life event for many women that can have profound, long-lasting effects on how they see themselves as women and mothers. Within the literature the importance of control over the birth experience and the support that the birthing woman receives from midwives is stressed. Methods: Six women who had recently given birth participated in one-to-one semi-structured interviews designed to explore the kinds of support they received before, during and after their birth. An inductive thematic analysis was employed in order to identify and explore key issues which ran throughout the interviews. Results: Within the interviews the importance of being an active mother, someone who made decisions in relation to her labour, was stressed. The analysis explores the ways in which communication style and compassionate care either enabled or prevented women from adopting the position of ‘active’ mother. Conclusion: It is argued that a personal connection with midwives and clear and open communication which places the birthing woman in a position of control are key to positive birth experiences.     

Emotions in labour: Italian obstetricians’ experiences of presence during childbirth

Objective: The present study represents a qualitative research aimed to explore the obstetricians’ psychological experiences of birth.

Background: During labour the role of obstetricians assumes a fundamental importance in hospitalised childbirth. However, literature analysis has shown that the psychological side of birth has been investigated only considering the woman’s and midwife’s points of view. The obstetricians’ psychological experiences have not been considered enough and only a few studies at a quantitative level have been performed.

Methods: Seven focus groups for a total of 72 obstetricians were conducted in hospital contexts in Italy. The qualitative methodology of grounded theory was adopted.

Findings: The results were divided into three different core themes: obstetricians’ approaches to delivery, critical aspects about relationships in the delivery room, and obstetricians’ feelings and emotions in the delivery room. Each theme was subdivided into different subthemes.

Conclusion: The results highlight different ways obstetricians approach their profession, the complex and multifaceted relationship with the woman and the extraordinary variety of feelings and emotions, which enrich, but also may complicate, life in the delivery room. Further studies could provide more details to help researchers to develop new and more effective strategies to support obstetricians’ training and work.     

A place for the partner? Expectations and experiences of support during childbirth

AIM: To explore the expectations primigravidae have concerning the support that they hoped to have and would need from their partner during childbirth, and whether these kinds of support were actually provided by their partner. Additionally, to explore the thoughts and feelings of male partners concerning their supporting role, and, in retrospect, how well they felt they had managed. PARTICIPANTS: Eight couples living in Hampshire, UK, who were interviewed six weeks before the birth and approximately 12 weeks following labour and delivery. METHODS: Semi-structured interviews were taped, transcribed and analysed. An ethnographic approach was used to identify concepts and themes. FINDINGS: Support provided by the male partner evoked very positive responses from the women. The fathers perceived that they were very helpful to their partner during childbirth. Though the women mostly found childbirth straightforward some fathers, nevertheless, found the experience stressful. CONCLUSIONS: The father's needs and role should be regularly assessed during childbirth.     

Prenatal diagnostic testing among women referred for advanced maternal age in Beijing, 2001–2012

Objective

To determine the proportion of women with advanced maternal age (AMA) undergoing amniocentesis and assess the recommended indication of 35 years or older in China.

Methods

Data were retrospectively evaluated from 9641 patients who underwent diagnostic prenatal amniocentesis in Beijing, China, between January 2001 and December 2012. Maternal age, indication for testing, and karyotype data were collected. Patients referred for AMA were stratified in 2 ways: 35–37 years, 38–40 years, and 41 years or older; and indication of AMA alone or combined with other screening. Outcomes and safety performance were compared among the groups.

Results

From 2001 to 2012, the annual rate of amniocentesis and the proportion of AMA-related indications increased (P < 0.01). Overall, 82 abnormalities were detected. In the AMA group, the spontaneous abortion rate was 0.5% (22/4748). The positive predictive value (PPV) of AMA alone was 0.5% for women aged 35–37 years. Only among women aged 41 years or older was the PPV of AMA alone better than that of AMA plus other indications (2.3% vs 1.5%, respectively).

Conclusion

The PPV of 35 years or older did not offset the risk of spontaneous abortion. AMA alone should not be used as an indication for amniocentesis especially among women aged 35–40 years.     

Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal testing be initiated?

We sought to determine if advanced maternal age (AMA) is a risk factor for intrauterine fetal demise (IUFD). We used a U.S. Centers for Disease Control and Prevention database and analyzed outcomes in women 15 to 44 years of age with term singleton gestations. Cox proportional hazards models and Cochran-Mantel-Haenszel tests were used. Results were controlled for maternal race and smoking. After excluding congenital anomalies and medical complications, 6,239,399 singleton term deliveries were identified. When compared with women 25 to 29 years of age, the risk of IUFD increased with advancing age: 30 to 34 years, odds ratio [OR] = 1.24 (95% confidence interval [CI], 1.13 to 1.36); 35 to 39 years, OR = 1.45 (95% CI, 1.21 to 1.74), and 40 to 44 years, OR = 3.04 (95% CI, 1.58 to 5.86). The risk of IUFD for women 40 to 44 years of age at 39 weeks is comparable with that of 42 weeks in those 25 to 29 years of age. We concluded that AMA is an independent predictor of IUFD, and a strategy of antenatal testing in those > or = 40 years of age beginning at 38 weeks may be considered.     

Early maternal sensitivity and child behaviour at toddler age: Does low maternal sensitivity hinder identification of behavioural problems?

In our well‐baby clinic study, we investigated how early maternal sensitivity predicted child behaviour two years later. On the basis of the early (6–8 weeks) maternal sensitivity (the CARE‐Index I), 74 dyads were divided into the groups ‘good enough’ (73.0%), ‘moderate problems’ (13.5%) and ‘at risk’ (13.5%). At child age of 24 months, the mother–child interactive style was assessed using the CARE‐Index (II), the mothers reported child behavioural problems on the CBCL/2‐3, and public health nurses reported their worries about the children and dyads and the need for extra services. The ‘risk group’ mothers were assessed as the least sensitive and most unresponsive, and their children as the least co‐operative and most passive. Also, the public health nurses were most often worried about the ‘risk group’ dyads and children. They arranged extra well‐baby clinic visits and wished to have supervision for themselves in dealing with the risk group dyads. An unexpected finding was that the ‘risk group’ mothers reported fewer child behavioural problems than mothers in the ‘moderate problem group’. In conclusion, unresponsive mothers may see their children differently than do professionals, and this discrepancy makes both screening and preventive work more challenging. Use of multiple informants and observations is essential when assessing this age group.     

Going back to work after childbirth: women’s lived experiences

Objective: The study aimed at understanding the experiences of first-time mothers who returned to work after paid maternity leave. It explored the challenges new mothers faced during the transition of having a baby, taking 14 weeks of paid maternity leave and then returning to work. Background: Traditionally women left paid employment and stayed at home while their children were still young, but recent times have seen a change in local women’s labour force participation and the actual lived experiences of Maltese women in the context of transition to parenthood had not been explored. Society still seems to expect that the idea of balancing work and family life is principally a women’s issue as traditional gender roles still appear to prevail. Methods: The qualitative paradigm was used to conduct the study by means of a semi-structured interview schedule at three different phases throughout the experience. Ten women were chosen to participate in this study by purposive sampling. The theoretical framework used to guide this thesis included phenomenology, transitional theory as described by van Gennep and feminism. Interpretative phenomenological analysis was used during the analysing phase. Results: The resulting three super-ordinate themes identified how after childbirth maternity leave is ‘a time of preparation and planning ahead’ followed by a period when ‘lightening strikes on rejoining the workforce’ and ‘weathering the storm’ via an attempt to balance work and family life. Conclusion: Findings showed that while society encourages mothers to return to work after the birth of their children, few attempts have actually been made to support them during this delicate transition. This study identified the need to improve local policy with regards to family-friendly measures and the importance of an increase in local maternity leave duration. Moreover, the midwife was identified as an important figure that can help empower mothers and prepare them for what is yet to come.     

Screening for fetal aneuploidy: is maternal age relevant?

The process of genetic screening has evolved from a simple notation of maternal age to a complex algorithm incorporating age, maternal serum screening, and sonographic findings. The extent to which each of these variables should contribute to the overall screening result is much debated and deserves continued research. It is clear that maternal age provides useful information when used as part of this equation but should not represent the sole screening modality. The use of genetic screening in a general population should be examined in terms of cost effectiveness without sacrificing patient preference and autonomy.     

Gestational age within normal range and infants’ health and temperament at 3-months of age

Objective: To examine the association between gestational age (GA) at birth across the normal GA spectrum (37–41 weeks) and the temperament and health of 3-month old infants.

Methods: The sample comprised 242 “low-risk” mothers and infants without chronic illnesses or severe pregnancy complications. Infant temperament was defined by three constructs: Negative Affectivity (NA), Extraversion, and Regulation, assessed by parents’ reports on the Infant Behavior Questionnaire. Infants’ health was defined as the number of nonroutine doctors’ visits attended by the infants since their release from the hospital after birth. Analyses employed a continuous measure of GA to assess outcomes across GAs and a categorical measure (37, 38, 39–41 weeks GA) to examine contrasts.

Results: Extraversion was positively related to GA primarily due to the lower scores of infants born at 37 weeks compared to infants born at 39–41 weeks GA. NA showed a similar effect. The odds of infants born at 37 weeks attending a nonroutine medical visit were 2.8 times that of infants born full-term.

Discussion: Infants born at 37 weeks GA express less affect and use more nonroutine medical services than do infants born at 39–41 weeks GA. The findings underscore the importance of considering the risks of pregnancy prolongation with the developmental risk associated with early-term delivery.     

Single indication of labor induction with prostaglandins: is advanced maternal age a risk factor for cesarean section? A matched retrospective cohort study

Abstract

Objective: The aim of this study is to investigate if advance maternal age is an independent risk factor for cesarean section in women induced with prostaglandins. Only patients with a single indication for induction of labor were considered.

Methods: A matched retrospective cohort study was conducted. A study group of 112 women aged 35 or older was enrolled. The control group included 216 women aged 34 or younger. Multivariate logistical regression models were fitted for the prediction of the cesarean section.

Results: There were no statistically significant differences in characteristics of the patients in the study and control groups. However, a higher prevalence of nulliparous women was found in control group (p?=?0.002). The indications of labor induction were homogeneous in the two groups. No significant differences were found in the route of delivery. The median time of labor was significantly shorter in the study group (p?=?0.002), and the birth weight and the placental weight were significantly lower in the study group. Advanced maternal age and newborn weight were directly related, whereas time of labor, Bishop score and parity were inversely related to a higher cesarean rate.

Conclusions: When single indication of induction of labor with prostaglandins is considered, advanced maternal age represents a significant independent risk factor for cesarean delivery.