The perinatal effects of delayed childbearing

Macro-economic conditions and infant health: a changing relationship for black and white infants in the United States

We study whether the relationship between the state unemployment rate at the time of conception and infant health, infant mortality and maternal characteristics in the United States has changed over the years 1980-2004. We use microdata on births and deaths for years 1980-2004 and find that the relationship between the state unemployment rate at the time of conception and infant mortality and birthweight changes over time and is stronger for blacks than whites. For years 1980-1989 increases in the state unemployment rate are associated with a decline in infant mortality among blacks, an effect driven by mortality from gestational development and birth weight, and complications of placenta while in utero. In contrast, state economic conditions are unrelated to black infant mortality in years 1990-2004 and white infant mortality in any period, although effects vary by cause of death. We explore potential mechanisms for our findings and, including mothers younger than 18 in the analysis, uncover evidence of age-related maternal selection in response to the business cycle. In particular, in years 1980-1989 an increase in the unemployment rate at the time of conception is associated with fewer babies born to young mothers. The magnitude and direction of the relationship between business cycles and infant mortality differs by race and period. Age-related selection into motherhood in response to the business cycle is a possible explanation for this changing relationship.

Health-related quality of life in pregnancy and postpartum among women with assisted conception in Canada

OBJECTIVE

To study the effects of mode of conception (spontaneous vs. assisted) on health-related quality of life (HRQoL) throughout pregnancy and in the postpartum period.

DESIGN

Secondary analysis of data from the All Our Babies cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 243 women with assisted conception and 3,309 women with spontaneous conception.

INTERVENTION(S)

Short Form 12 (SF-12) health survey administered by means of questionnaires at <25 weeks, 34-36 weeks of gestation, and 4 months postpartum.

MAIN OUTCOME MEASURE(S)

Changes in the SF-12 Physical (PCS) and Mental (MCS) Component Summary scores from pregnancy to postpartum.

RESULT(S)

The PCS scores were lower during pregnancy and at <25 weeks and 34-36 weeks of gestation among women with assisted conception, but were equivalent to those of women with spontaneous conception by 4 months postpartum. The MCS scores were higher at <25 weeks among women with assisted conception, but by 34-36 weeks of gestation and at 4 months postpartum they were similar regardless of the method of conception. Analysis of covariance showed no significant differences for the changes in PCS and MCS scores from pregnancy to postpartum between assisted and spontaneous conception groups, after adjusting for covariates.

CONCLUSION(S)

Women with assisted conception may report lower physical and better mental health during pregnancy than women with spontaneous conception. At 4 months postpartum, there were no differences in self-reported HRQoL between modes of conception. Women with assisted conception may benefit from support and reassurance that perception of suboptimal health may improve over pregnancy and into the postpartum period.

The association between maternal age and depression

OBJECTIVE

Postpartum depression is a relatively common and potentially debilitating condition but its relationship with advanced maternal age has not been adequately studied. We evaluated the relationship between age and depression in a population-based sample of Canadian women.

METHODS

Data on women aged 20 to 44 years were obtained from the Canadian Community Health Survey, 2007 to 2008. Depression was defined using the Short-Form score from the Composite International Diagnostic Interview (depression defined as a score of ≥ 5). Women were stratified according to whether they had a live birth within five years preceding the interview. Logistic regression was used to compare the prevalence of depression among women of advanced maternal age versus younger women after adjusting for education, marital status, and chronic disease.

RESULTS

Among women who had delivered recently, 8.0% (207 of 2326) were depressed compared with 10% (597 of 5610) of women who had not recently delivered. The prevalence of depression in women who had recently delivered was significantly higher in women aged 40 to 44 years than in women aged 30 to 35 years (adjusted OR 3.72; 95% CI 2.15 to 6.41). Depression rates were not higher among older women who had not had a recent delivery (adjusted OR among women 40 to 44 years 0.75; 95% CI 0.56 to 1.01).

CONCLUSION

Women of advanced maternal age have significantly higher rates of depression than younger women. Research is required to determine if a program of targeted depression screening and prevention will help reduce the burden of illness among older mothers.

Advanced Maternal Age and Risks for Adverse Pregnancy Outcomes: A Population-Based Study in Oman

To test the hypothesis that advanced maternal age (AMA) of 35 years and above is associated with increased risk of adverse pregnancy outcomes, we performed a population-based retrospective study using data from the 2000 National Health Survey in Oman. The last pregnancy outcomes of mothers aged ≥35 years were compared with adult mothers aged 20-34 years using bivariate and multivariate statistical techniques. Significantly increased risks of spontaneous abortion, gestational diabetes, preeclampsia, prolonged labor, and cesarean section delivery have been observed for advanced maternal age. Our findings may contribute to cross-cultural understanding of the risks associated with AMA and will facilitate evidence-based counseling of older expectant mothers.

Maternal age and preterm births in singleton and twin pregnancies conceived by in vitro fertilisation in the United States

BACKGROUND

Among natural conceptions, advanced maternal age (≥ 35 years) is associated with an increased risk of preterm birth. However, few studies have specifically examined this association in births resulting from in vitro fertilisation (IVF).

METHODS

A retrospective cohort study was conducted in 97288 singleton and 40961 twin pregnancies resulting from fresh non-donor IVF cycles using 2006-10 data from the Society for Assisted Reproductive Technology Clinic Online Reporting System.

RESULTS

Rates of very early preterm (<28), early preterm (<32), and preterm birth (<37 completed weeks) decreased with increasing maternal age in both singleton and twin births (PTrend <0.01). With women aged 30-34 years as the reference, those aged <30 years were at an increased risk of all types of preterm births. The adjusted odd ratio (95% confidence interval [CI]) for very early preterm birth, early preterm birth, and preterm birth in women aged 25-29 years were 1.3 [95% CI 1.1, 1.5], 1.2 [95% CI 1.1, 1.4], and 1.1 [95% CI 1.02, 1.2] in singletons. This increased risk of preterm births among younger women was even more significant in twin births. However, women aged ≥ 35 years were not at an increased risk of any type of preterm births in both singleton and twin births.

CONCLUSIONS

In contrast to natural conception, advanced maternal age is not associated with an increased risk of preterm births in pregnancies conceived by IVF. Women who seek IVF treatments before 30 years old are at higher risk of all stages of preterm births.

Consanguinity and late fertility: spatial analysis reveals positive association patterns

The role of consanguinity on human complex traits is an important and controversial issue. In this work we focused on the Sardinian population and examined the effect of consanguineous unions on late female fertility. During the last century the island has been characterized by a high incidence of marriages between relatives, favoured by socio economic conditions and geographical isolation, and by high fertility despite a widespread tendency to delay reproduction. Through spatial analysis techniques, we explored the geographical heterogeneity of consanguinity and late fertility, and identified in Central-Eastern Sardinia a common area with an excess of both traits, where the traits are positively associated. We found that their association did not significantly affect women's fertility in the area, despite the expected negative role of both traits. Intriguingly, this critical zone corresponds well to areas reported by previous studies as being peculiar for a high frequency of centenarians and for lower risk in pregnancy outcome. The proposed approach can be generally exploited to identify target populations on which socioeconomic, biodemographic and genetic data can be collected at the individual level, and deeper analyses carried out to disentangle the determinants of complex biological traits and to investigate their association.

Impact of maternal age on obstetric and neonatal outcome with emphasis on primiparous adolescents and older women: a Swedish Medical Birth Register Study

OBJECTIVES

To evaluate the associations between maternal age and obstetric and neonatal outcomes in primiparous women with emphasis on teenagers and older women.

DESIGN

A population-based cohort study.

SETTING

The Swedish Medical Birth Register.

PARTICIPANTS

Primiparous women with singleton births from 1992 through 2010 (N=798,674) were divided into seven age groups: <17 years, 17-19 years and an additional five 5-year classes. The reference group consisted of the women aged 25-29 years.

PRIMARY OUTCOME

Obstetric and neonatal outcome.

RESULTS

The teenager groups had significantly more vaginal births (adjusted OR (aOR) 2.04 (1.79 to 2.32) and 1.95 (1.88 to 2.02) for age <17 years and 17-19 years, respectively); fewer caesarean sections (aOR 0.57 (0.48 to 0.67) and 0.55 (0.53 to 0.58)), and instrumental vaginal births (aOR 0.43 (0.36 to 0.52) and 0.50 (0.48 to 0.53)) compared with the reference group. The opposite was found among older women reaching a fourfold increased OR for caesarean section. The teenagers showed no increased risk of adverse neonatal outcome but presented an increased risk of prematurity <32 weeks (aOR 1.66 (1.10 to 2.51) and 1.20 (1.04 to 1.38)). Women with advancing age (≥30 years) revealed significantly increased risk of prematurity, perineal lacerations, preeclampsia, abruption, placenta previa, postpartum haemorrhage and unfavourable neonatal outcomes compared with the reference group.

CONCLUSIONS

For clinicians counselling young women it is of importance to highlight the obstetrically positive consequences that fewer maternal complications and favourable neonatal outcomes are expected. The results imply that there is a need for individualising antenatal surveillance programmes and obstetric care based on age grouping in order to attempt to improve the outcomes in the age groups with less favourable obstetric and neonatal outcomes. Such changes in surveillance programmes and obstetric interventions need to be evaluated in further studies.

Pregnancy with chronic illness

OBJECTIVE

To describe the experience of pregnancy with a chronic illness.

DESIGN

Qualitative description.

SETTING

Tertiary Medical Center, Northeast United States.

PARTICIPANTS

A purposive sample of eight pregnant women with various chronic conditions.

METHODS

Telephone interviews.

RESULTS

The participants described their chronic illnesses as deviations from normality and their pregnancies brought them closer to normality. They described pregnancy as a balancing act between the fantasy of being normal and the reality of having a chronic disease. At the same time, women acknowledged the blessings and burdens of physical changes and intense vigilance. Participants also described emotional demands related to the need to be vigilant, additional physiological alternations, and information overload.

CONCLUSION

Pregnancy may alter chronic illness, increase stress, and create new health care needs for women. In turn, increased stress associated with chronic illness may alter perinatal outcomes. Pregnant women with chronic illness may benefit from interventions aimed at helping them balance the blessings and burdens associated with the symptoms of pregnancy.

Preconception care: promoting reproductive planning

INTRODUCTION

Preconception care recognizes that many adolescent girls and young women will be thrust into motherhood without the knowledge, skills or support they need. Sixty million adolescents give birth each year worldwide, even though pregnancy in adolescence has mortality rates at least twice as high as pregnancy in women aged 20-29 years. Reproductive planning and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and women. Smaller families also mean better nutrition and development opportunities, yet 222 million couples continue to lack access to modern contraception.

METHOD

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Comprehensive interventions can prevent first pregnancy in adolescence by 15% and repeat adolescent pregnancy by 37%. Such interventions should address underlying social and community factors, include sexual and reproductive health services, contraceptive provision; personal development programs and emphasizes completion of education. Appropriate birth spacing (18-24 months from birth to next pregnancy compared to short intervals <6 months) can significantly lower maternal mortality, preterm births, stillbirths, low birth weight and early neonatal deaths.

CONCLUSION

Improving adolescent health and preventing adolescent pregnancy; and promotion of birth spacing through increasing correct and consistent use of effective contraception are fundamental to preconception care. Promoting reproductive planning on a wider scale is closely interlinked with the reliable provision of effective contraception, however, innovative strategies will need to be devised, or existing strategies such as community-based health workers and peer educators may be expanded, to encourage girls and women to plan their families.

Would it be too late? A retrospective case-control analysis to evaluate maternal-fetal outcomes in advanced maternal age

PURPOSE

To evaluate maternal-fetal outcomes in women of advanced maternal age (AMA; >35 years old) and women of physiological maternal age as controls (C; <35 years old).

METHODS

Single-center, retrospective case-control analysis, from January 1 to December 31, 2013. For each group, we evaluated obstetric history, number of twin pregnancies, delivery mode, incidence of obstetric diseases and neonatal outcomes (5-min Apgar score, neonatal weight, meconium stained fluid rate, admission to the neonatal intensive care unit rate, and incidence of congenital malformations). Data are presented as n (%) and analyzed with χ (2) test and Fisher exact test (when required). A p value < 0.05 was considered statistically significant. Moreover, we calculated the odds ratio (OR), with confidence interval (CI) at 95 %.

RESULTS

We enrolled 1,347 pregnant women, 210 (15.6 %) in AMA and 1,137 (84.4 %) C. AMA patients showed a higher rate of previous (anamnestic) spontaneous abortion (SA; p = 0.001; OR = 2.10) and previous (anamnestic) voluntary pregnancy termination (p = 0.022; OR = 1.59), iterative cesarean section (p = 0.026; OR = 2.33), SA (p = 0.001; OR = 12.82), preterm delivery (p = 0.001; OR = 69.84), congenital malformations (p = 0.036; OR = 3.94). In C there was a greater number of nulliparous (p = 0.009; OR = 0.52) and vaginal deliveries (p = 0.025; OR = 0.41). There were not any statistically significant differences between the two groups for twin pregnancies (p = 0.862; OR = 0.97), first cesarean section (p = 0.145; OR = 0.95), other obstetric diseases and neonatal outcomes.

CONCLUSION

AMA could be considered an important risk factor only for SA and PTD and does not influence neonatal outcomes except for congenital malformations.

Outcome and management of pregnancies in severe chronic neutropenia patients by the European Branch of the Severe Chronic Neutropenia International Registry

Long-term granulocyte-colony stimulating factor treatment has been shown to be safe and effective in severe chronic neutropenia patients. However, data on its use during pregnancy are limited. To address this issue, we analyzed all pregnancies reported to the European branch of the Severe Chronic Neutropenia International Registry since 1994. A total of 38 pregnancies in 21 women with chronic neutropenia (16 pregnancies in 10 women with congenital, 10 in 6 women with cyclic, 12 in 5 women with idiopathic neutropenia) were reported. Granulocyte-colony stimulating factor was administered throughout pregnancy in 16 women and for at least one trimester in a further 5 women. No major differences were seen between treated and untreated women with respect to pregnancy outcome, newborn complications and infections. In addition, we evaluated the genetic transmission of known or suspected genetic defects in 16 mothers having 22 newborns as well as in 8 men fathering 15 children. As a proof of inheritance, neutropenia was passed on to the newborn in 58% from female and in 62% from male patients with ELANE mutations, but also to some newborns from parents with unknown gene mutation. Based on our results, granulocyte-colony stimulating factor therapy has been shown to be safe for mothers throughout pregnancies and for newborns without any signs of teratogenicity. With an increasing number of adult patients, genetic counseling prior to conception and supportive care of mothers during pregnancy are crucial. The acceptance of having affected children may reflect the high quality of life obtained due to this treatment.

Maternal occupation and term low birth weight in a predominantly latina population in los angeles, california

OBJECTIVES

Focusing on Latinas, we investigated whether maternal occupations during pregnancy increase term low birth weight (TLBW) (less than 2500 g; 37 weeks or more).

METHODS

In a case-control study (n = 1498) nested within a 2003 birth cohort (n = 58,316) in Los Angeles County, California (65% Latina), we assessed the influence of maternal occupation on TLBW, using Occupational Codes based on the 2000 US Census Occupational Classification System.

RESULTS

Odds ratios (ORs) for TLBW were increased among women working during pregnancy in "transportation and material moving operations" (adjusted OR = 3.28; 95% confidence interval = 1.00 to 10.73), "food preparation and serving occupations" (adjusted OR = 3.03, 95% confidence interval = 1.21 to 7.62), or "production occupations" (adjusted OR = 2.63, 95% confidence interval = 1.01 to 6.82) compared with "office occupations;" 73% to 93% of women working in these higher-risk jobs were immigrant Latinas.

CONCLUSIONS

Working conditions in various jobs held mainly by first-generation immigrant Latinas increase risks for TLBW and need to be addressed to develop strategies to reduce TLBW.

Maternal and infant predictors of attendance at Neonatal Follow-Up programmes

BACKGROUND

Neonatal Follow-Up (NFU) programmes provide health services for families of infants at high risk of developmental problems following difficult or extremely premature birth: yet, up to 30% of families do not attend these programmes with their infants.

METHODS

The study objective was to determine maternal and infant factors that predicted attendance at NFU programmes. Utilizing Andersen's Behavioural Model of Health Services Use, a prospective two-phase multi-site descriptive cohort study was conducted in three Canadian Neonatal Intensive Care Units (NICU) that refer to two affiliated NFU programmes. In Phase 1, 357 mothers completed standardized questionnaires that addressed maternal and infant factors, prior to their infants' NICU discharge. In Phase 2, attendance at NFU was followed at three time points over a 12-month period. Factors of interest included predisposing factors (e.g. demographic characteristics and social context); enabling factors (e.g. social support, travel distance, and income); and infant illness severity (i.e. needs factors). Multivariate logistic regression was used to estimate the odds ratio for each independent factor.

RESULTS

Mothers parenting alone, experiencing higher levels of worry about maternal alcohol or drug use, or at greater distances from NFU were less likely to attend. Mothers experiencing higher maternal stress at the time of the infant's NICU hospitalization were more likely to attend NFU. No infant factors were predictive of NFU attendance.

CONCLUSIONS

Mothers at risk of not attending NFU programmes with their infants require better identification, triage, referral and additional support to promote engagement with NFU programmes and improved quality of life for their high-risk infants.

Characteristics of primiparous women of advanced age and their partners: a homogenous or heterogenous group?

BACKGROUND

Recent studies have reported that primiparous women of advanced maternal age (AMA) appear to constitute a heterogeneous group, emphasizing the need to revise stereotyped views. The aims of this study were the following: 1) to describe the sociodemographic and marital characteristics of Portuguese couples who experienced first childbirth at advanced maternal age (the AMA group) compared with their younger counterparts (the comparison group); 2) to compare the reproductive characteristics of both groups and identify distinct reproductive trajectories within the AMA group; and 3) to distinguish among different subgroups of couples within the AMA group, depending on distinct patterns of sociodemographic, marital, and reproductive characteristics.

METHODS

The sample consisted of 250 couples. Both partners completed sociodemographic, marital, and reproductive health forms during pregnancy.

RESULTS

Despite being more highly educated, having a higher socioeconomic status, and having been employed longer, the AMA group displayed diverse conjugal configurations and reproductive trajectories over time. Within the AMA group, two subgroups were distinguished: couples who experienced infertility problems and couples who did not.

CONCLUSIONS

Couples who experience first childbirth at AMA constitute a heterogeneous group, which includes distinct subgroups with different psychosocial needs during the transition to parenthood. To revise stereotyped views of these couples, protective social policies should be improved, and health professionals should assume nonjudgmental attitudes and promote informed reproductive decisions. Psychoeducative programs concerning the transition to parenthood should take into account the distinct subgroups of couples who experience first childbirth at AMA.

Satisfaction with life during pregnancy and early motherhood in first-time mothers of advanced age: a population-based longitudinal study

Background

The trend to delay motherhood to the age of 30 and beyond is established in most high-income countries but relatively little is known about potential effects on maternal emotional well-being. This study investigates satisfaction with life during pregnancy and the first three years of motherhood in women expecting their first baby at an advanced and very advanced age.

Methods

The study was based on the National Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Data on 18 565 nulliparous women recruited in the second trimester 1999–2008 were used. Four questionnaires were completed: at around gestational weeks 17 and 30, and at six months and three years after the birth. Medical data were retrieved from the national Medical Birth Register. Advanced age was defined as 32–37 years, very advanced age as ≥38 years and the reference group as 25–31 years. The distribution of satisfaction with life from age 25 to ≥40 years was investigated, and the mean satisfaction with life at the four time points was estimated. Logistic regression analyses based on generalised estimation equations were used to investigate associations between advanced and very advanced age and satisfaction with life when controlling for socio-demographic factors.

Results

Satisfaction with life decreased from around age 28 to age 40 and beyond, when measured in gestational weeks 17 and 30, and at six months and three years after the birth. When comparing women of advanced and very advanced age with the reference group, satisfaction with life was slightly reduced in the two older age groups and most of all in women of very advanced age. Women of very advanced age had the lowest scores at all time points and this was most pronounced at three years after the birth.

Conclusion

First-time mothers of advanced and very advanced age reported a slightly lower degree of satisfaction with life compared with the reference group of younger women, and the age-related effect was greatest when the child was three years of age.

Induction of labour

OBJECTIVE

To review the most current literature in order to provide evidence-based recommendations to obstetrical care providers on induction of labour.

OPTIONS

Intervention in a pregnancy with induction of labour.

OUTCOMES

Appropriate timing and method of induction, appropriate mode of delivery, and optimal maternal and perinatal outcomes.

EVIDENCE

Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in 2010 using appropriate controlled vocabulary (e.g., labour, induced, labour induction, cervical ripening) and key words (e.g., induce, induction, augmentation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to the end of 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence in this document was rated using criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). SUMMARY STATEMENTS: 1. Prostaglandins E(2) (cervical and vaginal) are effective agents of cervical ripening and induction of labour for an unfavourable cervix. (I) 2. Intravaginal prostaglandins E(2) are preferred to intracervical prostaglandins E(2) because they results in more timely vaginal deliveries. (I).

Educational attainment, perception of workplace support and its influence on timing of childbearing for Canadian women: a cross-sectional study

Under Canada's Employment Insurance system, parents are entitled to receive up to 50 weeks of parental leave at 55 % of salary. Despite this national policy, women with higher education are more likely to delay childbearing. This analysis aimed to assess the association between workplace support, educational attainment and the timing of first births. Women who had recently given birth to their first live-born infant and lived in Alberta, Canada, were randomly selected to participate in a telephone survey. Logistic regression was used to assess the relationship between workplace support, educational attainment and timing of first pregnancy. Among 835 women with a planned pregnancy, 26 % agreed that support or lack of support for pregnant women at their workplace affected their decision about when to begin their family. After controlling for age and income, women who had completed a post-graduate degree were three times (OR 3.39, 95 % CI 1.69-6.81) more likely to indicate that support or lack of support for pregnant women in their workplace affected their childbearing decisions. In spite of national policies, and the potential risks associated with delayed childbearing, workplace support impacts timing of pregnancy, particularly for highly educated women.

Effect of advanced maternal age on perinatal outcomes in twins: the impact of chorionicity

PURPOSE

In contrast to singletons, twins born to older mothers have lower rates of perinatal mortality than twins born to younger mothers. We examined whether differences in chorionicity could explain this unexpected maternal age effect.

METHODS

We used population-based data on twins born to mothers aged 20-29 (n = 3702) and ≥35 years (n = 1880) in the North of England, UK, 1998-2007. We calculated rate ratios (RR) and 95% confidence intervals (CIs) to estimate the effect of maternal age; adjusted RRs (ARRs) were estimated by the use of generalized estimating equations for Poisson regression controlling for chorionicity and other confounders.

RESULTS

Older mothers had a lower proportion of monochorionic twins (17.6% vs. 24.3%, P < .01); lower neonatal (RR, 0.57; 95% CI, 0.34-0.95) and perinatal mortality (RR, 0.74; 95% CI, 0.53-1.04). Adjustment for chorionicity attenuated these associations (ARR, 0.59; 95% CI, 0.35-0.98 and ARR, 0.80; 95% CI, 0.57-1.12, respectively) and after further adjustment for additional factors, both associations became nonsignificant. Older mothers had greater rates of small-for-gestational-age infants (ARR, 1.59; 95% CI, 1.24-2.05), and cesarean delivery (ARR, 1.31; 95% CI, 1.16-1.48).

CONCLUSIONS

Perinatal death rates were lower but not statistically different for twins born to older versus younger mothers. This association was attenuated by adjustment for chorionicity.

Pregnancy Outcome in Women of Advanced Maternal Age: A Cross-Sectional Study in a Turkish Maternity Hospital

Background: There is a current trend towards delayed childbearing around the world. This is considered to increase the risk for poor maternal and neonatal outcomes. In this study, we evaluated pregnancy outcomes in women of advanced maternal age in a single maternity hospital in Turkey.Methods: Medical records of 517 women aged 35 years and older that gave birth between 2009 and 2010 were examined retrospectively. The chi-squared, Mann-Whitney U, and Student t tests were used for statistical analyses.Results: In total, 462 (89.3%) women aged 39 years or less and 55 (10.6%) women aged 40 years and older were included in the analysis. Cesarean sections, and neonatal mortality were more common in women of advanced maternal age (p = 0.004 and p=0.002, respectively). Neonatal mortality (OR: 0.1; 95% CI 0.02–1; p = 0.032), premature birth (OR: 0.4; 95% CI 0.2–0.8; p = 0.008), and low birth weight (LBW) (OR: 0.2; 95% CI 0.1–0.5; p < 0.001) were significantly higher in women 40 years and older. Respiratory distress syndrome (RDS) developed in 26% of babies with LBWs. All patients of neonatal death were diagnosed with asphyxiation or RDS.Conclusions: At the Bolu Izzet Baysal Maternity and Children’s Hospital, advanced maternal age was associated with increased adverse fetal and neonatal outcomes.

Trends and outcomes for donor oocyte cycles in the United States, 2000-2010

IMPORTANCE

The prevalence of oocyte donation for in vitro fertilization (IVF) has increased in the United States, but little information is available regarding maternal or infant outcomes to improve counseling and clinical decision making.

OBJECTIVES

To quantify trends in donor oocyte cycles in the United States and to determine predictors of a good perinatal outcome among IVF cycles using fresh (noncryopreserved) embryos derived from donor oocytes.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of data from the Centers for Disease Control and Prevention's National ART Surveillance System, to which fertility centers are mandated to report and which includes data on more than 95% of all IVF cycles performed in the United States. Data from 2000 to 2010 described trends. Data from 2010 determined predictors.

MAIN OUTCOMES AND MEASURES

Good perinatal outcome, defined as a singleton live-born infant delivered at 37 weeks or later and weighing 2500 g or more.

RESULTS

From 2000 to 2010, data from 443 clinics (93% of all US fertility centers) were included. The annual number of donor oocyte cycles significantly increased, from 10,801 to 18,306. Among all donor oocyte cycles, an increasing trend was observed from 2000 to 2010 in the proportion of cycles using frozen (vs fresh) embryos (26.7% [95% CI, 25.8%-27.5%] to 40.3% [95% CI, 39.6%-41.1%]) and elective single-embryo transfers (vs transfer of multiple embryos) (0.8% [95% CI, 0.7%-1.0%] to 14.5% [95% CI, 14.0%-15.1%]). Good perinatal outcomes increased from 18.5% (95% CI, 17.7%-19.3%) to 24.4% (95% CI, 23.8%-25.1%) (P < .001 for all listed trends). Mean donor and recipient ages remained stable at 28 (SD, 2.8) years and 41 (SD, 5.3) years, respectively. In 2010, 396 clinics contributed data. For donor oocyte cycles using fresh embryos (n = 9865), 27.5% (95% CI, 26.6%-28.4%) resulted in good perinatal outcome. Transfer of an embryo at day 5 (adjusted odds ratio [OR], 1.17 [95% CI, 1.04-1.32]) and elective single-embryo transfers (adjusted OR, 2.32 [95% CI, 1.92-2.80]) were positively associated with good perinatal outcome; tubal (adjusted OR, 0.72 [95% CI, 0.60-0.86]) or uterine (adjusted OR, 0.74 [95% CI, 0.58-0.94]) factor infertility and non-Hispanic black recipient race/ethnicity (adjusted OR, 0.48 [95% CI, 0.35-0.67]) were associated with decreased odds of good outcome. Recipient age was not associated with likelihood of good perinatal outcome.

CONCLUSIONS AND RELEVANCE

In the United States from 2000 to 2010, there was an increase in number of donor oocyte cycles, accompanied by an increase in good outcomes. Further studies are needed to understand the mechanisms underlying the factors associated with less successful outcomes.

Maternal age and adverse pregnancy outcome: a cohort study

OBJECTIVE

To examine the association between maternal age and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.

METHODS

This was a retrospective study in women with singleton pregnancies attending the first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation. Data on maternal characteristics, and medical and obstetric history were collected and pregnancy outcomes ascertained. Maternal age was studied, both as a continuous and as a categorical variable. Regression analysis was performed to examine the association between maternal age and adverse pregnancy outcome including pre-eclampsia, gestational hypertension, gestational diabetes mellitus (GDM), preterm delivery, small-for-gestational age (SGA) neonate, large-for-gestational age (LGA) neonate, miscarriage, stillbirth and elective and emergency Cesarean section.

RESULTS

The study population included 76 158 singleton pregnancies with a live fetus at 11 + 0 to 13 + 6 weeks. After adjusting for potential maternal and pregnancy confounding variables, advanced maternal age (defined as ≥ 40 years) was associated with increased risk of miscarriage (odds ratio (OR), 2.32 (95% CI, 1.83-2.93); P < 0.001), pre-eclampsia (OR, 1.49 (95% CI, 1.22-1.82); P < 0.001), GDM (OR, 1.88 (95% CI, 1.55-2.29); P < 0.001), SGA (OR, 1.46 (95% CI, 1.27-1.69); P < 0.001) and Cesarean section (OR, 1.95 (95% CI, 1.77-2.14); P < 0.001), but not with stillbirth, gestational hypertension, spontaneous preterm delivery or LGA.

CONCLUSIONS

Maternal age should be combined with other maternal characteristics and obstetric history when calculating an individualized adjusted risk for adverse pregnancy complications. Advanced maternal age is a risk factor for miscarriage, pre-eclampsia, SGA, GDM and Cesarean section, but not for stillbirth, gestational hypertension, spontaneous preterm delivery or LGA.

Variables predicting low infant developmental scores: Maternal age above 30 years is a main predictor

Aim: To explore variables predicting low developmental scores in 6-month-old infants in a population-based study. Methods: In a longitudinal study representative of pregnant women in Oslo, Norway, questionnaires were answered at 17 and 30 weeks of pregnancy and 6 months after term; N = 1053 after exclusions (women with non-Scandinavian ethnicity, twin births, infants <5.0 or >7.0 months corrected age, and birth weight <2.5 kg), and data were collected from the Norwegian Birth Registry. Measures included sociodemographic variables, maternal mental health and pregnancy life style, data concerning the birth/newborn, and the Ages and Stages Questionnaires (ASQ) for 6-month-olds. Logistic regression analyses were used to identify variables predicting an ASQ score ≤15th percentile. Results: In adjusted analyses, only increasing maternal age and infant having older siblings predicted a low score on ASQ Total. These variables also predicted low scores on several ASQ areas (i.e. Communication, Gross motor, Fine motor, Problem-solving and Personal social), together with maternal major lifetime depression and feeling lonely. Protective variables were increasing infant birth weight (Gross motor) and pregnancy smoking (Communication). Other maternal sociodemographic variables, and infant sex, had no predictive power. Already at a maternal age of 31, the mean age of the pregnant women, the possibility of a low infant score increased significantly. Conclusions: In this population-based study, higher maternal age, having older siblings, and a history of maternal major lifetime depression, mainly predicts low developmental scores in 6-month-old infants.

Attitudes toward fertility and childbearing scale: an assessment of a new instrument for women who are not yet mothers in Sweden

Background

Women in high-resource countries often postpone childbearing. Postponed childbearing may lead to increased health risks for both mother and child and may also result in childlessness. Attitudes among men and women about fertility and childbearing have been studied in different phases of fertile life, but instruments that assess attitudes toward fertility and childbearing among women without children are lacking. The aim of this study is to develop and evaluate a specific instrument, the Attitudes toward Fertility and Childbearing Scale (AFCS), to assess and compare attitudes toward fertility and childbearing using a national sample of Swedish women, who are not yet mothers.

Methods

This study reports on the development of a new instrument and was carried out in three steps: (1) Statements were constructed based on two qualitative studies; (2) Data were collected through web-based questionnaires, and (3) Data were analyzed using statistical tests for construct validity with exploratory factor analysis, internal consistency reliability, and comparative statistics. Student’s t-test and analysis of variance (ANOVA) were performed to analyze differences between the components and background characteristics. One hundred and thirty-eight women participated; they were 20–30 years of age, not mothers, and able to read and speak Swedish.

Results

The instrument showed acceptable sample adequacy, factorability, and reliability using Cronbach’s alpha. Three components were revealed, each one representing a specific underlying dimension of the construct: 1) importance of fertility for the future (Cronbach’s α, 0.901); 2) childbearing as a hindrance at present (Cronbach’s α, 0.908); and 3) social identity (Cronbach’s α, 0.805). Women who were students scored higher in importance of fertility for the future than did women who were unemployed. Women living in metropolitan areas and larger cities were more likely to score highly in childbearing as a hindrance at present than women living in middle-sized cities or in the countryside. Women in the age group from 25–26 agreed to the largest extent with childbearing as a hindrance at present.

Conclusions

The instrument shows acceptable factorability and reliability. Three components were found to be the best solution. Further evaluation is necessary.

Periconception maternal characteristics and embryonic growth trajectories: the Rotterdam Predict study

STUDY QUESTION

Are maternal characteristics and lifestyle factors associated with human embryonic growth trajectories?

SUMMARY ANSWER

Periconception maternal age is associated with increased, and smoking and alcohol use with decreased embryonic growth trajectories, estimated with crown-rump length (CRL) measurements.

WHAT IS KNOWN ALREADY

Fetal weight is associated with health and disease in later life. Maternal characteristics and lifestyle factors affect fetal growth in the second and third trimesters of pregnancy and at birth; however, little is known about the association of these characteristics with first trimester embryonic growth.

STUDY DESIGN, SIZE, DURATION

In a tertiary centre, pregnant women were recruited and enrolled in a prospective periconception cohort study before 8 weeks of gestation. We selected 87 spontaneously conceived singleton pregnancies of women recruited in 2009 and 2010 that ended in non-malformed live births.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We performed weekly three-dimensional ultrasound scans from enrolment up to 13 weeks of gestation. At enrolment, a questionnaire was completed. Embryonic CRL measurements were performed using the V-Scope software in the BARCO I-Space. Associations between maternal characteristics and embryonic growth were assessed using square root transformed CRL as response in linear mixed model analyses, adjusted for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Four hundred and ninety-six scans from 87 pregnancies were included. In the multivariable analysis, maternal age was positively associated with first trimester CRL (difference per maternal year of age 0.024√mm (95% confidence interval (CI) 0.009, 0.040), P = 0.001). At 6 and 12 weeks of gestation, the CRL of an embryo from a 40-year-old mother was estimated 2.0 mm (61%) and 7.2 mm (14%) larger, respectively, compared with an embryo from a 20-year-old mother. Smoking of 10 or more cigarettes per day was negatively associated with CRL (difference -0.211√mm (95% CI -0.416, -0.006), P = 0.04), with embryos that were 0.9 mm (18.7%) and 3.1 mm (5.5%) smaller at 6 and 12 weeks, respectively, compared with non-smokers. Periconception alcohol use was negatively associated with CRL growth rate (difference -0.0025√mm (95% CI -0.0047, -0.0003)/day gestational age, P = 0.022), with embryos that were 0.2 mm (3%) and 1.1 mm (2%) smaller at 6 and 12 weeks, respectively, compared with non-alcohol users. Parity, BMI and moment of initiation of folic acid use were not significantly associated with embryonic CRL.

LIMITATIONS, REASONS FOR CAUTION

Due to the selection of pregnancies in a tertiary centre and the small number of pregnancies, the external validity of the results has to be confirmed using larger sample sizes and other population-based periconception cohort studies.

WIDER IMPLICATIONS OF THE FINDINGS

The association of maternal age and smoking with embryonic growth is in line with previous literature, whereas the association between embryonic growth and alcohol use is a new finding. However, concerning exposure to alcohol, the effect estimate was small and it is questionable whether this is of clinical value. More research is warranted to unravel underlying mechanisms and to assess the implications for preconception and early pregnancy care, such as the development and implementation of effective lifestyle interventions.

STUDY FUNDING/COMPETING INTEREST(S)

The work was funded by the Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. The authors declare no conflicts of interest.

Assisted conception, maternal age and breastfeeding: an Australian cohort study

AIM

To establish the relationships between age, mode of conception and breastfeeding.

METHOD

Consecutive cohorts of nulliparous women >25 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age groups ≤30, 31-36 and ≥37 years were recruited. Data were obtained via telephone interviews and postal questionnaires in late pregnancy and 4 months postpartum. Sociodemographic characteristics, reproductive health, birth and breastfeeding experiences were assessed by study-specific questions. Self-rated general health and symptoms of depression and anxiety were assessed with standardized psychometric instruments. Main outcomes were exclusive breastfeeding at discharge from maternity hospital and 4 months postpartum.

RESULTS

Of 1179 eligible women, 791 (67%) participated; 549 (93%) had singleton infants, provided complete data and were included in analyses. Overall, 37.2% of participants aged ≤30, 33% aged 31-36 and 55.1% aged ≥37 years experienced Caesarean births. Regardless of age, compared with the SC group, ARTC women had twice the rate of Caesareans prior to labour. Controlling for other factors, exclusive breastfeeding rates at hospital discharge and 4 months postpartum were lowest amongst ARTC women who experienced Caesarean prior to labour (p < .001).

CONCLUSION

Independent of age, assisted conception increases the risk conferred by Caesarean birth to breastfeeding initiation and maintenance.

Associations of maternal age with maternity care use and birth outcomes in primiparous women: a comparison of results in 1991 and 2008 in Finland

OBJECTIVE

To compare birth outcomes and maternity care use in 1991 and 2008 by age among primiparous Finnish women.

DESIGN

Register-based study.

SETTING

Nationwide Medical Birth Register.

POPULATION

All primiparous women in 1991 (n = 24,765) and 2008 (n = 23,511).

METHODS

Women aged 35-39 and ≥40 years were compared with women aged 20-34 years in 1991 and 2008, using logistic regression to adjust for women's background.

MAIN OUTCOME MEASURES

Maternity care: prenatal visits, hospitalisation during pregnancy, labour induction, delivery mode, long postpartum hospital stay; and birth outcomes: birthweight, preterm birth, Apgar scores, intensive/observation unit, respiratory care, perinatal death.

RESULTS

In both years, older women's deliveries were more often induced, instrumental, or by caesarean section. In 2008 compared with 1991, hospitalisations were lower and instrumental deliveries and labour induction were higher in older women. A significant decrease in adjusted odds ratios (OR, 95% confidence intervals) between 1991 and 2008 among women aged 35-39 was found for preterm birth (1.47, 1.18-1.84 versus 0.96, 0.86-1.07) and for intensive/observation unit (1.73, 1.47-2.05 versus 1.21, 1.07-1.37) and, among women aged ≥40 years, for intensive/observation unit (3.14, 2.30-4.29 versus 1.64, 1.31-2.07). The risk for perinatal death (1.66, 0.60-4.60 versus 2.69, 1.07-6.79) was higher in 2008 than in 1991 among women aged ≥40.

CONCLUSIONS

In 2008, older primiparous women still used more maternity care, had more interventions, and poorer birth outcomes than younger women, regardless of care advances. Additional risks declined among women aged 35-39 but not among aged ≥40.

Predictors of perception of pregnancy risk among nulliparous women

OBJECTIVE

To determine factors associated with perception of pregnancy risk using a conceptual framework based on a review of the relevant literature and the psychometric model of risk perception.

DESIGN

A correlational study.

SETTING

Ambulatory care and antepartum units of two tertiary hospitals and selected obstetricians' offices and prenatal classes in Winnipeg, Canada.

PARTICIPANTS

A convenience sample of nulliparous women in their third trimester with a singleton pregnancy.

METHODS

Between December 2009 and January 2011, the following questionnaires were completed by 159 nulliparous women: the Perception of Pregnancy Risk Questionnaire, the Pregnancy-related Anxiety scale, Knowledge of Maternal Age-related Risks of Childbearing Questionnaire, the SF-12v2 Health Status Survey, the Multidimensional Health Locus of Control, and the Prenatal Scoring Form. Pearson's r correlations and stepwise multivariable linear regression analyses were conducted to achieve the research objectives.

RESULTS

Of the eight proposed factors in the conceptual framework, five factors were significant predictors of perception of pregnancy risk, including pregnancy-related anxiety, maternal age, medical risk, perceived internal control, and gestational age, accounting for 47% to 49% of the variance in risk perception. An interaction between the pregnancy-related anxiety score and maternal age was found.

CONCLUSIONS

These results contribute to the literature on perception of pregnancy risk by identifying a new predictor (gestational age), supporting the role of previously known factors in the state of pregnancy, and proposing pregnancy-related anxiety as a pregnancy dread factor in risk perception theories. This knowledge may have implications for developing more effective risk communication models.

Delivery outcomes for nulliparous women at the extremes of maternal age - a cohort study

OBJECTIVE

To examine the associations between extremes of maternal age (≤17 years or ≥40 years) and delivery outcomes.

DESIGN

Retrospective cohort study.

SETTING

Urban maternity hospital in Ireland.

POPULATION

A total of 36 916 nulliparous women with singleton pregnancies who delivered between 2000 and 2011.

METHODS

The study population was subdivided into five maternal age groups based on age at first booking visit: ≤17 years, 18-19 years, 20-34 years, 35-39 years and women aged ≥40 years. Logistic regression analyses were performed to examine the associations between extremes of maternal age and delivery outcomes, adjusting for potential confounding factors.

MAIN OUTCOME MEASURES

Preterm birth, admission to the neonatal unit, congenital anomaly, caesarean section.

RESULTS

Compared with maternal age 20-34 years, age ≤17 years was a risk factor for preterm birth (adjusted odds ratio [adjOR] 1.83, 95% confidence interval [95% CI] 1.33-2.52). Babies born to mothers ≥40 years were more likely to require admission to the neonatal unit (adjOR 1.35, 95% CI 1.06-1.72) and to have a congenital anomaly (adjOR 1.71, 95% CI 1.07-2.76). The overall caesarean section rate in nulliparous women was 23.9% with marked differences at the extremes of maternal age; 10.7% at age ≤17 years (adjOR 0.46, 95% CI 0.34-0.62) and 54.4% at age ≥40 years (adjOR 3.24, 95% CI 2.67-3.94).

CONCLUSIONS

Extremes of maternal age need to be recognised as risk factors for adverse delivery outcomes. Low caesarean section rates in younger women suggest that a reduction in overall caesarean section rates may be possible.

Age, mode of conception, health service use and pregnancy health: a prospective cohort study of Australian women

BACKGROUND

There is limited evidence about the ways in which maternal age and mode of conception interact with psychological, sociodemographic, health and health service factors in governing pregnancy health. The aim of this study was to establish in what ways maternal age and mode of conception are associated with, health behaviours, health service use and self-rated physical and mental health during pregnancy.

METHOD

A prospective cohort study was conducted in a collaboration between universities, infertility treatment services and public and private obstetric hospitals in Melbourne and Sydney, Australia,. Consecutive cohorts of nulliparous English-literate women at least 28 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age-groups: 20-30; 31-36 and at least 37 years were recruited. Data were obtained via structured individual telephone interviews and self-report postal questionnaires at recruitment and four months postpartum. Study-specific questions assessed: sociodemographic characteristics; reproductive health; health behaviours and health service use. Standardized instruments assessed physical health: SF 12 Physical Component Score (PCS) and mental health: SF12 Mental Component Score (MCS); State Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale. The main outcome measures were the SF 12 PCS, SF12 MCS scores and pregnancy-related hospital admissions.

RESULTS

Of 1179 eligible women 791 (67%) participated, 27 had fertility treatment without oocyte retrieval and were excluded and 592/764 (78%) completed all pregnancy assessments. When other factors were controlled speaking a language other than English, having private health insurance and multiple gestation were associated with worse physical health and having private health insurance and better physical health were associated with better mental health. Pregnancy-related hospital admissions were associated with worse physical health and multiple gestation.

CONCLUSIONS

Maternal age and mode of conception are not associated with pregnancy health and health service use when sociodemographic factors are considered.

Does advanced maternal age confer a survival advantage to infants born at early gestation?

BACKGROUND

Recent studies have shown that older mothers who deliver at preterm gestation have lower neonatal mortality rates compared with younger mothers who deliver at preterm gestation. We examined the effect of maternal age on gestational age-specific perinatal mortality.

METHODS

We compared fetal, neonatal and perinatal mortality rates among singleton births in the United States, 2003-2005, to mothers aged ≥35 versus 20-29 years. The analysis was stratified by gestational age and perinatal mortality rates were contrasted by maternal age at earlier (22-33 weeks) and later gestation (≥34 weeks). Gestational age-specific perinatal mortality rates were calculated using the traditional perinatal formulation (deaths among births at any gestation divided by total births at that gestation) and also the fetuses-at-risk model (deaths among births at any gestation divided by fetuses-at-risk of death at that gestation).Logistic regression was used to estimate adjusted odds ratios (AOR) for perinatal death.

RESULTS

Under the traditional approach, fetal death rates at 22-33 weeks were non-significantly lower among older mothers (AOR 0.97, 95% confidence interval [CI] 0.91-1.03), while rates were significantly higher among older mothers at ≥34 weeks (AOR 1.66, 95% CI 1.56-1.76). Neonatal death rates were significantly lower among older compared with younger mothers at 22-33 weeks (AOR=0.93, 95% CI 0.88-0.98) but higher at ≥34 weeks (AOR 1.26, 95% CI 1.21-1.31). Under the fetuses-at-risk model, both rates were higher among older vs younger mothers at early gestation (AOR for fetal and neonatal mortality 1.35, 95% CI 1.27-1.43 and 1.31, 95% CI 1.24-1.38, respectively) and late gestation (AOR for fetal and neonatal mortality 1.66, 95% CI 1.56-1.76) and 1.21, 95% CI 1.14-1.29, respectively).

CONCLUSIONS

Although the traditional prognostic perspective on the risk of perinatal death among older versus younger mothers varies by gestational age at birth, the causal fetuses-at-risk model reveals a consistently elevated risk of perinatal death at all gestational ages among older mothers.

Very advanced maternal age and morbidity in Victoria, Australia: a population based study

BACKGROUND

In Australia, approximately 0.1% of births occur to women 45 years or older and this rate has been increasing in recent years. There are however, few population based studies examining perinatal outcomes among this age group. The aim of this study was to determine the maternal and perinatal outcomes of pregnancies in women aged 45 years or older compared to women aged 30-34 years.

METHODS

Data on births at 20 or more weeks' gestation were obtained from the Victorian Perinatal Data Collection for the years 2005 and 2006. We examined selected maternal and perinatal outcomes for women of very advanced maternal age (VAMA) aged 45 years or older (n = 217) and compared them to women aged 30-34 years (n = 48,909). Data were summarised using numbers and percentages. Categorical data were analysed by Chi-square tests and Fisher's exact test. Comparisons are presented using unadjusted odds ratios, 95 percent confidence intervals (CIs) and p-values.

RESULTS

Women aged 45 years and older had higher odds of gestational diabetes (OR 2.05; 95% CI 1.3-3.3); antepartum haemorrhage (OR 1.89; 95% CI 1.01-3.5), and placenta praevia (OR 4.88; 95% CI 2.4-9.5). The older age-group also had higher odds of preterm birth between 32-36 weeks (OR 2.61; 95% CI 1.8-3.8); low birth-weight (<2,500 gr) (OR 2.22; 95% CI 1.5-3.3) and small for gestational age (OR 1.53; 95% CI 1.0-2.3). Stratified analysis revealed that VAMA was most strongly associated with caesarean section in primiparous women (OR 8.24; 95% CI 4.5, 15.4) and those using ART (OR 5.75; 95% CI 2.5, 13.3), but the relationship persisted regardless of parity, ART use and plurality. Low birthweight was associated with VAMA only in first births (OR 3.90; 95% CI 2.3, 6.6), while preterm birth was more common in older women for both first (OR 3.13; 95% CI 1.8, 5.3) and subsequent (OR 2.08; 95% CI 1.2, 3.5) births, and for those having singleton births (OR 2.11; 95% CI 1.3, 3.4), and those who did not use ART (OR 2.10; 95% CI 1.3, 3.4). Preterm birth was very common in multiple births and following ART use, regardless of maternal age.

CONCLUSIONS

This study demonstrates that women aged 45 years and older, in Victoria, Australia, have higher rates of pregnancy and perinatal complications, compared to women aged 30-34 years.

Hypothyroidism and diabetes mellitus - a risky dual gestational endocrinopathy

Objectives. Diabetes mellitus (DM) and hypothyroidism are each associated with increased rate of pregnancy complications. However, their combined morbidity during gestation is poorly studied. Therefore, the aims of this study were to determine the prevalence of the combined morbidity of DM & hypothyroidism and whether it is associated with adverse maternal and neonatal outcome.

Study design. This population based retrospective cohort study included 87,213 women who had 232,293 deliveries. All deliveries were divided into the following groups: (1) hypothyroidism & DM (n = 171); (2) hypothyroidism (n = 1502); (3) DM (n = 13,324); and (4) deliveries of women with neither endocrinopathy, who served as a control group (n = 217, 296).

Results. The prevalence of DM & hypothyroidism in our population was 0.17%. In comparisons to the other study groups, women with DM & hypothyroidism had higher rates of infertility (p < 0.001), preeclampsia (p < 0.001), chronic hypertension (p < 0.001), preterm birth (p < 0.001), and cesarean deliveries (p < 0.001). In Generalized Estimating Equations (GEE) model, hypothyroidism & DM was an independent risk factor for cesarean section (OR 3.46; 95% CI 2.53–4.75) and for preeclampsia (OR 1.82; 95%CI 1.16–2.84).

Conclusion. The combination of DM & hypothyroidism is rare, yet it is associated with higher rate of infertility, cesarean sections, preterm deliveries, and hypertensive disorders of pregnancy than the rest of the population. This dual endocrinological combination is an independent risk factor for preeclampsia and cesarean section. These findings suggest that these patients are at risk for perinatal complications and should be followed and delivered as high risk pregnancies.

Impact of prenatal care provider on the use of ancillary health services during pregnancy

Background

Recent declines in the provision of prenatal care by family physicians and the integration of midwives into the Canadian health care system have led to a shift in the pattern of prenatal care provision; however it is unknown if this also impacts use of other health services during pregnancy. This study aimed to assess the impact of the type of prenatal care provider on the self-reported use of ancillary services during pregnancy.

Methods

Data for this study was obtained from the All Our Babies study, a community-based prospective cohort study of women’s experiences during pregnancy and the post-partum period. Chi-square tests and logistic regression were used to assess the association between type of prenatal care provider and use of ancillary health services in pregnancy.

Results

During pregnancy, 85.8% of women reported accessing ancillary health services. Compared to women who received prenatal care from a family physician, women who saw a midwife were less likely to call a nurse telephone advice line (OR = 0.30, 95% CI: 0.18-0.50) and visit the emergency department (OR = 0.47, 95% CI: 0.24-0.89), but were more likely receive chiropractic care (OR = 4.07, 95% CI: 2.49-6.67). Women who received their prenatal care from an obstetrician were more likely to visit a walk-in clinic (OR = 1.51, 95% CI: 1.11-2.05) than those who were cared for by a family physician.

Conclusions

Prenatal care is a complex entity and referral pathways between care providers and services are not always clear. This can lead to the provision of fragmented care and create opportunities for errors and loss of information. All types of care providers have a role in addressing the full range of health needs that pregnant women experience.

HIV infection and its impact on fetal outcomes among women of advanced maternal age: a propensity score weighted matching approach

Advanced maternal age (AMA) and HIV status have been investigated separately for their influence on infant outcomes. Both are associated with adverse fetal growth outcomes, including low birth weight (LBW) and preterm birth (PTB). However, the impact of the cooccurrence of these factors in relation to birth outcomes remains relatively understudied. We analyzed Florida hospital discharge data linked to vital records. The study population consisted of women who had a singleton live birth between 1998 and 2007 (N=1,687,176). The exposure variables were HIV infection and maternal age, while the outcomes of interest were LBW, PTB, and small for gestational age (SGA). We matched HIV-positive women to HIV-negative women on selected variables using propensity scores. To approximate relative risks, we computed adjusted odds ratios (AOR) and 95% confidence intervals (CI) generated from logistic regression models and accounted for the matched design using the generalized estimating equations framework. After adjusting for demographic variables, clinical conditions, and route of birth, the risks of LBW, PTB, and SGA remained significant for HIV-positive women, regardless of age. HIV-positive women of AMA (≥35 years) were more likely to have infants of LBW (AOR=1.73, 95% CI=1.37-2.18), PTB (AOR=1.35, 95% CI: 1.06-1.71), and SGA (AOR=1.52, 95% CI=1.22-1.89), compared to uninfected mothers of younger age (<35 years). For women of advanced age, HIV positivity elevates their risk for LBW and PTB. The interplay of HIV status and age should be considered by healthcare providers when determining appropriate interconception strategies for women and their families.

Experience of childbirth in first-time mothers of advanced age - a Norwegian population-based study

Background

Delaying the first childbirth to an advanced age has increased significantly during the last decades, but little is known about older first time mothers’ experience of childbirth. This study investigates the associations between advanced maternal age in primiparous women and the postnatal assessment of childbirth.

Methods

The study was based on the National Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Data on 30 065 nulliparous women recruited in the second trimester 1999–2008 were used. Three questionnaires were completed: around gestational week 17 and 30, and at 6 months postpartum. Medical data were retrieved from the national Medical Birth Register. Advanced age was defined as ≥32 years and the reference group as 25–31 years. Descriptive and multiple logistic regression analyses were conducted.

Results

Primiparous women aged 32 years and above expressed more worry about the upcoming birth than the younger women (adjusted OR 1.13; 95% CI 1.06-1.21), and 6 months after the birth they had a slightly higher risk of having experienced childbirth as ‘worse than expected’ (adjusted OR 1.09; 95% CI 1.02-1.16). The difference in birth experience was explained by mode of delivery. Comparisons within subgroups defined by the same mode of delivery showed that the risk of a more negative birth experience in the older women only applied to those with a spontaneous vaginal birth (adjusted OR 1.12; 95% CI 1.02-1.22). In women delivered by cesarean section, the older more often than younger women rated childbirth as ‘better than expected’ (elective cesarean delivery: adjusted OR 1.36; 95% CI 1.01-1.85, emergency cesarean delivery: adjusted OR 1.38; 95% CI 1.03-1.84).

Conclusion

Postponing childbirth to ≥32 years of age only marginally affected the experience of childbirth. Older women seemed to manage better than younger with having an operative delivery.

Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort

BACKGROUND

Recent decades have witnessed an increase in mean maternal age at childbirth in most high-resourced countries. Advanced maternal age has been associated with several adverse maternal and perinatal outcomes. Although there are many studies on this topic, data from large contemporary population-based cohorts that controls for demographic variables known to influence perinatal outcomes is limited.

METHODS

We performed a population-based cohort study using data on all singleton births in 2004-2008 from the North Western Perinatal Survey based at The University of Manchester, UK. We compared pregnancy outcomes in women aged 30-34, 35-39 and ≥40 years with women aged 20-29 years using log-linear binomial regression. Models were adjusted for parity, ethnicity, social deprivation score and body mass index.

RESULTS

The final study cohort consisted of 215,344 births; 122,307 mothers (54.19%) were aged 20-29 years, 62,371(27.63%) were aged 30-34 years, 33,966(15.05%) were aged 35-39 years and 7,066(3.13%) were aged ≥40 years. Women aged 40+ at delivery were at increased risk of stillbirth (RR = 1.83, [95% CI 1.37-2.43]), pre-term (RR = 1.25, [95% CI: 1.14-1.36]) and very pre-term birth (RR = 1.29, [95% CI:1.08-1.55]), Macrosomia (RR = 1.31, [95% CI: 1.12-1.54]), extremely large for gestational age (RR = 1.40, [95% CI: 1.25-1.58]) and Caesarean delivery (RR = 1.83, [95% CI: 1.77-1.90]).

CONCLUSIONS

Advanced maternal age is associated with a range of adverse pregnancy outcomes. These risks are independent of parity and remain after adjusting for the ameliorating effects of higher socioeconomic status. The data from this large contemporary cohort will be of interest to healthcare providers and women and will facilitate evidence based counselling of older expectant mothers.

Induction of labour versus expectant management for nulliparous women over 35 years of age: a multi-centre prospective, randomised controlled trial

Background

British women are increasingly delaying childbirth. The proportion giving birth over the age of 35 rose from 12% in 1996 to 20% in 2006. Women over this age are at a higher risk of perinatal death, and antepartum stillbirth accounts for 61% of all such deaths. Women over 40 years old have a similar stillbirth risk at 39 weeks as women who are between 25 and 29 years old have at 41 weeks.

Many obstetricians respond to this by suggesting labour induction at term to forestall some of the risk. In a national survey of obstetricians 37% already induce women aged 40–44 years. A substantial minority of parents support such a policy, but others do not on the grounds that it might increase the risk of Caesarean section. However trials of induction in other high-risk scenarios have not shown any increase in Caesarean sections, rather the reverse. If induction for women over 35 did not increase Caesareans, or even reduced them, it would plausibly improve perinatal outcome and be an acceptable intervention. We therefore plan to perform a trial to test the effect of such an induction policy on Caesarean section rates.

This trial is funded by the NHS Research for Patient Benefit (RfPB) Programme.

Design

The 35/39 trial is a multi-centre, prospective, randomised controlled trial. It is being run in twenty UK centres and we aim to recruit 630 nulliparous women (315 per group) aged over 35 years of age, over two years. Women will be randomly allocated to one of two groups:

Induction of labour between 39^0/7 and 39^6/7 weeks gestation.

Expectant management i.e. awaiting spontaneous onset of labour unless a situation develops necessitating either induction of labour or Caesarean Section.

The primary purpose of this trial is to establish what effect a policy of induction of labour at 39 weeks for nulliparous women of advanced maternal age has on the rate of Caesarean section deliveries. The secondary aim is to act as a pilot study for a trial to answer the question, does induction of labour in this group of women improve perinatal outcomes? Randomisation will occur at 36^0/7 – 39^6/7 weeks gestation via a computerised randomisation programme at the Clinical Trials Unit, University of Nottingham. There will be no blinding to treatment allocation.

Discussion

The 35/39 trial is powered to detect an effect of induction of labour on the risk of caesarean section, it is underpowered to determine whether it improves perinatal outcome. The current study will also act as a pilot for a larger study to address this question.

Trial registration

ISRCTN11517275

Obesity, assisted reproductive technology, and early preterm birth--Florida, 2004-2006

Florida resident birth certificates for 2004-2006 were linked to the Centers for Disease Control and Prevention's National ART Surveillance System and were used to investigate 1) whether the association of assisted reproductive technology (ART) with preterm birth varies by prepregnancy body mass index and 2) whether the association varies by plurality. Preterm birth was defined as early preterm birth (gestation <34 weeks) and late preterm birth (gestation 34-36 weeks). Descriptive statistics and multinomial logistic regression were used to explore maternal and infant differences by ART status and plurality. Of 581,403 women included in the study, 24.0% were overweight, 18.6% were obese, 7.3% had late preterm birth, 2.6% had early preterm birth, and 0.67% conceived through ART. Among singleton births, ART was associated with increased early preterm birth risk among underweight (odds ratio (OR) = 2.94, 95% confidence interval (CI): 1.27, 6.81), overweight (OR = 1.75, 95% CI: 1.12, 2.72), and obese (OR = 2.37, 95% CI: 1.51, 3.71) women. Among twins, ART was significantly associated with increased risk among overweight (OR = 1.61, 95% CI: 1.12, 2.32) and obese (OR = 1.85, 95% CI: 1.18, 2.90) women. Differences in the associations between ART and early preterm birth by body mass index and plurality warrant further investigation.