Advanced maternal age: delayed childbearing is rarely a conscious choice a qualitative study of women's views and experiences

"I'm not your grandpa": Experiences of advanced age fathers raising their teenage children in Belgium, an interpretative phenomenological analysis

This study aims to gain more insight in the lived experience of men who became father at an advanced age (40 years or older). Advanced Parental Age (APA) is becoming an increasingly widespread phenomenon as the average age at which people have children has been increasing for decades now. However, the psychosocial dimension of APA-fatherhood in particular remains a highly understudied topic. This Interpretive Phenomenological Analysis presents findings from a qualitative interview study with seven men who fathered their (now teenage) children in their early 40s to early 50s. Interviews were semi-structured and focused on lived experiences of the participants and their normative stances regarding the topic of parenting at an advanced age. Three themes were identified: The fathers in our sample describe their APA as a result of life events rather than an intentional postponement. Second, they managed how they were perceived as APA-fathers by distancing themselves from 'too old' parents. However, these fathers did not perceive fatherhood at a younger age as better than their current APA. Three fathers, who also had an earlier fatherhood experience, provided a rich account of how they made sense of their fatherhood roles in both families. Third, the seven fathers encountered social stigma, leading to various coping strategies. These findings contribute to better understanding the psychosocial dimension of APA-fatherhood.

The reproductive journeys of French women over 40 seeking assisted reproductive technology treatments in Spain

Fertility decline is a complex phenomenon resulting from converging social and cultural changes that are governed through politics. As it has been discussed in many studies, the European's low fertility rate goes hand in hand with the trend of maternity postponement. Although in many European countries over the last decades reproduction is envisaged as an individual choice that can be made at older ages, having a child after a certain age can be impossible -either "naturally" or using assisted reproductive technology-depending on the medical and legislative possibilities and limits of the country in which people live. In the extremely diverse European reproscape, reproductive legislations have forced but also allowed many people to seek reproductive treatments outside their home countries. Spain is a leading destination in Europe for cross border reproductive travel and, of the foreigners it receives, the French are the largest group. Despite having a history of strong pro-natalist policies, France has been one of the strictest European countries regarding access to medically assisted procreation. Until 2022, only heterosexual couples in which women were under 43 years of age could access treatments. Despite the recent opening of access to "all women", including single women and same-sex female couples, women over 43 years of age were once again excluded from the new legal framework and therefore remain condemned to travel abroad to access reproductive treatments. In this article, we analyze the experience of French women over 40 who cross the Spanish border to access reproductive treatments in order to fulfill their desire to have children. Through ethnographic data emerging from six years of participant observation and in-depth interviews with 15 women, we explore why they remain excluded from the French system of reproductive governance and the obstacles they face during their reproductive journey.

"It was not an accident": Women's experiences of renewing motherhood at 40

In recent decades, there has been an increase in motherhood at an advanced age that has raised several medical and social concerns. We conducted a qualitative interview study, guided by Interpretative Phenomenological Analysis, to focus on the motivations and experiences of Belgian women who 'renewed' their motherhood later in life, meaning they had one or several children and then (at least 10 years later) had another child at the age of 40 or older. We focused on ten women's experiences of motherhood later in life, as well as on the way they managed social norms and expectations regarding family building and the appropriate life course. We identified two main themes. The first theme describes the participants' encounters with social norms that challenged their decision to reproduce and parent later in life, and how they managed and anticipated criticism, surprise, disbelief and incomprehension about their renewed motherhood in various ways. The second theme shows how these women talked about taking responsibility as a (renewed) mother of advanced age. For them, responsible motherhood involved making thoughtful reproductive choices, attending to the range of needs of their children, and making extra efforts to safeguard the social and emotional wellbeing of their youngest children, thereby seeking to reduce potential harm resulting from these reproductive choices. This study provides insight into these women's self-conception and their interactions with prejudiced social views of motherhood and family building.

Psychosocial experiences of involuntary definitive childless women: a comparative study based on reproductive status

STUDY QUESTION

Do involuntary definitive childless women have lower psychosocial adjustment levels than women with infertility diagnoses actively trying to conceive and presumably fertile women?

SUMMARY ANSWER

Involuntary definitive childless women have lower levels of sexual functioning than infertile women actively trying to conceive and presumably fertile women, and higher levels of depression than presumably fertile women.

WHAT IS KNOWN ALREADY

Involuntary definitive childless defines those who wanted to become parents but were unable to do so. Studies have provided evidence about infertility and its psychosocial consequences, but there is a lack of knowledge about the impact of involuntary definitive childlessness, namely on sexual function, social support, marital satisfaction, and psychological adjustment.

STUDY DESIGN, SIZE, DURATION

This associative study was conducted between July 2021 and January 2022 for involuntary definitive childless women and between July 2016 and February 2018 for women with an infertility diagnosis actively trying to conceive as well as presumably fertile women. An online questionnaire announced in social media and gynaecology and fertility clinics was used. The inclusion criteria for all participants were being childless, in a heterosexual relationship and cohabiting for at least 2 years. Specific inclusion criteria for involuntary definitive childless women were: trying to conceive for at least 2 years; not achieving pregnancy because of biological and medical constraints; and not undergoing fertility treatment or being a candidate for adopting a child at time of the study. For women with an infertility diagnosis the inclusion criteria were: actively trying to conceive (naturally or through fertility treatments); having a primary fertility diagnosis; and aged between 22 and 42 years old. For presumably fertile women, the inclusion criteria were: having a parenthood wish in the future; and not knowing of any condition that could prevent them from conceiving.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Out of 360 women completing the survey, only 203 were eligible for this study (60 involuntary definitive childless women, 78 women with an infertility diagnosis actively trying to conceive, and 65 presumably fertile women). All participants completed a questionnaire including sociodemographic and clinical data, the Female Sexual Function Index, the 2-Way Social Support Scale, the Relationship Assessment Scale, and Hospital Anxiety and Depression Scale. Binary logistic regression was performed to assess the relation between sexual function, social support, marital satisfaction, anxiety, depression, and reproductive status, adjusting for age, and cohabitation length. Presumably fertile women were used as a reference group.

MAIN RESULTS AND THE ROLE OF CHANCE

Women were 34.31 years old (SD = 5.89) and cohabited with their partners for 6.55 years (SD = 4.57). The odds ratio (OR) showed that involuntary definitive childless women had significantly lower sexual function than infertile women actively trying to conceive (OR = 0.88, 95% CI = 0.79-0.99) and presumably fertile women (OR = 34.89, 95% CI = 1.98-614.03), and higher depression levels than presumably fertile women (OR = 99.89, 95% CI = 3.29-3037.87). Women with an infertility diagnosis actively trying to conceive did not differ from presumably fertile women in sexual function, social support, marital satisfaction, anxiety, and depression.

LIMITATIONS, REASONS FOR CAUTION

The majority of childless women underwent fertility treatments, and childlessness for circumstantial reasons owing to lack of a partner was not included, therefore these results may not reflect the experiences of all women with an involuntary childless lifestyle. There was a time gap in the recruitment process, and only the definitive childlessness group filled out the questionnaire after the coronavirus disease 2019 pandemic. We did not ask participants if they self-identified themselves with the groups' terminology they were assigned to.

WIDER IMPLICATIONS OF THE FINDINGS

Our results emphasize the importance of future research to provide a more comprehensive understanding of the adjustment experiences of childless women and an awareness of the poor adjustment they might experience, highlighting the need to keep following women after unsuccessful treatments. Clinical practitioners must attend to these dimensions when consulting involuntary definitive childless women who might not have gone through treatments but also experience these adverse outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

This study was partially supported by the Portuguese Foundation for Science and Technology. The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Does information on age-related fertility decline and fertility policies affect university students' family and career expectations? Evidence from a randomized controlled trial

BACKGROUND

Past research shows that young adults have poor knowledge of age-related fertility decline and that the provision of information can improve fertility knowledge. We provide university students with information on age-related fertility and fertility-related policies and investigate whether the provision of such information affects their family formation and career expectations.

METHODS

A three-armed randomized controlled trial was conducted online in Singapore between September and October 2021. A total of 1000 undergraduate students were recruited through campus advertisements to complete a 30- to 45-minute online survey, which randomly exposed participants to one of three informational brochures on age-related fertility decline, fertility policies, or diabetes (control group). Participants answered questions on family formation and career expectations both before and after the information intervention. Analysis of covariance was used to assess the effects of the information intervention.

RESULTS

Exposure to age-related fertility information resulted in significant reductions in the ideal age at first childbirth, significant increases in the expected probability of marriage before age 30, and (among female participants) significant increases in the expected likelihood of undergoing social egg-freezing. No difference existed in child-number ideals, educational aspirations, and income expectations between groups after exposure. No difference existed between the fertility policy information group and the control group after exposure in any of the outcomes of interest.

CONCLUSIONS

Information on age-related fertility decline brought forward university students' expected timing of childbearing and marriage without reducing their educational and career expectations. The provision of fertility information at early ages, such as during university, can help correct widespread inaccurate beliefs about fertility and promote realistic family formation planning without adversely affecting educational and career goals.

TRIAL REGISTRATION

ClinicalTrials.gov.

Exploring the Complex Landscape of Delayed Childbearing: Factors, History, and Long-Term Implications

This review article delves into the intricate landscape of delayed childbearing, shedding light on the factors influencing individuals' decisions to postpone parenthood. In a world undergoing rapid social, economic, and technological transformations, the concept of when and why to become a parent has evolved significantly. We explore historical trends, societal norms, psychological dynamics, policy implications, and prospects surrounding delayed childbearing. This review underscores the diverse influences shaping this trend, from economic considerations and changing cultural perspectives to advancements in reproductive technologies and the complexities of work-life balance. By examining the emotional dimensions and long-term consequences, we comprehensively understand the implications for individuals, families, and societies. As we conclude, we emphasize the importance of addressing challenges and embracing opportunities to create a supportive environment for those navigating the complex decisions tied to delayed childbearing.

Married women's decision to delay childbearing, and loneliness, severe psychological distress, and suicidal ideation under crisis: online survey data analysis from 2020 to 2021

BACKGROUND

The COVID-19 pandemic has affected every aspect of our lives, including the decision to become pregnant. Existing literature suggests that infertility and the decision to delay childbearing at a younger age are associated with a lower level of well-being and regrets when women start to desire a baby. Thus, the decision to delay childbearing due to the pandemic could negatively affect the well-being of women. This study focuses on how pregnancy decisions affect the well-being of women during the COVID-19 pandemic.

METHODS

From the Japan COVID-19 and Society Internet Survey, a nationally representative web-based survey, 768 observations of married women aged 18 to 50 years who had the intention of getting pregnant during the pre-pandemic period (conducted in 2020 and 2021) were used. Loneliness, severe psychological distress, and suicidal ideation were used as well-being indicators. For pooled data, a generalised estimated equation (GEE) model was used to estimate how pregnancy decision related to well-being indicators. For a sub-analysis, the sample was divided by the survey year and a Poisson regression model was used.

RESULTS

The GEE analysis showed an association between delaying childbearing and severe psychological distress, with the prevalence ratio (PR) being 2.06 [95% CI (1.40-3.03)]. Furthermore, loneliness and suicidal ideation that occurred after the beginning of the pandemic were significantly related to the decision to delay childbearing-1.55 [95% CI (1.03,2.34)] and 2.55 [95% CI (1.45-4.51)], respectively. Moreover, these PRs were larger for 2021 compared to 2020.

CONCLUSION

During the COVID-19 pandemic, approximately one-fifth of married women who had childbearing intentions before the pandemic decided to postpone pregnancy. They exhibited a deteriorated mental health state. Furthermore, the negative associations were larger in 2021 compared to 2020. Loneliness has negative consequences for both mental and physical health, as well as elevated severe psychological distress and suicidal ideation among those who decided to postpone pregnancy. Therefore, the current results should not be overlooked by society.

Iranian women's attitude toward childbearing and its' association with generalized trust, social support, marital satisfaction and governmental childbearing incentives

Background

Having a child is important event for families worldwide. Attitudes toward childbearing are influenced by many factors. The aim of the present study was to investigate Iranian women's attitude toward childbearing and its association with generalized trust, social support, marital satisfaction, mental health, and socio-economic characteristics in Qazvin province.

Methods

A cross-sectional survey study was conducted between April and July 2022. Using convenience sampling, 347 women with no children or one child in Qazvin province (Iran) participated in the study. Data were collected via the Iranian online platform Porsline. The survey included a demographic and fertility characteristics questionnaire, Attitudes Toward the Government's Childbearing Incentives Scale (ATGCIS), Attitudes Toward Fertility and Childbearing Scale (ATFCS), ENRICH Marital Satisfaction Scale (ENRICH MSS), Patient Health Questionnaire (PHQ-4), Multidimensional Scale of Perceived Social Support (MSPSS), and Generalized Trust Scale (GTS).

Findings

The average age of participants was 35.66 years (SD = 6.89). The score of attitudes toward fertility and childbearing was 84.66 out of 134 (SD = 19.17). The average number of expected children by the couple was 2.36 (SD = 1.35). Multivariable linear regression found a positive and significant relationship between participants' attitudes toward fertility and childbearing (ATFC) and (i) governmental childbearing incentives (β = 0.365, p < 0.001, with 1.37 increase in ATFC with each unit increase in this scale) (ii) generalized trust (i.e., individual's expectation of others' trustworthiness), (β = 0.155, p < 0.003, with 0.60 increase in ATFC with each unit increase in generalized trust) and (iii) marital satisfaction (β = 0.146, p < 0.005, with 0.26 increase in ATFC with each unit increase marital satisfaction). The multivariable linear regression model also showed that attitudes toward fertility and childbearing was the only predictor of couples' expected number of children in the future (β = 0.214, p < 0.001, with 0.38 increase in couples' expected number of children with each unit increase in ATFC).

Conclusion

Government incentives were the strongest independent predictor of participants' attitudes toward childbearing which can indirectly influence couples' expected number of children in the future. Consequently, governments may be able to influence couples' childbearing decisions by providing appropriate incentives. Generalized trust and marital satisfaction were other significant predictors of attitudes toward childbearing. Therefore, implementing programs to improve generalized trust, and increasing marital satisfaction might be other influential measures in couples' childbearing decisions.

Women's reflections on timing of motherhood: a meta-synthesis of qualitative evidence

INTRODUCTION

Fertility declines with increasing age, especially in women. In recent decades women's age at the birth of their first child has risen markedly in many countries, and an increasing number of women do not establish a family until their late-twenties to mid-thirties. Although there can be various reasons that couples experience fertility problems, advanced maternal age is the most frequent cause for difficulties with achieving pregnancy.

OBJECTIVE

In this meta-synthesis, we investigated reflections on timing of motherhood in women who have not yet had children.

METHODS

A systematic literature search of six electronic databases and manual searches of reference lists identified eight qualitative studies published between 2011 and 2018 that focused on women's reflections on timing of motherhood. The studies were assessed with the Critical Assessment Skills Programme (CASP) quality appraisal tool. The results were synthesized using Noblit and Hare's meta-ethnographic approach as described by Malterud.

FINDINGS

An overall theme of 'Timing of motherhood' and four overlapping subthemes were identified: Making a life-changing decision, The right time, Fear of regret, and Plan B. The dilemmas associated with timing of motherhood leave women of reproductive age balancing their priorities and values against a biological deadline for having children naturally or through assisted reproductive technology.

CONCLUSIONS

Women of reproductive age are aware that they must make a life-changing decision as to if or when to have children, but they consider having children at 'the right time' to be important. Simultaneously, while some women are reluctant to have children for various reasons, they express fear that waiting too long could result in their regretting not having children later in life. Although women of reproductive age express concern about their ability to achieve pregnancy, they have limited focus on the medical risks associated with postponing motherhood. There is a need to establish preventive health initiatives to support women of reproductive age in their considerations regarding timing of motherhood.

TRIAL REGISTRATION NUMBER

PROSPERO: CRD42020175151.

Maternal exposure to pesticides and autism or attention-deficit/hyperactivity disorders in offspring: A meta-analysis

OBJECTIVE

To analyze the association between maternal pesticide exposure and autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorders (ADHD) in offspring.

METHOD

Five databases including PubMed, Embase, Web of Science, Medline, as well as PsycINFO were systematically retrieved for the records related to pesticide exposure during pregnancy and ASD and ADHD in offspring before August 30, 2022. The pesticide category, maternal age and window of exposure as the main subgroups were presented.

RESULTS

949 studies were initially identified, and 19 studies were eventually included. Eleven were on ASD, seven were on ADHD, and one was on both disorders. Maternal pesticide exposure was positively related to ASD (pooled OR = 1.19 (95%CI: 1.04 to 1.36)) and ADHD (pooled OR = 1.20 (95%CI: 1.04 to 1.38)) in offspring. In the subgroup analysis, organophosphorus pesticides (OPs) (pooled OR = 1.14 (95%CI: 1.04 to 1.24)), pyrethroid (pooled OR = 1.40 (95%CI: 1.09 to 1.80)), and maternal age ≥30 years old (pooled OR = 1.24 (95%CI: 1.10 to 1.40)) increased the risk of ASD in offspring. Maternal organochlorine pesticides (OCPs) exposure was a risk factor for ADHD in offspring (pooled OR = 1.22 (95%CI: 1.03 to 1.45)).

CONCLUSION

Maternal pesticide exposure increased the risk of ASD and ADHD in offspring. Moreover, OPs, pyrethroid, and maternal age ≥30 years old were found to be risk factors affecting children's ASD. Maternal exposure to OCPs increased the risk of ADHD in offspring. Our findings contribute to our understanding of health risks related to maternal pesticide exposure and indicate that the in utero developmental period is a vulnerable window-of-susceptibility for ASD and ADHD risk in offspring. These findings should guide policies that limit maternal exposure to pesticides, especially for pregnant women living in agricultural areas.

Exploring fertility knowledge amongst healthcare professional and lay population groups in the UK: a mixed methods study

As the average age of first-time parents continues to rise, there has been a concerted effort by educators, policy makers and several reproductive health groups to improve fertility awareness. This study explored fertility knowledge of lay men and women and healthcare professionals (HCPs) using the same test instrument, providing a new and unique perspective compared with previous studies. Results were obtained from 1082 survey respondents: 347 HCPs, 319 men and 413 women, 105 of whom were trying to conceive (TTC). A total of 35 interviewees were purposively sampled to include 9 HCPs, 13 men and 13 women from the reproductive age range and of varying ethnic and educational backgrounds. Interview data were transcribed and analysed using the framework method. The proportion of HCPs correctly answering the survey knowledge questions was 47.1 (95% CI = 41.7%, 52.5%) compared to 44.4% for women (95% CI = 38.9%, 50.1%); 49.9% (95% CI = 39.0, 59.9%) for women TTC; and 32.5% (95% CI = 27.1%, 37.9%) for men. HCPs were ranked as the most trusted source for seeking fertility information. Overall HCPs did not demonstrate better fertility knowledge than lay participants, with inconsistencies regarding where responsibility lies for providing the right information to patients. HCPs need to improve their knowledge about fertility to help improve patient's fertility awareness.

The importance of the 'family clock': women's lived experience of fertility decision-making 6 years after attending the Fertility Assessment and Counselling Clinic

This study explored women's lived experience of making fertility decisions six years after attending the Fertility Assessment and Counselling (FAC) clinic in Copenhagen, Denmark, which is a personalised fertility awareness intervention. We conducted a qualitative interview study with 24 women who attended the FAC clinic 6 years earlier. Interviews were semi-structured and broadly examined the women's perceptions and experience of the intervention during follow-up. Data was analysed using a phenomenological framework and themes were identified related to women's experience of making fertility decisions after attending the FAC clinic. The overarching theme regarding the women's lived experience of making fertility decisions after attending the FAC clinic was: Fertility decisions were guided by the 'family clock'. There were four themes: (i) Deciding to 'get started' by attending the FAC clinic; (ii) Sense of making informed and empowered decisions; (iii) Influence of partner status on fertility decisions; and (iv) Decisions dictated by circumstance over preference and knowledge. At follow-up, the majority (21 women, 88%) had become parents. More than half of the women said that they had not achieved their desired family size. Consideration of women's 'family clock' is necessary in personalised fertility awareness interventions to enable women to achieve their family goals.

What does family building mean? A qualitative exploration and a new definition: a UK-based study

Background

The importance of improving men’s and women’s knowledge of sexual and reproductive health has been emphasised in numerous global health policies. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, recent concerted effort to improve fertility-awareness warrants a closer investigation of basic reproductive health terminologies. The objective of this study is to explore participants’ views of “family building” and provide a definition.

Methods

We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. We asked participants about terms such as ‘family planning’ and ‘family building’ to elicit views and explored the appropriateness of the term “family building.” Data were transcribed and analysed via Framework analysis.

Results

When asked what ‘family planning’ meant to them, study participants stated that the term meant the avoidance of pregnancy. They viewed it as an “umbrella term for the use of contraception methods,” that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. Reasons cited for this perspective include the focus of school education and usage in clinical settings.

Conclusions

In the absence of an explicit definition in literature, we generated a new definition for family building as follows: “Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has.” Some balance in the global public health messages, including bridging the gap in reproductive health literature, policies, processes and practices may contribute to the effort to improve fertility knowledge. Use of appropriate terminologies help optimise reproductive health services in order to enable men and women achieve their desired fertility intentions, whatever they may be.

Trial registration Not applicable

Global health policies have emphasised the importance of improving individual’s knowledge of sexual and reproductive health. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, the recent concerted effort to improve fertility awareness warrants a closer investigation of basic terminologies in the field. For example, although the term family planning encompasses attaining the desired number of children and spacing pregnancies, it is almost synonymous with not having children, while there is currently no widely accepted equivalent terminology for planning to have children, either in general usage or clinical settings. We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. When asked what ‘family planning’ meant to them, study participants stated avoidance of pregnancy. They viewed it as an “umbrella term for the use of contraception methods”, that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. We introduced family building and provided a new definition. We believe that some balance in the global public health messages, including revisiting widely used terminologies can help bridge the gap in reproductive health literature, and contribute to the effort to improve fertility knowledge. Additionally, this has implications for promotion of preconception and optimising reproductive health in relevant policies, processes and practices, in order to help people achieve their desired fertility intentions, whatever they may be.

The ABC of reproductive intentions: a mixed-methods study exploring the spectrum of attitudes towards family building

STUDY QUESTION

What are the intentions of men and women of reproductive age in the UK regarding reproduction and family building?

SUMMARY ANSWER

We identified six main categories of people; Avoiders, Betweeners, Completers, Desirers, Expectants and Flexers, for whom reproduction education strategies should be tailored differently to suit intentions.

WHAT IS KNOWN ALREADY

Several studies have highlighted poor fertility awareness across men and women of reproductive age. As the average age of first-time parents continues to rise, there has been a concerted effort from educators, healthcare professionals, charities, reproductive health groups and government policymakers, to improve fertility awareness. In order to ensure that these messages are effective and to deploy the best strategies, it is important to understand people's reproductive health needs. This study therefore aimed to explore different reproductive intentions to aid tailoring of information to help individuals and couples achieve their family building desires.

STUDY DESIGN, SIZE, DURATION

We conducted a mixed-method study via a UK-wide cross-sectional survey with 1082 participants and semi-structured interviews of 20 women and 15 men who agreed to follow-up interviews. Interviews lasted an hour on average. Ethics approval from UCL Research Ethics Committee.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey participants were recruited nationwide via online newspaper and social media adverts. Interviewees were purposely sampled to include men and women from the reproductive age range (18-45 years), varying ethnicity and education background. Survey data were analysed using the Minitab statistical software package. Interview data were transcribed and analysed using the framework method.

MAIN RESULTS AND THE ROLE OF CHANCE

From the survey and interviews, we identified six key categories of people, grouped alphabetically, in a user-friendly manner to highlight a spectrum of reproductive intentions: Avoiders describes respondents who have no children and do not want to have children in the future; Betweeners describes those who already have child(ren) and want more in the future but are not actively trying to conceive; Completers describes those who have child(ren) but do not want more; Desirers describes those who are actively trying to conceive or plan to have child(ren) in the future; Expectants describes those who were pregnant at the time of the study; and Flexers describes those who may or may not already have and are unsure but or open to having child(ren) in the future. Analysis of survey data identified the following proportions in our study: Avoiders, 4.7%; Betweeners, 11.3%; Completers, 13.6%; Desirers, 36.9%; Expectants, 4.1%; and Flexers 28.4% and 2.4% preferring not to answer. There was one 'other' group from qualitative analysis, who would like to have children in the future but were unsure whether they could or had changing views. We recommend classifying as 'Desirers' or 'Flexers' for the purposes of fertility education. A majority of the survey population were trying to get pregnant; were pregnant; or planning to have a child in the future-whether actively, passively or simply open to the idea, with interviews providing deep insights into their family building decision-making.

LIMITATIONS, REASONS FOR CAUTION

Due to the online recruitment method, there may be a bias towards more educated respondents.

WIDER IMPLICATIONS OF THE FINDINGS

We developed a user-friendly, alphabetical categorization of reproductive intentions, which may be used by individuals, healthcare professionals, educators, special interest groups, charities and policymakers to support and enable individuals and couples in making informed choices to achieve their desired intentions, if and when they choose to start a family.

STUDY FUNDING/COMPETING INTEREST(S)

There was no external funding for this study. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Portuguese Version of the Spiritual Well-Being Questionnaire: Validation Study in People under Assisted Reproductive Techniques

Attention has been given to the experience of individuals undergoing assisted reproductive techniques. However, only recent literature has focused on the spiritual journey triggered by such an event and highlighted the nurses and midwives’ roles in the assessment of the spiritual needs of those living with infertility. This study aimed to perform a psychometric test of the factor structure of the Portuguese version of the Spiritual Well-being Questionnaire in a sample of people undergoing assisted reproductive techniques. This descriptive cross-sectional study was conducted between September 2019 and June 2020 on a sample of 104 Portuguese adults attending fertility treatment. An online questionnaire was released on fertility-related websites. A confirmatory factor analysis was conducted on six hypothesized models of the instrument. The findings provided evidence of an adequate internal consistency of the instrument, and the validity and reliability of the oblique four-factor model was confirmed. Spiritual well-being had a significant association with the nature of infertility and a higher score was achieved by participants that perceived religion as very important. This study provides a validated tool for nurses and midwives to assess spiritual well-being and promote an integrated reproductive healthcare approach. Further longitudinal research with bigger samples would provide more evidence of the spiritual needs of people living with this condition.

Fresh embryo transfer after in vitro insemination of fresh vs. cryopreserved anonymous donor oocytes: which has a better live birth rate? A Society for Assisted Reproductive Technology Clinic Outcome Reporting System analysis

OBJECTIVE

To determine if transfer of fresh embryos derived from fresh or cryopreserved donor oocytes yields a higher live birth rate.

DESIGN

Historical cohort study.

SETTING

Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

PATIENT(S)

A total of 24,663 fresh embryo transfer cycles of donor oocytes.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was live births per number of embryos transferred on day 5. The secondary outcomes included number of infants per embryo transfer, surplus embryos cryopreserved, and characterization of US oocyte recipients.

RESULT(S)

A total of 16,073 embryo transfers were from fresh oocytes and 8,590 were from cryopreserved oocytes. Recipient age, body mass index (BMI), gravidity, and parity were similar between the groups. Most recipients were of White non-Hispanic race (66.9%), followed by Asian (13.7%), Black non-Hispanic (9.3%), and Hispanic (7.2%). Fresh oocyte cycles were more likely to use elective single embryo transfer (42.5% vs. 37.8%) or double embryo transfer (53.2% vs. 50.4%) and resulted in more surplus embryos for cryopreservation (4.6 vs. 1.2). The live birth rate from fresh oocytes was 57.5% vs. 49.7% from cryopreserved oocytes. Negative predictors of live birth included the use of cryopreserved oocytes (odds ratio [OR] 0.731, 95% confidence interval [CI] 0.665-0.804), Black non-Hispanic race (OR 0.603, 95% CI 0.517-0.703), Asian race (OR 0.756, 95% CI 0.660-0.867), and increasing recipient BMI (OR 0.982, 95% CI 0.977-0.994) after controlling for recipient age, number of embryos transferred on day 5, and unexplained infertility diagnosis. The proportion of multifetal deliveries was greater in cycles utilizing fresh (26.4%) vs. cryopreserved (20.6%) oocytes.

CONCLUSION(S)

The live birth rate is higher with use of fresh oocytes vs. cryopreserved oocytes in fresh embryo transfer cycles. Negative live birth predictors include recipient Black non-Hispanic or Asian race and increasing BMI.

Age-associated changes in cumulus cells and follicular fluid: the local oocyte microenvironment as a determinant of gamete quality

The ovary is the first organ to age in humans with functional decline evident already in women in their early 30s. Reproductive aging is characterized by a decrease in oocyte quantity and quality, which is associated with an increase in infertility, spontaneous abortions, and birth defects. Reproductive aging also has implications for overall health due to decreased endocrinological output. Understanding the mechanisms underlying reproductive aging has significant societal implications as women globally are delaying childbearing and medical interventions have greatly increased the interval between menopause and total lifespan. Age-related changes inherent to the female gamete are well-characterized and include defects in chromosome and mitochondria structure, function, and regulation. More recently, it has been appreciated that the extra-follicular ovarian environment may have important direct or indirect impacts on the developing gamete, and age-dependent changes include increased fibrosis, inflammation, stiffness, and oxidative damage. The cumulus cells and follicular fluid that directly surround the oocyte during its final growth phase within the antral follicle represent additional critical local microenvironments. Here we systematically review the literature and evaluate the studies that investigated the age-related changes in cumulus cells and follicular fluid. Our findings demonstrate unique genetic, epigenetic, transcriptomic, and proteomic changes with associated metabolomic alterations, redox status imbalance, and increased apoptosis in the local oocyte microenvironment. We propose a model of how these changes interact, which may explain the rapid decline in gamete quality with age. We also review the limitations of published studies and highlight future research frontiers.

Fertility knowledge and its related factors among married men and women in Zanjan, Iran

This study aimed to investigate the fertility knowledge and its related factors in married men and women in Zanjan, Iran. In this cross-sectional study, 1200 individuals (including 600 women aged 18-49 years and 600 men aged 18-59 years) referred to urban and rural health centres in Zanjan, were recruited through cluster sampling from June to September 2020. The Cardiff Fertility Knowledge Scale was used to assess fertility knowledge. Data were analysed by descriptive statistical methods such as mean and standard deviation and analytical statistics, including independent sample t-test, ANOVA test, Pearson Correlation and Linear Regression were used. The average correct scores of fertility knowledge were 49.7%, 53.3%, and 51.55% for men, women, and in total, respectively. The multiple linear regression model showed that fertility knowledge was significantly related to being female, being from a higher economic status, having desire to have children in the future, and having desire to increase fertility knowledge (all p < 0.05). Fertility knowledge among the Iranian reproductive-age men and women was modest. The findings suggested that interventions to increase fertility knowledge are essential, especially interventions targeting men and lower socioeconomic groups.

Preconditions to parenthood: changes over time and generations

Reproductive decision-making and fertility patterns change with time and place, and are influenced by contemporary societal factors. In this paper, we have studied biosocial aspects of reproductive decision-making over time and generations in a Nordic setting. The aim was to explore intergenerational changes and influences on decision-making, especially regarding preconditions to first birth. Twenty-six focus group interviews were conducted in southern Sweden, including a total of 110 participants aged 17-90 years. The analysis of the interviews resulted in six themes: (i) 'Providing security - an intergenerational precondition'; (ii) 'A growing smorgasbord of choices and requirements'; (iii) 'Parenthood becoming a project'; (iv) 'Stretched out life stages'; (v) '(Im)possibilities to procreate'; and (vi) 'Intergenerational pronatalism'. Our findings reflect increasing expectations on what it means to be prepared for parenthood. Despite increasing awareness of the precariousness of romantic relationships, people still wish to build new families but try to be as prepared as possible for adverse events. The findings also show how increasing life expectancy and medical advancements have come to influence people's views on their reproductive timeline.

A Validation Study on the Frequency and Natural History of Miscarriages Using the Spanish Primary Care Database BIFAP

(1) Background: There is a major gap of knowledge towards the natural history of miscarriages in electronic medical records. We aimed to calculate the frequency of miscarriages using data from BIFAP database. (2) Methods: We identified all pregnancy losses and carried out a multistep validation exercise. Potential cases with positive predictive values (PPV) of miscarriage confirmation <85% or those confirming other pregnancy loss were excluded. Kaplan–Meier figures and incidence rates (IRs) of miscarriage with 95% confidence intervals (CIs) expressed by 1000 person-weeks were calculated. Stratifying analysis by age, specific high-risk groups, and drug exposure within the pre-pregnancy period were performed restricted to women with recording last menstrual period (LMP). (3) Results: Women with confirmed miscarriage (N = 18,070), tended to be older, with higher frequency of comorbidities and drug utilization. Restricting to women with LPM recorded, IR of miscarriage was 10.89 (CI 95% 10.68–11.10) per 1000 women-weeks, with a median follow-up of 10 weeks (IQR: 8–12). The IR according to age was: 2.71 (CI 95% 2.59–2.84) in those aged <30 years compared to 9.11 (CI 95% 8.55–9.70) in women aged ≥40 years. Advanced maternal age (Hazard Ratio (HR, 95% confidence interval) CI 95%: 3.34 (3.08–3.62)), use of antihypertensives (1.49 (1.21–1.84), and use of drugs classified as D or X during pregnancy (1.17 (1.07–1.29)) showed to be positive predictors associated with increased risk of miscarriages. (4) Conclusion: BIFAP database can be used to identify women suffering from miscarriages, which will serve to further study risk factors associated with miscarriages with special attention to drug utilization.

Pathways into childbearing delay of men and women in Australia

Childbearing delay is a pervasive feature of Australian society, but little research has been conducted to examine how socio-economic factors are linked to childbearing timing among Australian men and women. This paper addresses this by analysing the timing of first childbirth for a large sample of Australian residents (N = 4,444). The findings indicate that childbearing delay is socially patterned and that life course experiences shape the risk of delaying childbearing across genders. Having a tertiary qualification delays the transition to parenthood, especially for women. An uninterrupted career prolongs time to parenthood for women but accelerates it for men. Low occupational prestige, being married and having been in only one co-residential union are associated with earlier parenthood for both men and women. For each increase in education level, not being married is associated with increasing levels of childlessness. Clear-cut gender differences are found in the relationship between childlessness and childbearing delay.

Factors associated with giving birth at advanced maternal age in the United States

OBJECTIVE

In 2018, 17 percent of all births in the United States occurred to women of advanced maternal age (AMA.) While the outcomes of AMA pregnancies have been examined extensively, the drivers behind increasing rates of AMA pregnancies in the United States are less understood. Some scholars have asserted that women are increasingly delaying their first birth in favor of educational and career aspirations. Yet birth trends in the United States do not support this as the primary explanatory factor of AMA births. Other factors may also contribute to high rates of AMA in the United States. This study sought to identify main predictors of AMA birth using a cross-sectional retrospective sample.

DESIGN

We employed a multivariate logistic regression analysis on a cross-sectional retrospective sample to identify significant independent predictors of giving birth at advance maternal age (AMA) in the United States.

SETTING

Data was obtained from the Unites States Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 Core Questionnaire and linked birth certificates. Questions are designed to assess maternal attitudes and experiences before, during and just after pregnancy. Surveys for Phase 7 were completed in 2017 and 2018. The study population represents mothers from 34 states that met the CDC's 55% response rate threshold and Puerto Rico.

PARTICIPANTS

The PRAMS dataset comprises self-reported data and linked birth certificate data from women who recently gave birth. A total of 38,549 mothers are included in the Phase 7 dataset. State sample sizes ranged from 503 mothers in Wyoming to 1,897 mothers in Michigan. All mothers gave birth in the year 2017.

MEASUREMENTS AND FINDINGS

The outcome of interest was AMA birth, defined as conceiving and subsequently giving birth to a baby at age 35 or older. Predictors for AMA birth were selected a priori and included: pregnancy intention, history of previous live birth, insurance status, income, education, race/ethnicity, marital status, and urban location. Previous live birth to at least one child was a significant independent predictor for AMA birth. Mothers with high parity, defined as 6 or more previous live births, were 17 times more likely to give birth at advanced maternal age. Mothers with an unwanted pregnancy were 1.9 times more likely to have an AMA birth. College attainment, high income, marital status, urbanicity, and race/ethnicity were also independent predictors of AMA birth. Health insurance was not a significant predictor of AMA birth after accounting for other factors.

KEY CONCLUSIONS

Delayed and late childbirth may not be intentional for a significant group of older mothers. Converse to popular assumptions that women delay childbearing in favor of career aspirations, the majority of AMA mothers have previous children. Half of AMA mothers have two or more previous children. The findings in this paper suggests that multiple factors predict AMA births. There may be several subtypes of women who enter pregnancy at advanced maternal age.

IMPLICATIONS FOR PRACTICE

As women weigh personal desire to bear children against competing social expectations, they may find themselves navigating their own unique path shaped in part by the region in which they live. Better characterization of the circumstances that lead to advanced maternal age in the United States, including exploration of unintended and unwanted AMA pregnancy, is necessary to develop policies and interventions that meet women's needs. This work should utilize a reproductive justice framework to ensure that women's preferences, particularly women of color, are upheld while promoting health and wellbeing for women.

The breastfeeding and early motherhood experiences of older first-time mothers: A constructivist grounded theory study

OBJECTIVE

The objective of this paper is to present the results of a qualitative study that explored the factors surrounding decision-making related to breastfeeding and the experiences of early motherhood for 23 first-time mothers over the age of 35 in Canada. Previous studies on breastfeeding have not examined older first-time mothers as a group that is unique due to their experience of coming to motherhood in the context of the growing phenomenon of delayed childbearing in the 21st century. Many older women come to motherhood with both well- established life and professional experiences, and as such their needs may differ from their younger or multiparous counterparts. The research question was: "What factors affect how first-time mothers >35 years of age make decisions about breastfeeding, and how do these factors affect the decisions they make related to breastfeeding and their transition to motherhood in the first six months postpartum?"

DESIGN

Constructivist grounded theory FINDINGS: The theory of From Ideology to Independence: Older First-time Mothers, Breastfeeding, and Becoming a Mother provides a lens to view the underlying processes influencing the decisions the mothers made related to breastfeeding and early motherhood. The mothers worked through the processes of learning breastfeeding, redefining self, and defining motherhood. The mothers' belief that breastfeeding defines motherhood, coupled with lack of knowledge and control, had a negative effect on both early breastfeeding and their transition to motherhood. As the idea of breastfeeding equating successful mothering waned the mothers became active agents in decision-making related to infant feeding and mothering.

Guidelines informing counseling on female age-related fertility decline: a systematic review

PURPOSE

To identify, appraise, and assess clinical practice guidelines informing patient counseling on female age-related fertility decline.

METHODS

Searched electronic database records from January 1, 2006, to September 10, 2018, and professional society websites. The search terms included iterations of "guideline," "counseling," "preconception," "age-related fertility decline," and "reproductive life planning." English-language professional organization guidelines addressing patient counseling on age-specific reproductive health topics were included. Assessed the methodological quality of included guidelines using the AGREE II instrument. Guidelines were categorized as high quality or low quality based on AGREE II scores. Extracted age-specific reproductive health recommendations of high-quality guidelines.

RESULTS

The search identified 2918 records. Nineteen records addressed counseling on age-related fertility decline; only 6 focused only on reproductive aging, with the remaining 13 covering related topics. Eleven met criteria for high quality. All high-quality guidelines had high "rigor of development" scores on AGREE II. Ten high-quality guidelines stated an age at which female fertility declines, ranging from 30 to "late 30s." One recommended a specific age at which patients should be counseled. Five of eleven high-quality guidelines did not discuss the obstetric and perinatal risks of advanced maternal age.

CONCLUSIONS

Few high-quality guidelines address counseling on female age-related fertility decline, and existing guidance on reproductive aging counseling is inconsistent and incomplete. Greater rigor of development and incorporation of age-specific counseling recommendations into clinical practice guidelines could lead to improved patient anticipatory guidance and more informed reproductive choices.

Pregnancy and Fertility Concerns: A Survey of United States Obstetrics and Gynecology Residents

INTRODUCTION

Reproductive life planning is an important aspect of OBGYN resident education. Despite learning about declining fertility and the implications associated with delaying pregnancy, OBGYN residents overestimate the age when fertility declines and fertility treatment success rates.

OBJECTIVE

To characterize attitudes towards infertility, pregnancy timing, and fertility preservation among OBGYN residents at academic programs in the United States.

METHODS

Cross sectional study of female trainees from 27 academic OBGYN residency programs. A voluntary, anonymous online survey was used to assess reproductive experiences and characterize attitudes towards personal family planning and infertility.

RESULTS

Of 756 trainees who were sent the survey, 487 opened the email, and 309 participated (63.4% response rate per opened email, 40.9% overall). The majority of residents expressed a desire to have children, but had not started childbearing (75.8%, n = 210) with a planned delay for career/educational reasons (84.5%, n = 196). The majority planned to have children before age 35 (90%, n = 210). Of those not finished with childbearing, 78.5% reported worrying about infertility (n = 205) and 40.8% reported considering fertility preservation (n = 111). If interested in fellowship, trainees were more worried about infertility (p = 0.01, OR 2.74 (95% CI 1.24 -6.04)).

CONCLUSIONS FOR PRACTICE

Female OBGYN residents learn to help patients with reproductive planning and many may personally delay family building. To help alleviate anxiety, improve reproductive autonomy, and prevent future regret, OBGYN residents may benefit from counseling regarding declining fertility with age and the advantages and disadvantages of fertility preservation, specifically emphasizing the realistic chance of success with oocyte cryopreservation compared to conception at a young age.

The Biological Clock: Age, Risk, and the Biopolitics of Reproductive Time

The present article explores the social and subjective dimensions of the biological clock and its implications for reproductive time through a qualitative study based on 40 life story interviews of women from Santiago de Chile. Although the narrative of the biological clock has become a prevalent frame for addressing reproductive time in the context of late childbearing, age-related infertility, and the use of assisted reproductive technologies, few studies engage in an in-depth analysis of the biological clock—its boundaries, dynamics, and the particular ways in which it shapes women’s views and experiences of reproductive time. The present article aims to advance current knowledge on the intersection of time, reproduction, and biopolitics by arguing that the biological clock regulates reproductive time by shaping the boundaries and dynamics of female fertility through the clock. By determining reproductive time as quantitative, standardised, linear, and irreversible and by outlining the passing of time through pressure, risk, and burden, the biological clock determines when it is possible and desirable to have children and regulates reproduction, gender, and the female life course. These findings highlight the importance of critically addressing the narrative of the biological clock and its implications for women’s views and experiences of reproductive time.

Uninformed decision-making and regret about delaying childbearing decisions: A cross-sectional study

Aim

The aim of this study was to examine regret over the timing of the childbearing decision and reasons for its delay.

Design

A cross-sectional study.

Methods

This cross-sectional study included 219 women and 169 men referred to fertility facilities in Japan from July-December 2018. Participants completed a questionnaire on the reasons for their delay in childbearing decision and the degree of regret regarding their decision. Multiple linear regression was used to analyse the association between degree of regret and the reasons for the delay.

Results

The top three reasons for the delay in childbearing decision in women were "Establishing the relationship," "Health problems," and "Financial security." The top three reasons in men were "Establishing the relationship," "Financial security," and "Lack of fertility knowledge." Multiple linear regression showed that lack of fertility knowledge was associated with regret over the timing of childbearing decisions in women and men.

Regret over the delay in childbearing decision negatively associates with life satisfaction among Japanese women and men seeking fertility treatment: a cross-sectional study

BACKGROUND

Currently, in developed countries, increasing numbers of women and men are delaying childbearing but begin seeking fertility treatment later in life. Some women undergoing infertility treatment develop negative feelings such as depression associated with low life satisfaction and regret over the delay in childbearing. We therefore examine the association of life satisfaction with regret over the delay in childbearing decision and infertility-related factors among Japanese women and men seeking fertility treatment.

METHODS

This cross-sectional study included 253 women and 196 men referred to fertility facilities in Japan from July to December 2018. Participants completed a questionnaire on life satisfaction, regret over the delay in childbearing decision, infertility-related factors and sociodemographic characteristics. Life satisfaction was measured using the Satisfaction with Life Scale (SWLS), and the degree of regret over delay in childbearing decision was measured on a 7-point Likert scale. Multiple linear regressions, conducted separately by sex, were used to analyze the association of life satisfaction with regret over the delay in childbearing decision and infertility-related factors.

RESULTS

Of the 253 women and 196 men, 102 (40.3%) women and 43 (21.9%) men answered "strongly agree" regarding their regret over the delay in childbearing decision. Among women, life satisfaction was negatively associated with regret (β = - 0.155, 95% CI [- 0.938, - 0.093], p = 0.017), use of assisted reproduction technology (ART) (β = - 0.135, 95% CI [- 2.977, - 0.020], p = 0.047). In contrast, previous live birth was positively associated with life satisfaction (β = 0.134, 95% CI [0.122, 3.739], p = 0.037). In men, we found no significant association of life satisfaction with regret over the delay in childbearing decision and infertility-related factors.

CONCLUSIONS

Regret over the delay in childbearing decision is negatively associated with life satisfaction among Japanese women seeking fertility treatment. It may be important for women to make better informed decision regarding the timing of childbearing to not regret later in life. Health professionals should address regret over the delay in childbearing decision during fertility treatment and explore ways to spread information on fertility awareness.

Latest-Late Fertility? Decline and Resurgence of Late Parenthood Across the Low-Fertility Countries

After decades of fertility postponement, we investigate recent changes in late parenthood across low-fertility countries in the light of observations from the past. We use long series of age-specific fertility rates from the Human Fertility Database (1950-2016) for women, and new data covering the period 1990-2016 for men. In 1950, the contribution of births at age 40 and over to female fertility rates ranged from 2.5 to 9 percent, but then fell sharply until the 1980s. From the 1990s, however, the prevalence of late first births increased rapidly, especially so in countries where it was initially lowest. This has produced a late fertility rebound in the last two decades, occurring much faster for women than for men. Comparisons between recent and past extremely late (age 48+) fertility levels confirm that people are now challenging the natural fertility barriers, particularly for a first child.

Concordance of various chromosomal errors among different parts of the embryo and the value of re-biopsy in embryos with segmental aneuploidies

Chromosomal mosaicism detected during preimplantation genetic testing for aneuploidy (PGT-A) and its impact on embryo implantation have been widely discussed, and healthy live births from mosaic embryos were reported by many groups. On the other hand, only very few studies have focused on segmental chromosome aneuploidies and their clinical impact. Eighty-nine embryos with various PGT-A results (trophectoderm 1: TE1) were re-analysed using a second trophectoderm biopsy (TE2) and the rest of the embryo (RE) for testing. Of 19 euploid TE1 biopsies, 18 were concordant across TE2 and RE. Similarly, whole chromosomal aneuploidies were concordant in 59 of 62 TE1-TE2 and 58 TE1-RE. In contrast, from 31 segmental aneuploidies detected in TE1, only 15 were observed again in TE2 and 14 in RE. If a TE1 segmental abnormality appeared again in TE2, it was almost always present in RE (17/18) as well. Moreover, when a TE1 segmental abnormality was not detected in TE2, in 12 out of 13 cases RE was also unaffected. Similarly, only 1 of 26 TE1 whole chromosome mosaics were repeated in TE2 and 7 in RE. Our study confirms that euploid and whole chromosomal aneuploidy results are highly predictive of the embryo. In contrast, mosaicism has a very low concordance rate. Most importantly, re-biopsy of embryos with segmental aneuploidies demonstrated that they are mostly not uniform across the embryo. Finally, in the case of segmental aneuploidy, the second biopsy enables an accurate prediction of the real status of the embryo and could be offered to patients undergoing PGT-A.

Is it time to establish age restrictions in ART?

Providers specializing in reproductive medicine are treating increasing numbers of women pursuing parenthood in their 40s, 50s, and beyond. The rise in later-life parenting can be linked to factors ranging from the advent of assisted reproductive technologies and donor oocytes to the highly publicized pregnancies of older celebrities. We explore the medical and psychosocial implications of this trend for both older parents and their children. We also discuss ethical arguments regarding older parents' access to fertility care, existing professional guidelines, and both public and provider opinions about setting age limits for fertility treatment. Finally, we share preliminary considerations of whether age policies should be established, applied to men as well as women, and standardized or considered on a case-by-case basis.

Declining realisation of reproductive intentions with age

STUDY QUESTION

What is the likelihood of having a child within 4 years for men and women with strong short-term reproductive intentions, and how is it affected by age?

SUMMARY ANSWER

For women, the likelihood of realising reproductive intentions decreased steeply from age 35: the effect of age was weak and not significant for men.

WHAT IS KNOWN ALREADY

Men and women are postponing childbearing until later ages. For women, this trend is associated with a higher risk that childbearing plans will not be realised due to increased levels of infertility and pregnancy complications.

STUDY DESIGN, SIZE, DURATION

This study analyses two waves of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey. The analytical sample interviewed in 2011 included 447 men aged 18–45 and 528 women aged 18–41. These respondents expressed a strong intention to have a child in the next 3 years. We followed them up in 2015 to track whether their reproductive intention was achieved or revised.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Multinomial logistic regression is used to account for the three possible outcomes: (i) having a child, (ii) not having a child but still intending to have one in the future and (iii) not having a child and no longer intending to have one. We analyse how age, parity, partnership status, education, perceived ability to conceive, self-rated health, BMI and smoking status are related to realising or changing reproductive intentions.

MAIN RESULTS AND THE ROLE OF CHANCE

Almost two-thirds of men and women realised their strong short-term fertility plans within 4 years. There was a steep age-related decline in realising reproductive intentions for women in their mid- and late-30s, whereas men maintained a relatively high probability of having the child they intended until age 45. Women aged 38–41 who planned to have a child were the most likely to change their plan within 4 years. The probability of realising reproductive intention was highest for married and highly educated men and women and for those with one child.

LIMITATIONS, REASONS FOR CAUTION

Our study cannot separate biological, social and cultural reasons for not realising reproductive intentions. Men and women adjust their intentions in response to their actual circumstances, but also in line with their perceived ability to have a child or under the influence of broader social norms on reproductive age.

WIDER IMPLICATIONS OF THE FINDINGS

Our results give a new perspective on the ability of men and women to realise their reproductive plans in the context of childbearing postponement. They confirm the inequality in the individual consequences of delayed reproduction between men and women. They inform medical practitioners and counsellors about the complex biological, social and normative barriers to reproduction among women at higher childbearing ages.

STUDY FUNDING/COMPETING INTEREST(S)

This research was partly supported by a Research School of Social Sciences Visiting Fellowship at the Australian National University and an Australian Research Council Discovery Project (DP150104248). Éva Beaujouan’s work was partly funded by the Austrian Science Fund (FWF) project ‘Later Fertility in Europe’ (Grant agreement no. P31171-G29). This paper uses unit record data from the HILDA Survey. The HILDA Project was initiated and is funded by the Australian Government Department of Social Services (DSS) and is managed by the Melbourne Institute of Applied Economic and Social Research (Melbourne Institute). The findings and views reported in this paper, however, are those of the authors and should not be attributed to either DSS or the Melbourne Institute. The authors have no conflicts of interest.

Socio-demographic factors associated with delayed childbearing in Nigeria

Objective

Delayed childbearing is an emerging public health issue in developing countries compared with more developed countries, where it is already a major clinical and public health concern. Previous studies have mostly focused on either the health risks associated with delayed childbearing or the reasons for it with little done around the socio-demographic factors associated with it in developing countries. The objective of the study was to examine associated socio-demographic factors of delayed childbearing in Nigeria.

Results

The study used secondary data pooled from 2003 to 2013 Nigeria Demographic and Health Surveys. The outcome variable was delayed childbearing. The explanatory variables are selected individual socio-demographic characteristics and community characteristics. A weighted sample size of 20,550 women was analysed. Results showed a prevalence of 8.0% delayed childbearing in Nigeria. Socio-demographic factors such as higher maternal education, age at first marriage of 25 years or older, modern contraceptive use, and remarriage status were significantly associated with delayed childbearing. Significant associations were also observed with high community literacy level and high proportion of women who ever used modern contraceptive in the community.

Awareness of fertility and reproductive aging in women seeking oocyte cryopreservation, reproductive aged controls, and female health care professionals: A comparative study

OBJECTIVE

To compare the awareness of fertility and reproductive aging in women seeking oocyte cryopreservation (OC) with age matched controls.

STUDY DESIGN

In this cross-sectional comparative study, women who were candidates for OC due to impending oocyte depletion (n = 81) were compared to age matched reproductive aged women (RAW) (n = 91) and female healthcare professionals (FHP) (n = 82) in terms of awareness about fertility and reproductive aging and knowledge about OC. A study specific 18-item questionnaire was constructed on the basis of previous research on OC and fertility.

RESULTS

Awareness of fertility and reproductive aging was similar among groups. The majority of study population was quite realistic of women's most fertile age period whereas they were fairly optimistic about the age that a woman may lose her ability to conceive, monthly fecundity rate, and estimated in vitro fertilization treatment success. OC candidates and FHP were more realistic compared to RAW regarding the age after which the chances of conception is severely diminished (p = 0.005). When the knowledge on OC and willingness to preserve fertility in the future were asked to FHP and RAW, 90% stated that they were aware of the option (93% in FHP versus 88% in RAW, p = 0.006). However, they lacked detailed information about OC and they were unlikely to consider it in the future.

CONCLUSIONS

Women seeking OC did not appear to have a better awareness of reproductive ageing compared to the general female population. The results of this study highlight the need for additional awareness campaigns and education on both personal and professional levels.

Status one year after fertility assessment and counselling in women of reproductive age-a qualitative study

INTRODUCTION

Over the past 50 years women and men have postponed family formation in high-income societies. Fertility assessment and counselling has been suggested as a method to reduce delayed childbearing and its consequences. This study explored women's perceptions of how attending a fertility assessment intervention influenced their decisions and choices regarding family formation and childbearing.

MATERIAL AND METHODS

Follow-up data from a longitudinal semi-structured qualitative interview study including 20 women aged 35-40 years seeking individual fertility counselling at the Fertility Assessment and Counselling Clinic at Rigshospitalet, Copenhagen, Denmark. The interviews were conducted one year after their consultation. Data were analysed by qualitative content analysis.

RESULTS

The women perceived an increase in their knowledge after they had attended the counselling. The women saw the counselling as a catalyst for change-they changed their behaviour and relationship status. The women stopped thinking about the pros and cons of childbearing and acted instead. The women did not experience any regrets about acting. Some of the women felt that they were still in limbo as they were still in doubt concerning childbearing. The consultation had not given them an answer with a clear deadline in terms of delaying attempts to become pregnant, and this frustrated them.

CONCLUSIONS

Our study highlights the impact of a fertility assessment and counselling intervention which included a perceived increase in knowledge. The clinic allows for an individualized approach to fertility awareness which is necessary given the unique nature of childbearing decisions.

Knowledge of age-related fertility decline in women: A systematic review

Age-related fertility decline (ARFD) knowledge has been evaluated in the past decade, showing that there is a general knowledge of the reduction of fertility with age. Here we review the studies published up to date which quantitatively measure this ARFD knowledge, to answer the question: how aware about ARFD is our society? We searched the terms "age", "fertility knowledge", "fertility awareness", "reproduction knowledge", "reproductive knowledge" and "reproductive health knowledge" in PubMed, Web of Science, PsychINFO and Scopus, within January 2000 and December 2016. We found 41 studies that quantitatively measured ARFD knowledge by asking for the most fertile age for a woman and/or when there are a slight and a marked decrease in female fertility. We obtained this searching for the questions: What is the most fertile age for a woman? (Q1). When there is a slight decrease in female fertility? (Q2) and, When there is a marked decrease in female fertility? (Q3). We further evaluated the knowledge increase in the 6 studies assessing an educational intervention, 4 of them randomized controlled trials (RCT). Participants reporting the most fertile age for women to be at 20-24 y.o. ranged 16%-89.4% (Q1); participants reporting a slight decrease in female fertility at 25-29 y.o. ranged 5.1%-83% (Q2), and those reporting that a marked decrease occurs between 35-39 y.o. ranged 5.6%-60% (Q3). On the whole, the studies included in this review conclude that ARFD knowledge is insufficient, particularly in determining when female fertility markedly decreases. ARFD knowledge can be increased through targeted campaigns, but few interventional studies have been performed up to date. In view of these results, ARFD campaigns targeted to reproductive age people and healthcare providers are necessary; this would help the society to make informed reproductive decisions throughout life.

Actions to increase knowledge about age-related fertility decline in women

OBJECTIVE

There is a strong body of published data corroborating the current lack of awareness of age-related fertility decline (ARFD), but few studies have evaluated specific interventions aimed at increasing ARFD knowledge. Here, we review the literature examining the instruments developed and the educational interventions performed to date.

METHODS

We carried out a narrative review based on a literature search in PubMed, Web of Science, PsycINFO and Scopus between January 2010 and December 2017.

RESULTS

The instruments available comprise websites, paper brochures, slide presentations and tailored information, mainly developed with the input of university students. The eight interventions reviewed include surveys before and/or after a specific intervention, with and without a control group, in randomised and non-randomised designs. Overall, the interventions were effective in increasing ARFD knowledge and lowering the desired age for childbearing in the short term. These results were not always maintained, however, in the long term, possibly due to a lack of perceived risk of future infertility among those studied.

CONCLUSION

Further interventions need to be targeted to both young people and health care providers, and should be as personalised as possible. A greater number of validated instruments are also needed to reliably measure the effectiveness of any intervention.

Development and Psychometric Properties of The Delayed Childbearing Questionnaire (DCBQ-55)

The comprehensive assessment of delayed childbearing needs a valid and reliable instrument. Therefore, the aim of the present study was to develop an instrument to evaluate factors influencing delayed childbearing among women and to assess its psychometric properties. The current methodological study was performed in two phases of (i) qualitative instrument development, and (ii) quantitative psychometric assessment of the developed instrument. Face and content validity of the instrument was assessed by eligible women and a panel of experts. Construct validity was assessed using the exploratory factor analysis (EFA). For reliability, internal consistency reliability and intra-rater reliability analysis were used. The initial instrument developed from the qualitative phase consisted of 60 items, which were reduced to 55 items after the face and content validity processes. EFA (n = 300) using the Kaiser criteria (Eigenvalues > 1) and the scree plot led to a six-factor solution accounting for 61.24% of the observed variance. The Cronbach’s alpha coefficient, Spearman’s correlation, test–retest and intra-class correlation coefficients for the whole instrument were reported as 0.83, 0.86 and 0.81, respectively. The final instrument entitled the delayed childbearing questionnaire (DCBQ-55) included 50 items with six domains of ‘readiness for childbearing’, ‘stability in the partner relationship’, ‘awareness about the adverse outcomes of pregnancy in advanced maternal age’, ‘attitude toward delayed childbearing’, ‘family support’, and ‘social support’ on a five-point Likert scale. The DCBQ-55 as a simple, valid and reliable instrument can assess factors influencing delayed childbearing. It can be used by reproductive healthcare providers and policy makers to understand factors influencing delayed childbearing and devise appropriate strategies.

Exploring the perception of childbearing barriers in a low fertility subgroup of Iran: a qualitative study

Background

In Iran, the total fertility rate is 1.8 and it is especially low in highly educated women. Also, there is a considerable difference between the ideal and realized fertility in this sub-population. Clear knowledge on the barriers to achieve the ideal family size is necessary to formulate policies.

Objective

The study aimed at explaining the barriers of childbearing in this sub-population.

Methods

This was a qualitative study using conventional content analysis. The study was conducted from April 2015 to January 2016 across the colleges of Kerman University of Medical Sciences in the southeast of Iran. The study population consisted of PhD students and faculty members who were studying and working in this university. We used semi-structured interviews to collect data. The sampling procedure was purposeful sampling and it continued until data saturation was achieved. Conventional content analysis was performed to analyze the gathered data.

Results

Twenty two participants took part, all of whom were married and half of whom were women. Eight of the participants were faculty members and the rest were PhD students. Two categories were extracted, including lake of enabling environment and personal preferences as the main barriers to childbearing in the highly educated subpopulation. Each of the categories included corresponding secondary and primary categories.

Conclusions

Different factors affect childbearing decision making in highly educated people. Taking into account these barriers is important at the time of formulating pro-natalist policies.

Conceptualising women's motivations for social egg freezing and experience of reproductive delay

As the average age of motherhood in many Western countries continues to rise, the spectacle of the older mother and the trend towards delayed childbearing has been the subject of much public debate and interest. Concurrent to this trend has been the development and use of a new form of fertility preservation - social egg freezing - a technology which by its very nature is meant to enable reproductive delay. Whilst previous studies have been able to provide insights into the complex and often interrelating structural, economic, and relational factors shaping the timing of motherhood, and in some cases women's use of social egg freezing, fewer studies have clearly demonstrated the way these factors themselves, as well as the accounts of individual women, can be seen as being shaped by ideological and discursive forces. Drawing on interviews with 31 users of social egg freezing this article will demonstrate how women's accounts of reproductive delay and use of egg freezing technology can be seen as being shaped by neoliberal rationality, heteronormativity, discourses of 'appropriate parenting' and gendered ideologies of parenthood.