Childless by circumstance - Using an online survey to explore the experiences of childless women who had wanted children

Business case for psychosocial interventions in clinics: potential for decrease in treatment discontinuation and costs

RESEARCH QUESTION

From a value-based healthcare (VBHC) perspective, does an assessment of clinical outcomes and intervention costs indicate that providing cognitive behavioural therapy (CBT) or mindfulness to women seeking fertility treatment add value compared with no such intervention?

DESIGN

Proof-of-concept business case based on a VBHC perspective that considers clinical outcomes and costs. Potential effects on psychological and fertility outcomes were based on existing research. Cost outcomes were estimated with a costing model for the Dutch fertility treatment setting.

RESULTS

Thirty-two studies were identified; 13 were included. Women who received CBT had 12% lower anxiety, 40% lower depression and 6% higher fertility quality of life; difference in clinical pregnancy rates was six percentage points (CBT [30.2%]; control [24.2%]); difference in fertility discontinuation rates was 10 percentage points (CBT [5.5%]; control [15.2%]). Women who received training in mindfulness had 8% lower anxiety, 45% lower depression and 21% higher fertility quality of life; difference in mean clinical pregnancy rate was 19 percentage points (mindfulness [44.8%]; control [26.0%]). Potential total cost savings was about €1.2 million per year if CBT was provided and €11 million if mindfulness was provided. Corresponding return on investment for CBT was 30.7%, and for mindfulness 288%. Potential cost benefits are influenced by the assumed clinical pregnancy rates; such data related to mindfulness were limited to one study.

CONCLUSIONS

The provision of CBT or mindfulness to women seeking fertility treatment could add value. Higher quality primary studies are needed on the effect of mindfulness on clinical pregnancy rates.

The Way Older Childless Women Value Their Life-A Qualitative Study

Older women without children, like all older adults, evaluate their lives and face a conflict between despair and ego integrity as proposed by Erikson's theory of development. Their uniqueness lies in their deviation from the societal norm of parenthood prevalent in pro-natalist societies such as Israel. This study aims to explore how older childless women evaluate their lives. Using a qualitative approach, 20 semi-structured, in-depth interviews were conducted with women over 60 years of age who do not have children. Three main themes emerged from the participants' responses: their experiences as women without children in a pro-natalist society, the significance of freedom in their lives, and their life experiences from conflicting perspectives-an internal and external locus of control. The study's findings demonstrate that older childless women adeptly utilize different perspectives across various aspects of their lives, contributing to ego integrity, contrary to the prevailing societal notion that in the absence of children, women are damaged and lack identity. It is conceivable that other segments of the older adult population, diverging from mainstream societal norms, may similarly leverage these different perspectives to uphold their ego.

Perimenopausal women's voices: How does their period at the end of reproductive life affect wellbeing?

OBJECTIVE

To explore perimenopausal women's feelings towards their periods, the impact on their wellbeing and how we can support them.

STUDY DESIGN

Participants were recruited for focus groups through social media advertisements. In 6 online focus groups, 31 perimenopausal women aged 40-55 living in the UK were asked 5 questions relating to periods and perimenopause, support and education.

MAIN OUTCOME MEASURES

Content analysis.

RESULTS

When asked How do you feel about having a period? The participants often related back to the stress of menarche and said their period negatively impacted their wellbeing their whole lives. During perimenopause, their periods had become unpredictable, heavy, and a debilitating disruption to their lives. The women desired support at work through policy, and from family and friends. They believed that educating girls and boys during school was the best place to start, but that education through work and community groups was also needed. They felt healthcare professionals should have mandatory training regarding women's health issues and menopause.

CONCLUSION

The study highlights the impact of menstrual experiences on the wellbeing of perimenopausal women, emphasising the need for improved menstrual education from an early age. Comprehensive menstrual education in schools involving both genders to enable informed decision-making and improved training for healthcare professionals are recommended. Support networks for perimenopausal women will promote better quality of life for women as they go through their perimenopause journey.

Reproduction in a changing world

Although the global population continues to increase, the total fertility rate in many high-income countries (HICs) is below replacement, a trend apparent over several decades. The timing and pace of this change will shape the age distribution in these countries, leading to an increasing proportion of older people. The well-established links of the "demographic transition" between improving female education and improved access to contraception continue to drive down the fertility rates in low-/middle-income countries. However, changes in the age distribution will not be as marked as in HICs in the coming decades. These relationships may now be changing in some HICs with greater prosperity at both the personal (in some sectors of society) and national levels, linked to an increase in the total fertility rates despite continuing trends toward older age at first birth. Key drivers in these countries include improved provision of free/low-cost childcare, paid parental leave, and higher paternal contributions to childcare. However, there is also an increase in the number of women who do not have children or who may be unable to complete their family plans. Coronavirus disease 2019 and environmental factors, including the increasing prevalence of obesity, add to pressures on the fertility rates. Variable knowledge of the realities of female reproductive aging, particularly by men, is also a contributing factor, and this complex mix has fueled the increase in the number of elective egg freezing.

Reproductive health education in the schools of the four UK nations: is it falling through the gap?

Reproductive health education is crucial to ensure young people understand their reproductive system and can make informed decisions about their sexual lives and fertility, including whether they want to have children or not. This study involved an investigation of the intended UK school curricula for 14-18 year-olds as they relate to reproductive health. Analysis revealed substantial differences. Most, but not all, specifications include sexually transmitted infections, hormonal aspects of reproduction, contraception, the menstrual cycle and assisted reproductive technology (ART). Important topics, such as endometriosis, fertility, preconception health, pregnancy, miscarriage, menopause and infertility (except in the context of ART) are missing from examination specifications and/or the RSE/RSHP curricula. We conclude that many young people in the UK are at risk of leaving school with inadequate understanding of concepts that have important implications for their reproductive health. There are differences between nations, with Scotland having the most comprehensive coverage of topics in its curriculum. High-quality reproductive health education should be an entitlement for all young people. It should give young people accurate and up-to-date information and enable them to discuss issues and develop their own thinking. Ideally, sex and reproductive health education would be taught comprehensively across the RSE/RSHP and science curricula.

The development and phase 1 evaluation of a Decision Aid for elective egg freezing

BACKGROUND

Elective egg freezing decisions are complex. We developed a Decision Aid for elective egg freezing and conducted a phase 1 study to evaluate its acceptability and utility for decision-making.

METHODS

The online Decision Aid was developed according to International Patient Decision Aid Standards and evaluated using a pre/post survey design. Twenty-six Australian women aged 18-45 years, interested in receiving elective egg freezing information, proficient in English, and with access to the internet were recruited using social media and university newsletters. Main outcomes were: acceptability of the Decision Aid; feedback on the Decision Aid design and content; concern raised by the Decision Aid, and; utility of the Decision Aid as measured by scores on the Decisional Conflict Scale and on a study-specific scale assessing knowledge about egg freezing and age-related infertility.

RESULTS

Most participants found the Decision Aid acceptable (23/25), balanced (21/26), useful for explaining their options (23/26), and for reaching a decision (18/26). Almost all reported satisfaction with the Decision Aid (25/26) and the level of guidance  it provided (25/26). No participant reported serious concerns about the Decision Aid, and most would recommend it to other women considering elective egg freezing (22/26). Median Decisional Conflict Scale score decreased from 65/100 (Interquartile range: 45-80) pre-Decision Aid to 7.5/100 (Interquartile range: 0-37.5) post-Decision Aid review (p < 0.001). Median knowledge score increased from 8.5/14 (Interquartile range: 7-11) pre-Decision Aid to 11/14 (Interquartile range: 10-12) post-Decision Aid review (p = 0.01).

CONCLUSION

This elective egg freezing Decision Aid appears acceptable and useful for decision-making. It improved knowledge, reduced decisional conflict and did not raise serious concerns. The Decision Aid will be further evaluated using a prospective randomised control trial.

STUDY REGISTRATION

ACTRN12618001685202 (retrospectively registered: 12 October 2018).

An online survey of UK women's attitudes to having children, the age they want children and the effect of the COVID-19 pandemic

STUDY QUESTION

What are women's views on having children, including the age they want to have them and other influences such as the coronavirus disease 2019 (COVID-19) pandemic?

SUMMARY ANSWER

Women's views on having children, at their preferred age of 30 years, included their maternal urge and concerns about their biological clock and stability, while 19% said COVID-19 had affected their views.

WHAT IS KNOWN ALREADY

Women globally are delaying the birth of their first child, with the average age of first birth approaching 32 years in some countries. The average age women have their first child in the UK is 30.7 years and over 50% of women aged 30 years are childless. The fertility rate stands at 1.3 in several European Union countries. Some people are not having their desired family size or are childless by circumstance. It is essential to understand people's attitudes to having children in different countries to identify trends so we can develop educational resources in an age-appropriate manner.

STUDY DESIGN, SIZE, DURATION

We conducted an anonymous, online survey of multiple choice and open-ended questions. The survey was live for 32 days from 15 May 2020 to 16 June 2020 and was promoted using social media.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 887 women from 44 countries participated in the survey. After filtering out women who did not consent, gave blank or incomplete responses, and those not in the UK, 411 responses remained. From the data, three areas of questioning were analysed: their views on having children, the ideal age they want to have children and the effects of the COVID-19 pandemic. Qualitative data were analysed by thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The average age (±SD) of the women who completed the survey was 32.2 years (±5.9), and they were mainly heterosexual (90.8%) and 84.8% had a university education. One-third of women were married/in a civil partnership (37.7%) and 36.0% were cohabitating. In relation to their views on having children, the main themes identified were: the maternal urge, the ticking of the biological clock, why did no one teach us this?, the need for stability and balance in their life, pressure to start a family and considering other ways to have a family. When asked 'In an ideal world, at what age approximately would you like to have had or have children?' a normal distribution was observed with a mean age of 29.9 (±3.3) years. When asked 'What factors have led you to decide on that particular age?' the most frequent choice was 'I am developing my career'. Three themes emerged from the qualitative question on why they chose that age: the need for stability and balance in their life, the importance of finding the right time and life experiences. The majority of women felt that the COVID-19 pandemic had not affected their decision to have children (72.3%), but 19.1% said it had. The qualitative comments showed they had concerns about instability in their life, such as finances and careers, and delays in fertility treatment.

LIMITATIONS, REASONS FOR CAUTION

The survey was promoted on social media only and the women who answered the survey were highly educated.

WIDER IMPLICATIONS OF THE FINDINGS

The women surveyed ideally want children at age 30 years but there are obstacles in their way, such as the need to develop their career. Global tailored fertility education is essential to ensure people make informed reproductive choices. In addition, it is essential for supportive working environments and affordable childcare to be in place in every country.

STUDY FUNDING/COMPETING INTEREST(S)

J.C.H. is founder of www.globalwomenconnected.com and Reproductive Health at Work, and author of the book Your Fertile Years. This project was funded by the Institute for Women's Health, UCL.

TRIAL REGISTRATION NUMBER

N/A.