28 February 2014
February digest: What’s the problem with older mothers?
This month's top stories on Reproductive Review.
This Q&A reviews the scientific and medical debates about later motherhood, seeking a balance between understanding the biological barriers to having babies in later life, and the lived reality – that many women do have healthy pregnancies in their late thirties. It situates this discussion in its wider social context, and indicates the policy implications that might flow from a trend towards later maternal age.
• The trend towards later maternal age arises from personal, cultural and social factors, and will not be affected by health professionals or policymakers encouraging women to have their children early.
• Most of the rise in ‘older mothers’ is to women aged 35-40. For this group, the chances of being able to conceive a healthy pregnancy and give birth without serious complications are good.
• Difficulties in conceiving, and risks in childbirth, become more marked for women aged 40 and over. But even for this group, women have different levels of general and reproductive health.
• The risk of certain fetal anomalies rises with maternal age, but the majority of pregnancies will be unaffected.
• There is no evidence women are postponing motherhood because of a misplaced reliance on future IVF. Women who seek IVF because of age-related fertility problems know that this is not a ‘magic bullet’, but are also aware that as a last resort, fertility treatment can work.
• The policy implications that arise from later maternal age should focus on supporting women as they are, rather than attempting to cajole them into reproducing earlier. Sensible policy measures would include:
- Access to prompt fertility treatment for women who need it, including greater support for gamete donation and egg freezing.
- Organising the maternity service more around the needs of older mothers, thereby ensuring that complications in labour and birth can be properly managed.
- Prenatal screening and provision for disabled people, taking into account that the risk of certain fetal anomalies rises with maternal age; that some women with an affected pregnancy will want a termination and that others will want to continue.
Health professionals and policymakers are drawing increasing attention to women’s alcohol consumption during pregnancy: to the point where women who are pregnant, or thinking of becoming pregnant, are officially advised to abstain from alcohol altogether. But how much do we know about the effects of alcohol upon the developing fetus? And does this justify the current guidance?
Data released by BPAS indicates that two thirds (66%) of women having an abortion at its clinics reported using a form of contraception when they conceived.
The reasons for not using contraception are diverse: sex may be unplanned and women are not prepared. A small group of women will be ending a planned pregnancy, and there will also be instances of coercion into unprotected sex. But many do not use contraception because they under-estimate their fertility and the risk of pregnancy. For older women this may be linked to public health messaging about the difficulties their age group faces conceiving wanted pregnancies. For younger women, the belief that a previous diagnosis of chlamydia may have permanently damaged their fertility is not uncommon, or if they have had unprotected sex and did not become pregnant they assume they are infertile.
Women across all age groups report being unhappy with the side-effects of some hormonal contraception, or believe they are not having sex frequently enough to warrant long-term contraception. Some then switch to fertility awareness and/or withdrawal which requires a lot of attention, commitment and control.
Ann Furedi, chief executive of BPAS, said:
‘An unintended pregnancy is often a happy accident – and a large proportion of births in this country are unplanned. But for many women an unplanned pregnancy causes considerable distress, coming at a time in their lives when they are not in the position to start or expand their family. Ultimately women cannot control their fertility through contraception alone, and need accessible abortion services as a back-up for when their contraception lets them down.
‘We need new contraceptive options. We are excited by research into a “pericoital” pill that women could take at the time of sex. This would be of great benefit to those women who don’t feel they are having sex often enough to need an on going method, but who do not wish to rely solely on condoms.’
In this round-up of interviews, Ann Furedi of BPAS, and Suchitra Dalvie of the Asia Safe Abortion Partnership, challenge the way fears over sex selection have been used to undermine women’s abortion rights.
The US abortion rate declined to 16.9 abortions per 1,000 women aged 15–44 in 2011, well below the 1981 peak of 29.3 per 1,000 and the lowest since 1973 (16.3 per 1,000), according to research by the Guttmacher Institute. Between 2008 and 2011, the abortion rate fell 13%, resuming the long-term downward trend that had stalled between 2005 and 2008.
While the study did not specifically investigate reasons for the decline, the authors note that the study period (2008–2011) predates the major surge in state-level abortion restrictions that started during the 2011 legislative session, and that many provisions did not go into effect until late 2011 or even later. The study also found that the total number of abortion providers declined by only 4% between 2008 and 2011, and the number of clinics (which provide the large majority of abortion services) declined by just 1%. This suggests that state-level restrictions are not the cause of the fall in the abortion rate.
The Daily Mirror’s scare story about ‘internet gangs’ selling ‘deadly abortion pills to desperate teen girls’ needs a bit of balancing.
Dr Garson, a champion of women’s reproductive choice who survived numerous attempts on his life for providing abortion care, died in hospital on 30 January after a period of illness.
In a speech given in 2008, marking the twentieth anniversary of R. v. Morgentaler, the landmark Supreme Court decision that struck down the laws restricting abortion in Canada, Dr Garson said:
‘I love my work. I get enormous personal and professional satisfaction out of helping people, and that includes providing safe, comfortable, abortions. The people that I work with are extraordinary, and we all feel that we are doing important work, making a real difference in people’s lives.
‘I can take an anxious woman, who is in the biggest trouble she has ever experiences in her life, and by performing a five-minute operation, in comfort and dignity, I can give her back her life.
‘After an abortion operation, patients frequently say “Thank You Doctor.” But abortion is the only operation I know of where they also sometimes say “Thank you for what you do.”’
Progress Educational Trust’s annual conference tackled a number of contentious issues.
A ‘no-frills’ IVF treatment costing under £1,000 should be available to British women within weeks, the Daily Mail reports.