Naturally occurring advanced maternal age

There are many reports of women naturally conceiving and bearing children in their 50s and even 60s, although it has been suggested that in truth the oldest naturally conceived pregnancy was in a 57-year-old woman [2]. A more representative picture of age and reproduction can be found by examining birth rates in populations that proscribe contraception and encourage reproduction until menopause. Researchers have looked at the rates of reproduction for women 45 years and beyond in two such populations: the Bedouins and those in ultra-orthodox Jewish communities. Births to this older group of women accounted for only 0.2 to 0.38% of all deliveries at the medical centers that serve these communities [4,5].

This data suggests that unassisted conception above the age range of 45–50 is exceptionally rare. Academically, these occurrences may be viewed as “outliers.” One may conclude that without medical intervention, only a very small minority (perhaps less than 0.38%) of births would be to women 45 and beyond.

Changes in reproduction patterns

The median age of menopause is 51.4 years and there is some scant evidence that women with higher educational attainment, higher socio-economic status and physical activity may experience menopause a few months later than women of prior generations [6]. While further data would be helpful in clarifying whether women are experiencing later menopause, substantial data confirms that women are having children later in life. Data from the United States National Center for Health Statistics indicates that, across the country, the average age at which women had their first child increased from 21.4 to 25.0 years (a 3.6 year increase) from 1970 to 2006 [7]. This increase varied geographically; women in more central states showed a comparatively modest increase in age at first birth by having their children 2.0 to 2.6 years later in 2006 compared to 1970, whereas women in the northeast had their first child 4.3–5.5 years later in the same time frame. This trend towards later parenting, especially pronounced in more urban areas, has also been found in other developed countries [8].

Further data from the National Center for Health Statistics allows a closer look at the increased incidence of women having children later in life [9]. From 1996 to 2008, the overall birth rate in the United States rose 9.15%. In this same time frame, the birth rate to women aged 40–44 years rose 47.6% from 72 000 births to 106 000 births. The birth rate to women aged 45–49 rose 133% from 3000 births to 7000 births. Finally, although the absolute number of births in the 50–55 year maternal age bracket has remained small, the increase from 114 births in 1997 to 541 in 2008 represents an increase of 276%. Further, as women delay childbearing and age at first birth increases, the total number of children born to each woman decreases [2].

While it is possible that the average age of menopause may be increasing slightly, it would be folly to attribute the rise of births to older women to this potential marginal increase in childbearing years. Rather, it is clear that the increase in births to women 45 years and above is due to the rise in oocyte donation and IVF.

Older reproduction possible with the advent of IVF and oocyte donation

Those in the field of assisted reproduction are well acquainted with the fact that Louise Brown, born in 1978, was the first child born via in vitro fertilization (IVF). Six short years later in 1984, the world welcomed the first children born via egg donation [10]. Initially, premature ovarian failure, gonadal dysgenesis, cancer treatments and oophorectomy were the indications for oocyte donation; however, this treatment now extends to women of advanced maternal age who have experienced menopause.

Psychological and emotional contributors to older parenthood

Certainly, it’s reasonable to presume that older prospective parents are looking forward to parenting for the same reasons as their younger counterparts. They may be anticipating “Happiness” (expected feelings of affection and happiness in the relationship with a child); “Well-being” (an expected positive impact on the individual’s life); “Motherhood/Fatherhood” (an expectation of enjoying and being satisfied by parental activities); “Identity” (a means of enhancing one’s self-concept and attaining adulthood); “Continuity” (opportunity to live on through children, have a relationship with children in old age, and pass on family names and traditions); “Social Control” (implied or explicit pressure from outside the couple to procreate); and “Marital Completion” (children are the reason for marriage and children are important for a happy marriage) [11].

These potential parents differ from their younger counterparts, however, in that they have postponed parenting. Many factors may explain this postponement. Usually the first step to parenting is having a suitable partner who is ready and willing to have a child. A recent study found that the combined concerns of partner suitability and partner interest in having a child were second only to concerns of financial preparedness in regards to factors influencing decisions to have a child [12]. Another partner-related issue is second marriages. As noted in the opening case, many feel that having a child adds to marital completion; thus, those entering into a second union may be motivated to have a child, which will occur later in life.

It is also clear that the need to be “prepared” to have a child is contributing to the postponement of childbearing. Financial preparedness has been found to be the primary factor influencing readiness for childbearing [13]. There is an interesting paradox about preparedness, especially for women, the prospective parents who are most likely to experience reduced income due to leaving the workforce or working fewer hours because of children’s needs. In short, researchers have found that attainment of higher education and income can actually act as a disincentive for women to have children. The explanation is simple in that, as women attain higher wages, they stand to lose more by decreased work hours relative to when they had lower hourly wages; higher wage earners simply lose more money by having children than lower wage earners. It can be theorized then, that as women work to prepare themselves for children, they will perceive a greater economic disadvantage to having a child and further postpone childbearing until they have reached a point of perceived economic security.

It has also been asserted that men and women are postponing childbearing because they believe they have an ample number of years left in their lives to provide sufficient and effective parenting [14]. Two factors contribute to this thinking. The first fact is that people are living longer. Table 11.1 illustrates this: in comparison to their counterparts born in the 1930s, white men and women born in 2007 can expect an additional 17 years of life [15]. Black males and females can anticipate an additional 25 years of life. The second issue is that people tend to “feel younger” than they are. In a 2009 Pew Research Center survey, nearly half of 50-year-olds reported “feeling” at least 10 years younger than their age. Those who were 65–74 years old reported feeling 10–19 years younger than their age [16]. The experience of feeling younger than one’s age, coupled with the expectation of a lengthy additional life expectancy, may lead individuals to conclude that they can safely embark on parenting late in life.

Finally, some instances of late parenting are prompted by the death of another child within the family [17]. Although there may be some instances in which this new child can be seen as a “replacement child,” other times a new child is brought into a grieving family to create a new sense of hope and happiness.

Social acceptance of older childbearing

As in developing countries, Western cultures are often described as “pronatalist” in that there is a social dictate to have children, but with limits. Indeed, Western societies have proscriptions about engaging in childbearing either too early or too late [18]. A European study of nearly 22 000 men and 22 000 women across 25 countries demonstrated that society has firm ideas about when it is no longer appropriate for men and women to have children [18]. When asked, “After what age would you say a woman [or man] is generally too old to consider having any more children?” over 96% of respondents cited a mean maternal age limit of 41.7 years with 57% suggesting a deadline of less than 40 years for potential mothers. The data was slightly more permissive for potential fathers with over 90% of respondents citing a mean paternal age limit of 47.3 years and nearly half suggesting a deadline of 45 years for potential fathers.

A similar Australian survey asked respondents at what age a woman is too old to have a child using another woman’s eggs [19]. Only a minority, 37.9%, of respondents agreed that a postmenopausal woman should be able to use another woman’s eggs to have a child. Interestingly, older respondents were significantly less accepting of postmenopausal women receiving donated eggs.

Strategic social comparison process

Weiss has noted that, like gender and ethnicity, age is a fundamental social category to which an individual belongs, unfortunately however, as one grows older, chronological age becomes a less desirable or even an undesirable characteristic. Thus, growing older is a challenge in that one is confronted with a possible worsening of one’s self-concept. Individuals are motivated to maintain a positive view of themselves, and thus they will try to evade threats to their positive self-concept. One proposed mechanism for diminishing the threat of a worsening age-associated self-concept is to differentiate or contrast one’s self from same-age peers [20]. Individuals may judge themselves to be “atypical” for their age. They may conclude that, “I am better than my age group.” As older adults differentiate themselves from their age-mates, they perceive themselves as being similar to and a part of a younger age group. Weiss describes this as a “strategic social comparison process.”

It is interesting to view older parenting within the “strategic social comparison process” concept. It may be that as older adults assimilate to younger age cohorts, they may consider enacting life choices that are characteristic of that younger cohort. They may engage in late reproduction to demonstrate that they still retain the qualities of youth and productivity, which are valued in our society.

Egocentrism

Egocentrism is a theory originally put forth by Piaget that refers to an individual’s difficulty in considering and understanding another’s point of view. The individual’s self-perspective interferes with the ability to fully appreciate the perspective of another. As Piaget described, the individual with egocentrism has not yet discovered the multiplicity of possible perspectives and remains blind to all but his own as if that were the only one possible [21]. While initially applied to children, the theory of egocentrism is also applicable to adults.

An older individual’s decision to have a child late in life may be viewed within the context of egocentrism. As an older individual considers having a child, possibly due to a tendency to see themselves as atypical for their age group and more like younger adults, they may be making the decision based on their own psychological needs. It is certainly true that research on motivations for having children suggests that most, perhaps all, adults anticipate personal benefit to having children (e.g., it’s fun, someone to be with in my old age, etc.), and thus perhaps all individuals have some degree of egocentrism impacting their desire to have children. It can be argued, however, that older adults may neglect or not fully appreciate the child’s experience of being parented by older adults as they contemplate having children.

Medical risk associated with delayed parenting

Even with the use of donated eggs, women of advanced maternal age face increased risks during pregnancy and delivery. Older women are more likely to experience pregnancy induced hypertension, gestational diabetes, placenta previa and Caesarean section [2,22]. Older women are also more likely to present with pre-existing hypertension, diabetes, obesity and chronic disease; these pre-existing factors result in a 2- to 3-fold increased rate of hospitalization, Caesarean section, and pregnancy related complications relative to younger, healthier women [2]. The risk of maternal death also increases with age although the overall risk of dying during childbirth is very low in developed countries [2]. Finally, some studies have suggested an increased risk of low birth weight and fetal mortality in pregnancies occurring in women over 50 [22].

Advanced paternal age has been defined as a paternal age ≥ 45 [23]. Decreased fertility associated with advanced paternal age has a number of causative factors including decreased coital frequency, reduced sexual function and poorer semen quality [2]. Advanced paternal age is associated with increased risk of Down syndrome, Klinefelter syndrome, achondroplasia and some forms of childhood cancer [2,22]. Autism, schizophrenia, bi-polar disorders, attention deficit disorder, suicide attempts, substance use problems and lower academic achievement are more common in children of older fathers and, strikingly, a dose–response relationship has been found between paternal age and incidence of these disorders [23]. More specifically, comparisons of siblings born to the same father reveal that children born later in that same father’s life are more likely than their older siblings to demonstrate these difficulties. Paternal age is also associated with cleft lip and cleft palate independently of maternal age [24]. An additional, perhaps surprising, finding is that advanced paternal age may also be associated with increased risk of Caesarean section independent of maternal age [25]. It is often concluded that the individual increased risk to the offspring attributable to advanced paternal age is low. However, as the incidence of advanced paternal age increases, the impact of these well-documented disadvantages may become more apparent [24].

Impact on the parenting experience

Researchers have examined the perceived benefits and detriments for those embarking on later parenting [26]. In interviews with men and women who had their children when the woman was 40 or older, reported benefits of delayed parenting included maturity, emotional readiness, financial security and strong co-parenting relationships. Older parents also reported that having children later in life helped them to feel young longer and motivated them to stay physically fit.

Disadvantages were also reported. Beyond the need for fertility treatment, the most commonly cited drawback for delayed parenting was a lack of physical energy. Another significant concern was fewer life years with their children and awareness that, due to their age, parents were more likely to become ill and die while their children were still comparatively young. The authors of this study note that parental concerns over the risk of illness and death only emerged after their children were born. These parents also noted that, despite initial desires for larger family sizes, the demands of parenting at an older age ultimately led them to have just one child. Finally, older parents reported concerns that their child would experience social stigma related to having parents who were visibly older than other parents.

A concern regarding fewer years with children is supported by actuarial data. Analysis of data from the United States Life Tables (2006) allows for the prediction of years of parenting and a child’s age at the time of the mother and father’s expected deaths (see Tables 11.2 and 11.3) [27]. Looking at the data within Table 11.2 it is clear that nearly 10% of children fathered by 45-year-old men will lose their fathers by the time they turn 15 and nearly 16% will lose their fathers by the time they are 20. In contrast, when fathered by a man of 35, less than 5% of 15-year-olds will have lost their fathers and less than 8% of 20-year-olds will have lost their fathers. For children fathered by 55-year-olds, nearly 20% will lose their father by age 15 and more than 30% will lose him by age 20. In short, the risk of losing one’s father by age 15 or 20 doubles when the father is 45 versus 55; and the risk increases more than 4-fold when comparing risk of paternal loss when the father is 35 versus 55 at the time of birth.

Table 11.3

Child’s expected age at time of mother’s death.

Mother’s Age at Child’s Birth	Mother’s Expected Age at Death, at Time of Child’s Birth	Child’s Expected Age at Mother’s Death	Mother’s Probability of Death by Child Age 5	Mother’s Probability of Death by Child Age 10	Mother’s Probability of Death by Child Age 15	Mother’s Probability of Death by Child Age 20
20	81	61	0.24%	0.53%	0.89%	1.42%
25	81	56	0.28%	0.64%	1.18%	2.03%
30	81	51	0.36%	0.90%	1.75%	3.03%
35	81	46	0.54%	1.39%	2.68%	4.51%
40	82	42	0.86%	2.15%	4.00%	6.62%
45	82	37	1.30%	3.16%	5.81%	9.86%
50	82	32	1.88%	4.57%	8.67%	14.47%
55	83	28	2.73%	6.92%	12.83%	21.60%
60	84	24	4.30%	10.38%	19.39%	32.86%
65	85	20	6.35%	15.77%	29.85%	48.76%
70	86	16	10.06%	25.09%	45.28%	67.94%
75	87	12	16.71%	39.16%	64.35%	85.45%

Source: Life Tables, United States, 2006, National Vital Statistics Reports, June 2010

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