Evidence-based practice inquiry

Health Care for Women International, 28:534–555, 2007 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399330701334356

First Mothering Over 35 Years: Questioning the Association of Maternal Age

and Pregnancy Risk

M. CAROLAN School of Nursing and Midwifery, Victoria University, Melbourne, Australia

S. NELSON School of Nursing, University of Toronto, Toronto, Canada

Women having a first baby at 35+ years are commonly considered to be “at risk” for pregnancy complications. This understanding appears to be based primarily on age, and curerntly many healthy women are included in this category. There is clear evidence to suggest that, for these women, being considered “at risk” is anxiety provoking.

In this Australian qualitative study of first mothering over 35 years, we found four risk-related themes, “realizing I was at risk,” “hoping for reassurance,” “dealing with uncertainty,” and “getting through it/negotiating risk.” We concluded that successful adjustment to motherhood related principally to participants negotiating risk and also to the infant growing and becoming more responsive. Attitudes of health professionals were found to contribute to rather than ameliorate participant dilemmas.

Understanding how healthy women over 35 years engage with and negotiate notions of risk may assist health professionals in the provision of more meaningful maternal support for this growing group of women.

BACKGROUND

In the past four decades, there have been many changes to childbearing trends in the advanced industrial world. Those changes include fewer

Received 1 September 2005; accepted 26 August 2006. Address correspondence to Dr. Mary Carolan, School of Nursing and Midwifery,

Victoria University, St. Albans Campus, P.O.Box 14428, Melbourne 8001, Australia. E-mail: [email protected]

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children, born closer together, to older mothers. This “graying” of maternity gives rise to many concerns and dilemmas, not the least of which is the asso- ciation of maternal age and pregnancy risk among healthy mature women. First-time mothers over 35 years are often labeled as “elderly primigravidae” and as “at risk,” which is an issue of concern to a wide range of health professionals and to a growing group of parturient women and their families.

Historically, the term “Elderly primigravida” was first coined in the 1950s to describe women of 35 years and above embarking on their first pregnancy (International Council of Obstetricians, 1958; as cited by Barkan & Bracken, 1987, p. 101 Waters & Wager, 1950). At that time, obstetric outcomes for “el- derly” mothers were considered to be significantly less favorable than those for younger women. Mature childbearing of this era tended to be an indicator of socioeconomic disadvantage (Neumann & Graf, 2003; Wildschut, 1999), and very often included mothers of many children who had commenced childbearing several years earlier. First mothering over 35 years was a rela- tively unusual event and typically was related to late marriages or infertility (Harker & Thorpe, 1992). Now, however, in the twenty-first century, maternal age greater than 35 is an increasing trend in the developed world (Australian Bureau of Statistics [ABS], 2000, 2003; Australian Institute of Health and Welfare [AIHW], 2000; National Statistics U.K., 2001; U.S. Center for Disease Control and Prevention, 2001), and a significant percentage of this group are first-time mothers. This pattern relates to changing social trends and value shifts, including increasing female participation in higher education and the workforce (Berkowitz, Shovron, Lapinski, & Berkowitz, 1993; Berryman, Thorpe, & Windridge, 1999; Cunningham & Leveno, 1995; Hewlett, 2002a, 2002b; Ozer, 1995) and feminist ideology of the last four decades (Welles- Nystrom, 1997), which has changed the possible trajectory of women’s lives. Currently, for women actively engaged in a career, postponement of first birth is usual, and for many, this juncture at 35+ may represent the first opportunity for pause in a woman’s working life (Hewlett, 2002b).

The resulting cohort of childbearing women, though not homogeneous, tends to be composed of well-educated women (Berryman et al., 1999; Stark, 1997), who participate in highly paid employment (Berkowitz et al., 1993; Berryman et al., 1999; Ozer 1995). As such, these women are likely to be financially secure (Cunningham & Leveno, 1995), to pursue healthy lifestyle choices (Berryman et al., 1999), to eat a balanced diet and to abstain from smoking (Berryman et al., 1999; Najman, Lanyon, Andersen, Williams, Bor, & O’Callaghan, 1998). Higher maternal education is also commonly associated with increased health awareness and greater use of health care facilities (Morrison, Najman, Williams, Keeping, & Anderson, 1989; Raum, Arabin, Schlaud, Walter, & Schwartz, 2001; Richman, Miller, & LeVine, 1992). Nonetheless, despite their well-educated and well resourced status, contemporary women appear to experience later first mothering as problematic. Particular difficulties are said to include heightened anxiety

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(Nicholson, 1998; Windridge & Berryman, 1999) and an increased incidence of postnatal depression.1 Greater attendance at mother and baby units is noted (Fisher, Feekery, Amir, & Sneddon, 2002), and it seems likely that perceptions of mature first mothering, as risky, may impact negatively on the experiences of these women.

Literature Review

THE CONSTRUCTION OF RISK FOR “OLDER” PREGNANCY

The notion of risk as applied to maternity over 35 years, particularly primiparity, appears to be composed of two separate strands. The first is concerned with medical risk, as related to an aging reproductive system, and an aging body, which is considered less able to withstand the physiological challenges of pregnancy. The second includes a social discourse of risk, which embodies notions of the “right time to have a baby,” and also includes suggestions of responsible risk management such as availing of prenatal testing.

Within the medical literature, “older” mothers (over 35 years) and their infants are considered to be at increased risk of multiple complications (Ataullaha & Freeman-Wang, 2005) including high blood pressure (Barton et al., 1997; Heffner, 2004; Kullmer, Zygmunt, Munstedt, & Lang, 2000), preeclampsia (Heffner, 2004; Sibai et al., 1997; Tan & Tan, 1994), gestational diabetes (Amarin & Akasheh, 2001; Bobrowski & Bottoms, 1995; Dildy et al., 1996), maternal mortality (Ataullaha & Freeman-Wang, 2005; Freeman- Wang & Belski, 2002), chromosomal abnormality (Heffner, 2004; Hollier, Leveno, Kelly, McIntire, & Cunningham, 2000), prematurity (Ataullaha & Freeman-Wang, 2005; Scholz, Haas, & Petru, 1999), low-birth-weight infants (Bonellie, 2001; Cnattingius, Forman, Berendes, & Isotalo, 1992; Scholz et al., 1999), and unexplained stillbirth (Anderson, Wohlfahrt, Christens, Olsen, & Melbye, 2000; Fretts, 2001; Heffner, 2004; Jacobsson, Ladfors, & Milsom, 2004). Throughout, there is a suggestion that the over 35 mother and her infant fare less well than younger mothers, although the actual statistics relating to infant morbidity do not significantly differ between the groups. This theme of greater risk without actual increase in infant morbidity is repeated in several studies, such as those by Pollock (1996); Prysak, Lorenz, and Kisly (1995); Spellacy, Miller, and Winegar (1986); and Smit, Scherjon, and Treffers (1997). Similarly, British psychologists, Windridge and Berryman (1999), who conducted a broad based-comparative study among pregnant women of all ages, discovered that “professionals were more likely to place women over 35 years than those aged 20 to 29 years in a ‘high-risk’ category,

1 Maternal depression following birth commonly described as postnatal depression in Australia and as postpartum depression in the United States.

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but medical records of labor and delivery revealed few maternal age effects” (p. 16).

What is not clear from the literature is the extent to which age-associated risk relates to preexisting maternal compromise, for example, chronic hypertension or to lifestyle influences, such as smoking, maternal weight, and general health. It seems likely that today’s healthy mature mothers may not attract the same degree of risk as did mature maternity of earlier decades. Some researchers, such as Mansfield and McCool (1989), suggest that researchers have failed to allow for important contextual differences in the childbearing experiences of younger and older women. This, they contend, can account for a considerable portion of differential results, “mistakenly ascribed to reproductive age” (p. 395). In a related theme, Hanson (2003) suggests that negative views of female aging lead to the conclusion that “older” maternity is filled with risk, and also that this belief persists in the absence of corroborating evidence.

In addition to medical discourses of “older” maternity as fraught with physical compromise, social discourses construct later first mothering as both problematic and risky. These discourses are underpinned by notions of socially “appropriate” time to childbear and according to Daniels and Weingarten every generation has an “implicit consensus about the right time” to become a parent (1982, p. 13). That “right” time is contingent on prevalent social mores and in contemporary Australia is at approximately 30 years, similar to the statistical average age of childbearing (ABS, 2003). Consequently, women over 35 years, and especially those over 40 years having a first baby, may feel “out of time” with their peers (Dobrzykowski & Stern, 2003; Neurgarten & Datan, 1973; Rossi, 1980) and also may feel that in postponing pregnancy that they have contributed to physiological risk. Notions of age-associated pregnancy risk are ubiquitous, and Lupton’s (1999) work on “pregnancy risk” is drawn upon here to explicate this association. Although Lupton’s work centers on pregnancy in general, and does not make age-related comparisons, it seems likely that this view of pregnancy at 35+, as especially risky, is an extension of the discourse of risk that surrounds all pregnant women. Indeed, the notion of risk in pregnancy seems to have grown considerably in recent years and may relate to advances in risk-related knowledge and technologies within prenatal care. Greater public awareness may also contribute. Whatever the origin, Lupton considers that “the [pregnant] woman is surrounded by and constructed through a plethora of expert and lay advice” (1999, p. 89). This advice is directed at how she should conduct her life to best facilitate the development of her precious fetus. Prevalent discourses suggest that she is responsible for her baby’s health, and should she ignore medical advice, then she has only herself to blame if things go badly (Lupton, 1999). Lupton further suggests that the pregnant woman is positioned in a “web of surveillance” that requires constant effort on her part, such as “seeking out knowledge about risks to

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her fetus, acting on that knowledge” (p. 89). Women are generally compliant and “choose” prenatal testing because they too want to maximize their chances of having a perfect baby. Discourses of risky mature mothering are common in lay literature and, indeed, one need only look at women’s magazines and newspapers to understand that “older maternity is difficult and risky.” Beaulieu and Lippman (1995) present a useful case in point. These researchers surveyed the contents of 10 major women’s magazines for stories about “mature” pregnancy and associated risks and found three commonly articulated themes: a “need” for women to be fully informed of the facts and risks of being pregnant when older; a further need to find out the physical state of the fetus (through medical testing); and a suggestion that the pregnant woman can best meet these needs by “choosing prenatal diagnosis” (p. 59). Throughout most of this literature, concepts of risk are interwoven with suggestions of responsible bahavior, aimed at “ensuring” the health of the fetus.

Methods

SAMPLE

The study reported here involved a longitudinal, qualitative study conducted at a major maternity hospital in metropolitan Melbourne, Australia, and recruitment is described in detail elsewhere (Carolan, 2005a). In brief, primigravid women aged 35+ were recruited purposively on the basis of age and primiparity. The following inclusion criteria were employed:

Ĺ First-time mothers, Ĺ aged 35 years or mature at time of booking, Ĺ uncomplicated pregnancy, Ĺ no major underlying medical complication, Ĺ english speaking.

In all 22 women were interviewed. Following recruitment it was apparent that participants fell by self-selection into two groups, women who considered themselves career women (n = 16) and those who did not (n = 6). In addition to being well-educated (tertiary degree/diploma), career women tended to be self-proclaimed “high achievers” and “perfectionists.” They included a doctor, a journalist, accountants, lawyers, businesswomen, an academic, computer specialists, a project manager, a teacher, and a registered nurse. For the most part, these women described approaching childbearing as a well-delineated “plan” and most had reached a certain level of career achievement prior to choosing to conceive. Almost all had postponed childbearing in pursuit of other goals/career plans. For some, the motivation for having a baby was related to feeling that “time was

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running out” or that now was the “right time.” For two mothers, increasing dissatisfaction with work provided the trigger. A total of 16 mothers fit this category, 7 of whom had required some degree of intervention to conceive.

The remaining 6 women did not mention career as an identifying characteristic, and this group of women was less likely to have electively delayed childbearing. Most spoke of having wanted a baby for quite some time but parturition plans had been thwarted by lack of a partner, divorce, reluctance in a partner, or fertility difficulties. Of the 6 women who fit this category, 4 had completed high school and the remaining 2 had left school during year 11. Their occupations included hairdresser, receptionist, waitress, exotic dancer, secretary, and clerk. These women tended to describe being “really ready for a baby/aching for one” and described their pregnancy as a “dream come true.”

DATA COLLECTION AND RATIONALE

Data from a larger qualitative study investigating the transition to moth- erhood experiences of first-time mothers over 35 years (Carolan, 2005a) provided the material used in this secondary analysis. The prime intent of that study was to examine the broad experience of first maternity for “older” childbearing women, and participants described a temporally ordered progression through well-defined junctures at 1–4 weeks, 1–4 months, 4–6 months, and 6–8 months. Although specific questions about perceptions of risk were not asked, it nonetheless became clear that the notion of risk was pervasive and underpinned the women’s accounts. Indeed the data seemed to “tell two stories.” The first story was the sequential transition to motherhood (reported in an earlier paper, Carolan, 2005b) and the second story seemed to relate to the negotiation of risk.

Although risk was reviewed in the earlier article as a background characteristic, it actually went much deeper than this and over time I (first author) became concerned that this notion of risk, particularly as it applied to maternal age, had not been given due attention. Later conversations with midwifery colleagues and obstetricians confirmed my fears. The notion of risk, as allied to “older” maternity, was everywhere, and this premise was firmly held by many health professionals. I revisited the data and found that many participants had indeed been consumed with angst, which they related to “the risks they were facing,” and at this point I decided to reanalyze the data from a new lens, specifically seeking out notions of risk. I also looked specifically at the question, “What might have helped?” asked in the final interview, to see if participants were retrospec- tively providing answers on ways to provide more meaningful maternal support.

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DATA ANALYSIS

Data were systematically analyzed using thematic content analysis and followed the following steps. I (first author) read and reread the data and sought out statements and terms that seemed related to risk. Examples included, “The odds seemed stacked against us,” “I thought I was fine, til I found out about all the risks,” and “I realized I was in a bad category.” These terms and fragments were highlighted and moved together within individual accounts. Later when rereading gave me a broader understanding of individuals’ experience of risk, these highlighted areas were matched up with similar ideas from other women’s accounts and then within the body of data. At each stage, data were reduced to exclude words that detracted from key ideas. In this way, analysis progressed through increasingly higher levels of abstraction, until only themes and related fragments remained. Similar methods have been abundantly described in the literature surrounding qualitative research, for example, Bowling (2002), Clifford (1997), Downe- Wamboldt (1992), Graneheim and Lundman (2003), Holsti (1969), Morgan (1993), Patton (2002), and Robson (2002).

Through repeated discussion with colleagues in clinical practice and reflection, and reading and rereading of the reduced data, it eventually became clear to me that participants journeyed through distinct stages in relation to risk. Those stages were highlighted in identifying colors and separated out of the main body of data. Final data analysis involved the amalgamation of 4 separate themes: “realizing I was at risk,” “hoping for reassurance,” “dealing with uncertainty,” and “getting through it/negotiating risk.”

Findings

REALIZING I WAS AT RISK

Here, many participants described their prepregnancy health as above average, which is consistent with other studies of primiparae over 35 years (Berryman et al., 1999; Ventura, 1989). On interacting with the health system, however, these women often learned that, despite prepregnancy health, they were now regarded as being “at risk” related to their age. There is some suggestion within the literature that this labeling of “high risk” and “elderly primigravida” contributes to perceptions of heightened fetal vulnerability (Berryman et al., 1999; Payne, 2002), and a similar association is noted here. Participants describe their surprise at realizing they were considered to be at risk, despite their understanding of good health. Elizabeth (40 years) explains:

Before I had the baby I was very fit. I worked out at the gym and went to yoga and swimming regularly. I thought I would be pretty okay

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during pregnancy, especially since no one in my family had ever had any problems [having babies]. Then I went to see the doctor and he painted a very different picture. He said because of my age and all that, that he would need to see me more often and I would have to go to Clayton [tertiary facility] in case I needed an emergency delivery. He said I was more at risk. I walked out of there thinking, “Oh my God, the baby could die, I could die.”

Abigail (39), too, picked up on age-associated risk and felt her pregnancy was disadvantaged by her age:

I worried, too, about my age, I worried ’cause they said there was a greater chance that things could go wrong with the baby. I worried; I counted his fingers and toes. I think partly my age makes a difference in that I thought, “If something happens to our baby, you know, what chance have we got?”

And Carol (43) felt concerned that her pregnancy was particularly subject to loss, because of age-related physiological changes:

So far as my age is concerned, I’m in the top end of IVF. . . . I worried that I didn’t have enough of the right hormones to keep him. . . . it seemed like the odds were stacked against us. . . . All the reading was done out in percentages [of having a healthy term infant] and they just kept going down and down [related to advancing age]. . . . “God,” I thought, “I’m in a really bad category. . . ."

HOPING FOR REASSURANCE

Most women in this study were cared for in tertiary-level care, which seemed unrelated to “medical risk status.” This “choice” appeared to have been driven by both the women and care providers. Increased surveillance was common and, in turn, precipitated a snowball effect of testing and retesting. The women, well-educated, articulate, and Internet literate, for their part, often insisted on additional ultrasonic scans and genetic testing as reassurance for their perceivably vulnerable pregnancy. Although most women described being keen to know if anything was “wrong with the baby,” repeated testing seemed to fuel rather than alleviate anxiety. For example, Jane describes anxiously moving along from one test to the next, hoping for some reassuring news:

So at all these scans, I had one at 6 weeks, 12 weeks, 18 weeks, another one a week after that, and 33 weeks, and I would go hoping that they would say, “Everything’s fine, you don’t have to come back anymore. . . .” But I tended to look at the scans and, like I’ve no idea what I’m looking

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at, and I’d think, “Oh, that doesn’t look good!” I didn’t ask questions, I tended to just look at it, “What’s that flapping?” It can’t be right, there’s something wrong with that!"

The flapping Jane describes is the fetal heartbeat, though such was her fear when she attended her various scans and tests that she never asked for an explanation. Meanwhile, Elizabeth was so concerned about having an abnormal infant that she did everything in her power to prevent this from happening:

We decided we would make a final determination when we found out if anything was the matter with it, so we had some additional tests because we thought, there was no way. . . . I didn’t think I would want to bring a child into the world with all those problems. We’ve got a couple of friends who’ve given birth to children and at birth something happened to them. . . .

And Petra explains how each new test brought a new level of worry:

And you know, all those tests, I was sure they would find something wrong. We had the first scan and they found that the baby’s kidney was swollen, so we had to have more scans to check that was okay. Then they found a cyst on his head. That really worried me as we were advised to have the amnio, so we did that. It just seemed to go on and on . . . like one thing just led to another, and in the end it was all for nothing [nothing was wrong].

Jane describes the agony lurching from one test to another, hoping for good news: “I went through this sort of . . . being healthy, waiting for the next scan, praying he’s alright, but it does put . . . that urgency on you. . . .”

When the sought for reassurance did not eventuate, several participants described how they dealt with the uncertainty of “not knowing.”

DEALING WITH UNCERTAINTY

Here, most women addressed concerns about risk in one or both of two clearly defined ways: seeking out more information or suspending their emotional investment in the pregnancy. Some leaned particularly toward accessing information in a bid to be as fully informed and prepared as possible, and several went to impressive lengths to understand “what they were facing.” Some had read as many as 12 pregnancy and medical guides. A few women had read several more. This tendency was seen exclusively among career-orientated participants and, for these women, this was a normal work strategy. Rachel presents a case in point and discusses how at ultrasound that it was discovered that her baby had two vessels in the

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cord (rather than the more usual three). She describes her frustration in accessing information about this variance and, retrospectively, wishes she had not known:

I felt that every time they told about something that I had, like the one artery [in the cord] that was a different branch of research that I couldn’t get from them . . . I felt it would’ve been better for me not to know there was one artery, not to know. . . . Because of my PhD I am someone who likes to research. . . . I had to do all these searches to get any information and it was only in American books that I found reference to it. . . .

Jane muses on how she approached pregnancy, rationalizing that she could not do it any differently:

I suppose with work and all that. . . . like we’ve come to a certain point where we know a lot more than we would have 20 years ago, and we want to know, the risks and all that. . . . I don’t know if I could approach it any other way. . . . If my doctor didn’t give me enough information, I would’ve got it somewhere else. . . .

For many, keeping some distance from the pregnancy helped them to deal with the uncertainty of “not knowing.” For example, Carolyn describes not wanting to get too close to her twin babies when she was not sure what might eventuate:

The reason I don’t know what my babies are, whether they’re boys or girls is because I didn’t want to know. . . . For me it was if I knew they were two boys or two girls or boy and girl, I would start planning their life. And what happens if I didn’t make it to week 18? For me it was to prevent . . . not to get too close to them. . . . I can do that, just put things aside. . . . I had to. . . . At week 15 they told me I was AFP positive and I had gone to my ultrasound on Thursday and then he phoned, and whenever he phoned, it’s like, “Oh no, what now,. . .” and he said, “Now don’t worry, 95% of the women with alpha protein don’t have it (neural tubal defect), so you have 5% risk. . . .” It’s like a lottery. . . .

Jennifer worked at distracting herself from risk-related thoughts:

Well, that issue was worrying me, was she going to be okay? . . . It used to get into my head and I would just get up and do things so I didn’t have to think about it. . . . I’d watch a movie or I’d be doing things, I’d be cleaning up in the kitchen, ironing. . . .

Elizabeth on the other hand, took a more proactive approach and demanded a caesarean delivery:

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So I walked into the doctor and I said to him, “When we have this baby, I want to have a caesarean,” and he said, “What for?” and I said I wanted to counteract all these difficulties. I know that that’d be a real life sentence to have a child like that and that your life is, you know, the years have ticked on and you’ve now lost 10 more years of your life and it’s going to be taking up the next 20 years with a seriously difficult situation.

Even when the baby was born fit and well, many mothers continued to be overly concerned about the infant’s health and possible imminent demise. Most continued to read extensively; however, reading did little to allay their anxiety. Several displayed a limited understanding of normal neonatal behavior and a seeming inability to distinguish normal behavior from more significant concerns. This situation seems to be a consequence of understanding the baby to be at “high risk.” Professional attitudes were also identified by participants as adding to their dilemmas.

PROFESSIONAL ATTITUDES: ADDING TO THE DILEMMA

Although it should be pointed out that most women were happy with the care they received in hospital, several considered that health professionals were insensitive and dismissive of their concerns. Jane explains:

The gynecologist was far too dismissive for my liking! I would often leave there feeling like I didn’t get my questions answered, and felt like I’d been deprived a bit,. . .Like questions about what would happen if I had to have a caesarean, he dismissed me. . . . Everything I read or discussed with anyone else pointed that way, and if I mentioned it to him, he’d just say we’ll see later on, your health’s okay, don’t worry! And he would brush me off and I found that really frustrating.

This study also found that participants often would pretend they were managing well in the early postpartum period, rather than ask for assistance, particularly if the “vibes” from the midwife or carer were unfavorable. Many worried about asking “dumb questions.” Rachel had this to say:

Suddenly this baby’s there and I think there’s an expectation, a lot of the nursing staff. . . . because you’re older, [think] that you instinctively know what to do, but I don’t think you do. . . . It makes you sometimes feel a little bit inferior because you don’t know what to do . . . just a few looks or comments or whatever, you think, “Should I have known that? Was that a dumb sort of question?”

Others describe a difficulty in losing face and particularly valued respectful engagement. These women spoke of disliking to be patronized, spoken down to, or “told off” by nursing staff. Sally explains:

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I was just so fed up with the constant changing [advice]. That was probably the biggest problem, that week in the hospital and I’m the sort of person that I don’t like to be criticized and at this stage of your [sic] life, I’m 45, for goodness sake, I don’t like to be talked down to, and a lot of them [nurses] did, and I didn’t like that!

“GETTING THROUGH IT” NEGOTIATING RISK

Here, being at risk was experienced by mothers as something of a “crisis” related principally to perceptions of infant vulnerability and concerns of infant demise. This situation was mostly resolved by approx 4–6 months postpartum, however, and participants spoke of suddenly realizing that the infant was “just a baby,” rather than the enormous responsibility she or he had been until this point. At this stage, most participants had relaxed their approach to mothering and, interestingly, the infant seemed to bring about this change and help lessen the mother’s anxiety. Several women also had gained sufficient perspective to rationalize the risk for their particular situation. Abigail explains:

You know the first few months I used to bring her to the doctors probably every week, and I used to worry so much about SIDS and about her dying. . . . You know, it was risk, risk, risk and then nothing [no follow up]. You don’t sort of realize how nervous you’ve become. . . . I suppose for me the big turnaround came when she started smiling and, you know, she was glad to see me. . . . It made me realize sort of that she was a person . . . and that there was really no reason why she would just get sick. . . . I tried to remind myself that my mother raised all of us without hardly ever going to the doctor. . . . I mean, I still worry, but not anything like as much as at first. . . .

And Kerri found that as her baby grew she began to realize it was less fragile: “All of a sudden you just realize it’s just a baby, I’m not treating it like a China doll anymore. . . .”

Jane had this to say:

when I look back now, I don’t know how I got through it. . . . I was a nervous wreck before the baby was born. . . . It took a long while for me to forget that so many things could go wrong. . . . I remember thinking when he was born, “Phew, that worked, now I’ve just got to keep him [prevent him from dying]!” I went through this terrible worry about SIDS. I would check him a hundred times between feeds . . . and even things went through my mind, like what on earth if I die? I didn’t expect to go through the sort of anxiety I went through. . . . I talked to my sister a lot, ’cause we’ve always been really close, and that helped me a lot. She had her children when she was very young, and she sort of could see

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that what I was doing was because I was older and because of the IVF and thinking I’d never get through it [get through the pregnancy without miscarrying]. . . . I think with that support and Kevin, I guess growing and becoming what I perceived as stronger and not feeling as wobbly [better neck control], like you’ve got to be really careful in the beginning.

What Might Help?

During the final interview, women in this study were asked what might have helped during their transition to early motherhood. When revisiting the data for this article, specific suggestions related to negotiating risk were sought, and, overwhelmingly, mothers had suggested that having some positive information about mature mothers would have helped. These women described receiving information outlining age-related pregnancy risk, fetal disorders, and declining odds of successful fertility treatment. Most suggested that they perhaps were not so much empowered by having this information as terrified by the burden it imposed. Abigail explains:

I think that that the overemphasis on the problems that older women have is very destructive, and I really want to emphasize that point. It’s destructive to her capacity to just roll into the role [cope]. I already feel far more competent than a lot of women that are 10 years younger than me, but I was so afraid about whether this baby was going to be okay.

Having some positive information on mature mothering may have helped mothers gain a little perspective. Jane explains:

. . . like you telling me you knew someone who’s 48 having her first child, when you said that to me I thought, “Wow, isn’t that terrific, isn’t that brilliant?” It’s, like, amazing, because I wasn’t at any point when I was building up towards having Kevin. . . . That’d probably help a lot of people in our position, because there isn’t a lot of information, you know, on the view that over 40 or 45 you really still had hope. . . .

And Jennifer had this to say:

Well, that’s the other thing, with an older Mum, I think it would be lovely to have people who are older Mums that can actually talk, understand you, that have actually been [through it]. . . a lot of people don’t really understand. . . . I mean, you understand it because of the study and that sort of thing and hearing other people, if you’re not, if you’ve had your kids when you were younger and see someone else, it is very hard to . . . you sort of have to put your best foot forward so they don’t think you’re hopeless. . . .

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Many women also felt they would have benefited from having some easily accessible brief written information on on basic care such as how to settle an infant to sleep, and how to recognize an unwell infant might have proved helpful and allayed concern. Anthea and Jennifer explain:

I think they should discuss the safety, as in what happens if your baby chokes, or coughs, how do you cope? Or simple things like when they’re sick, don’t panic! It could be this, it could be this, how to recognize a sick baby. . . . It would help if you had some basic information to refer to.

We couldn’t get him to sleep, we didn’t know what to do, all this sort of stuff. . . . You come home with nothing [from the hospital]. Well, the babies don’t know what to do anyway, you don’t even have anything written out to [refer to] that gave me an idea of how long they should be sleeping, all that sort of thing and when, how many feeds. You really have to work all that out yourself. . . . You don’t know in the beginning that it’s not going to die of crying. Looking back now, I didn’t realize really how fragile I was. . . . If someone had just given us something [information] about how to get him to sleep. . . .

In retrospect, many recognized that initial worries related more to heightened anxiety during pregnancy than to any untoward event. Notwith- standing an initial anxious period, however, the women of this study were found to be proactive seekers of services and advice, and reported a successful though somewhat delayed transition to motherhood.

RESOURCEFUL AND PROACTIVE

Despite common understandings of mature primiparae as superanxious and prone to high levels of postnatal depression, participants here did not demonstrate high levels of postnatal maladjustment. Indeed, of the 22 mothers in this study, only one suffered from a minor degree of postnatal depression [PND], which is significantly less than the estimated national incidence of approximately 10%–20% of all new mothers (Bewley, 1999; Green, 1998). Although many participants identified an early need for additional professional and social support, most were confident and proactive in seeking assistance to meet their needs. Additionally, after an initial adjustment period, the women’s organizational skills and work experiences seemed to equip them well to deal with childcare dilemmas and decisionmaking. Gayle and Sally explain:

I’d always had to organize things at work, so the skills that were there actually came to the fore a bit with her. . . .

548 M. Carolan and S. Nelson

I would just go to plan B. I’ve been a project manager for many years, and we always come up with problems and hiccups and you get over them, so, fortunately, that’s my background. So, if there’s a hiccup, that’s okay, so what are my other options. My options are this, so let’s see if we can do that.

By 6–8 months most were overwhelmingly positive about their expe- riences and variously described mothering as the best thing they had ever done. Annie seems to sum up the mood:

I only have to look at her. It’s the best thing I’ve ever done in my life, it’s the most frightening thing I’ve ever done. . . . You know when people say I’ve done a lot of silly things, and I’ve done a lot of wrong things, but this is the best thing I’ve ever done in my life.

DISCUSSION

Many parallels are to be found among the experiences of this study’s participants and those of all new mothers, particularly in regard to new maternity as a time of disruption, anxiety, and chaos (Antonucci & Mikus, 1988; Barclay, Everitt, Rogan, Schmied, & Wyllie, 1997; Pridham & Chang, 1992). Some new information is also reported here, however, and it relates principally to the high levels of concern voiced by participants who all had healthy full-term pregnancies. A delayed though ultimately successful negotiation of risk is reported by these women, despite common perceptions of maladjustment. Some confounding factors, such as tensions between participants and health care professionals, also are discussed.

Overall, it is clear that the application of an “at-risk” label alters the experience of maternity for women aged 35+. For most, this means having restrictions placed on care options, such as being denied the option of care at a low-risk facility. Almost invariably, it means that the woman is exposed to increased pregnancy surveillance (Berryman et al., 1999; Windridge & Berryman, 1996), including additional screening tests (Muggli & Halliday, 2003; Bell, Campbell, Graham, Penney, Ryan, & Hall, 2001). In addition to extra screening, Bell and colleagues (2001) found that “older” first-time mothers were more likely to have an antenatal admission, more than two scans, amniocentesis, caesarean section, assisted delivery, induction, and augmentation than were younger women. At the same time, higher levels of intervention among older women were not explained by obstetric complications. Greater intervention in turn appears to affect higher rates of maternal morbidity (Albers, Lydon-Rochelle, & Krulewitch, 1995; Ecker, Chen, Cohen, Riley, & Lieberman, 2001; Freeman-Wang & Belski, 2002; Scholz et al., 1999) and so the care received by this group of women

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may become a self-fulfilling prophecy of greater intervention leading to poorer outcomes. Although it is not immediately apparent what drives this pattern, many explanations are posited. For example, Freeman-Wang and Beski suggest that “anxiety in both the mature mother and the obstetrician may be responsible for a greater degree of medical intervention” (2002, p. 41). Meanwhile, Albers and colleagues (1995) found an association between maternal social advantage and increased caesarean section rates. Others have suggested that decreasing maternal fertility and fertility treatment together impact on caesarean rate for primiparae older than 40 years (Scheiner, Shoham-Vardi, Hershkovitz, Katz, & Mazor, 2001), while still others suggest that medical fears spur the physician to greater caution with this group (Freeman-Wang & Belski, 2002).

Although it is not entirely clear that this group of women is truly at greater risk physiologically, it is clear that a small increase in risk appraisal may result in an inordinate emotional response in the mother (Baillie, Smith, Hewison, & Mason, 2000; Getz & Kirkengen, 2003; Watson, Hall, Langford, & Marteau, 2002). For example, Getz and Kirkengen (2003), who discussed differences in risk perception between physicians and women, suggested that “to the clinician, risk retains the character of a population-based number, but to the individual pregnant woman, the population base is one, herself, and ‘one in a hundred’ means that she can be the one” (p. 2051). This situation of being considered at risk and being referred for additional tests caused participants in this study considerable angst, and many described entering maternity as “nervous wrecks.” Many dealt with anxiety by seeking out more information, and women discussed reading avidly, conducting Internet searches, and seeking information from doctor’s surgeries and hospitals. Nonetheless, this access to information did little to reassure them and instead seemed to heighten anxieties. Moreover, the largely medical-type information favored by well-educated women in this study seemed to alert them to myriad additional possible complications in the fetus. Lesser educated women here, although also concerned, seemed to embrace a less expansive range of worries and tended to access information on a “need to know” basis. Similar findings of greater information searching among well-educated and well-resourced women are reported in the literature, for example, Deutsch, Brooks-Gunn, Fleming, Ruble, and Stangor (1988); Gottesman (1992); Mercer (1986); and Viau, Padula, and Eddy (2002).

Some participants considered that professional attitudes and misun- derstandings contributed to their dilemmas, and several discussed mid- wives/nurses and doctors as dismissive of their concerns, particularly minor worries and attention to detail such as, “How long should I burp my baby for?” These attitudes can perhaps be explained by busy workloads and also by the fact that the facility in which the participants gave birth also cared for seriously ill pregnant women, some of whom had life-threatening conditions. In this major hospital, the minor concerns and time-consuming questions

550 M. Carolan and S. Nelson

of the mature primipara may have been given little priority by midwives and other health professionals when compared with other “real” concerns. Additionally, extensive worries and “knowing too much” caused a certain percentage of participants to challenge health professionals, many of whom did not know the latest research on every obscure event. This degree of knowledge acquisition is frequently understood by health professionals as problematic and inappropriate, and as contributing to the difficulties mature mothers face (Dobrzykowski, 1998). Indeed, health professionals often find well-informed mature primiparae to be a challenging and demanding group to care for, and, in this study, a sense of antagonism arose between health professionals and participants. Career women particularly were extremely knowledgeable about all sorts of eventualities and seemed to then distrust health professionals who were unable to answer their questions. Together these factors made for a tumultuous initial postpartum period. A resolution of sorts ultimately was brought about by the mothers themselves and related to the women “working through” the risk rather than having their needs met by health care regimes.

CONCLUSION

This research is a beginning in identifying the special needs of mature first-time mothers, particularly career-orientated postponers. These women represent a new social group and, as such, do not fit within contemporary Western notions of maternity. Nonetheless, they are a growing cohort, particularly in affluent countries, and it is important that health professionals learn as much as possible about the needs and experiences of this group of mothers in order to better support their transition to motherhood. There is some evidence to suggest that current health care regimes do not cater well to their needs and also that professional preconceptions and misunderstandings affect their experiences of maternity. Close attention to the experiences described and recommendations made by participants here may shed some light on the unique experiences and challenges of first-time mothering over 35 years. New understandings gained here may thus inform future nursing and medical care for this group of women.

Finally, notions of risk impact negatively on mature mothers in terms of concern and additional surveillance. At the same time, it is not clear just how advanced maternal age alone contributes to risk in a healthy cohort. It is therefore important that current perceptions of maternal age, as a predictor of pregnancy risk, are challenged. Further broad-based studies are needed to establish the true level of risk for healthy mature childbearing women.

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REFERENCES

Albers, L., Lydon-Rochelle, M., & Krulewitch, C. (1995). Maternal age and labor complications in healthy primigravidas at term. Journal of Nurse-Midwifery, 40(1), 4–12.

Amarin, V., & Akasheh, H. (2001). Advanced maternal age and pregnancy outcome. Source Eastern Mediterranean Health Journal, 7(4/5), 646–651.

Anderson, A., Wohlfahrt, J., Christens, P., Olsen, J., & Melbye, M. (2000). Maternal age and fetal loss: Population based register linkage study. British Medical Journal, 320, 1708–1712.

Antonucci, T., & Mikus, K. (1988). The power of parenthood: Personality and attitudinal changes during the transition to parenthood. In G. Michaels & W. Goldberg (Eds.), Transition to parenthood: Current theory and research (pp. 62–84). New York: Cambridge University Press.

Ataullaha, I., & Freeman-Wang, T. (2005). The older obstetric patient. Current Obstetrics & Gynaecology, 15, 46–53.

Australian Bureau of Statistics (ABS). (2000). 3301 Australian births 1999. Canberra: Australian Government Press.

Australian Bureau of Statistics (ABS). (2003). 3301.0 Births, Australia 2002. Canberra: Australian Government Press.

Australian Institute of Health and Welfare (AIHW), N.P.S.U. (2000). PER15. Canberra: Australian Government Press.

Baillie, C., Smith, J., Hewison, J., & Mason, J. (2000). Ultrasound screening for chromosomal abnormality: Women’s reactions to false positive results. British Journal of Health Psychology, 5, 377–394.

Barclay, L., Everitt, L., Rogan, F., Schmied, V., & Wyllie, A. (1997). Becoming a mother—An analysis of women’s experiences of early motherhood. Journal of Advanced Nursing, 25(4), 719–728.

Barkan, S., & Bracken, M. (1987). Delayed childbearing: No evidence for increased risk of low birth weight and preterm delivery. American Journal of Epidemiol- ogy, 125, 101–109.

Barton, J., Bergauer, N., Jacques, D., Coleman, S., Stanziano, G., & Sibai, B. (1997). Does advanced maternal age affect pregnancy outcome in women with mild hypertension remote from term? American Journal of Obstetrics and Gynecology, 176, 1236–1243.

Beaulieu, A., & Lippman, A. (1995). Everything you need to know: How women’s magazines structure prenatal diagnosis for women over 35. Women & Health, 23(3), 59–74.

Bell, J., Campbell, D., Graham, W. J., Penney, G., Ryan, M., & Hall, M. (2001). Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? BJOG: an International Journal of Obstetrics & Gynaecology, 108(9), 910.

Berkowitz, G., Shovron, M., Lapinski, R., & Berkowitz, R. (1993). Does delayed childbearing increase risk? Journal of the American Medical Association, 269(6), 745–748.

Berryman, J., Thorpe, K., & Windridge, K. (1999). Mature mothers, conception, pregnancy and birth after 35. London: Harper Collins Publishers.

552 M. Carolan and S. Nelson

Bewley, C. (1999). Postnatal depression. Nursing Standard, 13, 49–56. Bobrowski, R., & Bottoms, S. (1995). Under appreciated risks of the elderly multipara.

American Journal of Obstetrics and Gynecology, 172, 1764–1770. Bonellie, S. (2001). Effect of maternal age, smoking and deprivation on birth weight.

Paediatric and Perinatal Epidemiology, 15(1), 19–26. Bowling, A. (2002). Research methods in health: Investigating health and health

services. Philadelphia: Open University Press. Carolan, M. C. (2005a). Doing it properly: The experience of first mothering over

35. Unpublished doctoral dissertation, University of Melbourne, Melbourne, Australia.

Carolan, M. C. (2005b). Doing it properly: The experience of first mothering over 35. Health Care for Women International, 26(9), 764–787.

Clifford, C. (1997). Qualitative research methodology in nursing and health care. New York: Churchill Livingstone.

Cnattingius, S., Forman, M., Berendes, H., & Isotalo, L. (1992). Delayed childbearing and risk of adverse perinatal outcome. Journal of the American Medical Association, 268(7), 886.

Cunningham, G., & Leveno, K. (1995). Childbearing among mature women—The message is cautiously optimistic. The New England Journal of Medicine, 333(15), 1002–1004.

Daniels, P., & Weingarten, K. (1982). Sooner or later: The timing of parenthood in adult lives. New York: Norton.

Deutsch, F., Brooks-Gunn, J., Fleming, A., Ruble, D., & Stangor, C. (1988). Information seeking and maternal self-definition during the transition to motherhood. Journal of Personality and Social Psychology, 55, 420– 421.

Dildy, G., Jackson, G., Fowers, G., Oshiro, B., Varner, M., & Clark, S. (1996). Very advanced maternal age: Pregnancy after age 45. American Journal of Obstetrics and Gynecology, 175, 668–674.

Dobrzykowski, T. (1998). The spiralling process of childbirth after the age of 30: Mature mothering and no unfinished business. Unpublished doctoral dissertation. School of Nursing, Indiana University, South Bend, IN.

Dobrzykowski, T., & Stern, P. (2003). Out of sync: A generation of first time mothers over 30. Health Care for Women International, 24, 242–253.

Downe-Wamboldt, B. (1992). Content analysis: Method, applications, and issues. Health Care for Women International, 13(3), 313–321.

Ecker, J., Chen, K., Cohen, A., Riley, L., & Lieberman, E. (2001). Increased risk of cesarean delivery with advancing maternal age: Indications and associated factors in nulliparous women. American Journal of Obstetrics and Gynecology, 185, 883–887.

Fisher, J., Feekery, C., Amir, L., & Sneddon, M. (2002). Health and social circumstances of women admitted to a private mother baby unit: A descriptive cohort study. Australian Family Physician, 31(10), 966–970.

Freeman-Wang, T., & Beski, S. (2002). The older obstetric patient. Current Obstetrics & Gynaecology, 12, 41–46.

Fretts, R. (2001). Maternal age and fetal loss: Mature women have increased risk of unexplained fetal deaths. British Medical Journal, 322, 430.

Questioning the Risk 553

Getz, L., & Kirkengen, A. (2003). Ultrasound screening in pregnancy: Advancing technology, soft markers for fetal chromosomal aberrations, and unacknowl- edged ethical dilemmas. Social Science and Medicine, 56(10), 2045–2057.

Gottesman, M. (1992). Maternal adaptation during pregnancy among early, middle and late childbearers: Similarities and differences. Maternal-Child Nursing Journal, 20(2), 93–110.

Graneheim, U. H., & Lundman, B. (2003). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105–112.

Green, J. (1998). Postnatal depression or perinatal dysphoria? Journal of Reproductive and Infant Psychology, 16, 143–155.

Hanson, B. (2003). Questioning the construction of maternal age as a fertility problem. Health Care for Women International, 24, 166–176.

Harker, L., & Thorpe, K. (1992). ‘The last egg in the basket’: Elderly primiparity—A review of the findings. Birth, 19(1), 23–30.

Heffner, L. (2004). Advanced maternal age—How old is too old? The New England Journal of Medicine, 351(19), 1927–1929.

Hewlett, S. (2002a). Creating a life: Professional women and the quest for children. New York: Talk Miramax.

Hewlett, S. (2002b). Executive women and the myth of having it all [Electronic version]. Harvard Business Review On Point (product no. 9616).

Hollier, L., Leveno, K., Kelly, M., McIntire, D., & Cunningham, F. (2000). Maternal age and malformations in singleton births. Obstetrics and Gynecology, 96(5), 701–706.

Holsti, O. R. (1969). Content analysis for the social sciences and humanities. New York: Addison-Wesley.

Jacobsson, B., Ladfors, L., & Milsom, I. (2004). Advanced maternal age and adverse perinatal outcome. Obstetrics & Gynecology, 104(4), 727–733.

Kullmer, U., Zygmunt, M., Munstedt, K., & Lang, U. (2000). Pregnancies in primiparous women 35 or mature: Still risk pregnancies? Geburtshilfe und Frauenheilkunde, 60(11), 569–575.

Lupton, D. (1999). Risk. London: Routledge. Mansfield, P., & McCool, W. (1989). Toward a better understanding of the “advanced

maternal age” factor. Health Care for Women International, 10(4), 395–415. Mercer, R. (1986). First time motherhood; Experiences from teens to forties. New York:

Springer. Morgan, D. L. (1993). Qualitative content analysis: A guide to paths not taken.

Qualitative Health Research, 3, 112–121. Morrison, J., Najman, J., Williams, G., Keeping, J., & Anderson, H. (1989). Socio-

economic status and pregnancy outcome: An Australian study. British Journal of Obstetrics and Gynecology, 96, 298–307.

Muggli, E., & Halliday, J. (2003). Report on prenatal diagnostic testing in Victoria 2002. Melbourne: Murdoch Children’s Research Institute.

Najman, J., Lanyon, A., Andersen, M., Williams, G., Bor, W., & O’Callaghan, M. (1998). Socioeconomic status and maternal cigarette smoking before, during and after a pregnancy. Australian and New Zealand Journal of Public Health, 22(1), 60–66.

554 M. Carolan and S. Nelson

National Statistics U.K. (2001). Social trends. London: Her Majesty’s Stationary Office. Nicholson, P. (1998). Post-natal depression: Psychology, science and the transition to

motherhood. London: Routledge. Neumann, M., & Graf, C. (2003). Pregnancy after age 35: Are these women at high

risk? AWHONN Lifelines, 7(5), 422–430. Neurgarten, B., & Datan, N. (1973). Sociological perspectives on the life cycle. In

P. Baltes & K. Schaie (Eds.), Life span development psychology: Personality and socialization (pp. 53–69). New York: Academic Press.

Ozer, E. (1995). The impact of childcare responsibility and self-efficacy on the psychological health of professional working mothers. Psychology of Women Quarterly, 19, 315–335.

Patton, M. Q. (2002). Qualitative research & evaluation methods. Thousand Oaks, CA: Sage.

Payne, D. (2002).. The elderly primigravida: Contest and complexity. Unpublished doctoral dissertation, Palmerston North, New Zealand: Massey University

Pollock, J. (1996). Mature maternity: Long term associations in first children born to mature mothers in 1970 in the UK. Journal of Epidemiology and Community Health, 50(4), 429–435.

Pridham, K., & Chang, A. (1992). Transition to being the mother of a new infant in the first 3 months: Maternal problem solving and self appraisals. Journal of Advanced Nursing, 17, 204–216.

Prysak, M., Lorenz, R., & Kisly, A. (1995). Pregnancy outcome in nulliparous women 35 years and older. Obstetrics and Gynecology, 85(1), 65–70.

Raum, E., Arabin, B., Schlaud, M., Walter, U., & Schwartz, F. (2001). The impact of maternal education on intrauterine growth: A comparison of former West and East Germany. International Journal of Epidemiology, 30, 81–87.

Richman, A., Miller, P., & LeVine, R. (1992). Cultural and educational variations in maternal responsiveness. Developmental Psychology, 28(4), 614–621.

Robson, C. (2002). Real world research: A resource for social scientists and practitioner-researchers. Oxford: Blackwell.

Rossi, A. (1980). Life span theory and women’s lives. Signs: Journal of women in Culture and Society, 6, 4–32.

Scheiner, E., Shoham-Vardi, I., Hershkovitz, R., Katz, M., & Mazor, M. (2001). Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. American Journal of Obstetrics and Gynecology, 185, 888–892.

Scholz, H., Haas, J., & Petru, E. (1999). Do primiparas aged 40 years or older carry an increased obstetric risk? Preventive Medicine, 29(4), 263–266.

Sibai, B., Ewell, M., Levine, R., Klebanoff, M., Esterlitz, J., Catalano, P., Goldenberg, R., & Joffe, G. (1997). Risk factors associated with pre-eclampsia in healthy nulliparous women. American Journal of Obstetrics and Gynecology, 177, 1003– 1010.

Smit, Y., Scherjon, S., & Treffers, P. (1997). Elderly nulliparae in midwifery care in Amsterdam. Midwifery, 13, 73–77.

Spellacy, W., Miller, S., & Winegar, A. (1986). Pregnancy after 40 years of age. Obstetrics and Gynecology, 68, 452–454.

Questioning the Risk 555

Stark, M. A. (1997). Psychosocial adjustment during pregnancy: The experience of mature gravidas. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26(2), 206–211.

Tan, K. T., & Tan, K. H. (1994). Pregnancy and delivery in primigravidae aged 35 and over. Singapore Medical Journal, 35, 495–501.

U.S. Center for Disease Control and Prevention. (2001). Births: Final data for 1999 National Vital Statistics Report Vol. 49, No. 4. Atlanta, GA: Author.

Ventura, S. (1989). First births to older mothers. American Journal of Public Health, 79, 1675.

Viau, P., Padula, C., & Eddy, B. (2002). An exploration of the health concerns and health promotion behaviors in pregnant women over age 35. The American Journal of Maternal/Child Nursing, 27(6), 328–334.

Waters, E., & Wager, H. (1950). Pregnancy and labor experiences of elderly primigravidas. American Journal of Obstetrics and Gynecology, 59, 296–304.

Watson, M., Hall, S., Langford, K., & Marteau, T. (2002). Psychological impact of the detection of soft markers on routine ultrasound scanning: A pilot study investigating the modifying role of information. Prenatal Diagnosis, 22(7), 569– 575.

Welles-Nystrom, B. (1997). The meaning of postponed motherhood for women in the United States and Sweden: Aspects of feminism and radical timing strategies. Health Care for Women International, 18(3), 279–299.

Wildschut, H. (1999). Sociodemographic factors: Age, parity, social class and ethnicity. In D. James, P. Steer, C. Weiner, & B. Gonik (Eds.), High risk pregnancy (pp. 39–52). London: W.B. Saunders.

Windridge, K. C., & Berryman, J. C. (1999). Women’s experience of giving birth after 35. Birth, 26(1), 16–23.

Windridge, K. C., & Berryman, J. C. (1996). Maternal adjustment and maternal attitudes during pregnancy and early motherhood in women 35 and older. Journal of Reproductive and Infant Psychology, 14, 45–55.