Advanced maternal age (AMA) is defined as childbearing in mothers ≥35 years of age and is becoming increasingly prevalent in high income countries. AMA has been associated with increased risk of adverse pregnancy outcomes, particularly stillbirth. Although AMA mothers have higher rates of chromosomal abnormalities and maternal co-morbidities, AMA remains an independent risk factor for stillbirth. Despite these findings, the etiology behind this increased risk is unknown. We hypothesise that an altered maternal environment, including increased oxidative stress and inflammation, due to ageing causes placental dysfunction which increases AMA mothers’ vulnerability to stillbirth. A holistic approach was applied to investigate placental dysfunction in AMA. Firstly, a systematic review and meta-analysis comprehensively reviewed existing data on AMA and associated adverse pregnancy outcomes. Secondly, Manchester Advanced Maternal Age Study (MAMAS), a multi-centre prospective observational cohort study, was conducted to investigate risk factors for composite adverse pregnancy outcome (CAPO) in AMA. MAMAS utilised both uni- and multivariate analysis on demographic and clinical data, and measuring biomarkers of ageing and placental dysfunction by ELISA in maternal circulation during the third trimester of pregnancy. Utero-placental dysfunction was directly investigated in uncomplicated AMA pregnancies by quantifying placental morphology, placental nutrient transport capabilities and both placental and maternal uterine vascular responses. Finally, a C57BL/6J murine model of AMA was developed and characterised to further investigate maternal age on pregnancy outcome and the role of the placenta. In the meta-analysis, maternal age was linearly associated with increased risk of stillbirth and other adverse outcomes strongly associated with placental dysfunction (fetal growth restriction, preeclampsia and placental abruption). In MAMAS, smoking status and primiparity were predictive of CAPO. After adjustment, AMA mothers had an odd ratio of 2.05-3.43 of CAPO compared to 20-30 year old mothers. AMA mothers showed evidence of increased oxidative stress and pro-inflammatory bias. AMA mothers who suffered CAPO showed reduced placental endocrine capacity seen in placental dysfunction. Placentas from uneventful AMA pregnancies showed evidence of accelerated ageing and placental adaptation with increased nutrient transport, increased placental weight but reduced efficiency, and altered vascular function. AMA mice showed many similar aspects to human AMA with increased fetal loss, fetal growth restriction and increased placental size. These studies provide robust evidence for increased incidence of adverse pregnancy outcome due to placental dysfunction in pregnancies of women of AMA. This finding requires the appropriate recognition in a clinical context, with a greater focus on personalised obstetric care in an attempt to reduce stillbirth rates in this high risk population. By optimising antenatal and obstetric care for AMA mothers, we could reduce stillbirth rates by 4.7% - the population attributable risk due to AMA. These studies highlight key areas of future research that will further understanding into stillbirth risk in AMA pregnancy, test predictive models and test therapies and clinical care interventions an ultimately improve pregnancy outcome in mothers of AMA.

Introduction: The past decade has seen a significant shift in the demographics of childbearing in the United States. The average age of women at first birth has steadily increased over the last four decades, with the birth rate for women aged 40-44 more than doubling from 1990 to 2012. The aim of this study was to evaluate the risk of adverse pregnancy outcomes with increasing maternal age and paternal age using national health statistics data. Methods: The study population included 3 495 710 live births among women 15-54+ years of age from the 2012 Natality dataset. Outcomes were modeled for both maternal and paternal 5-year age groups using logistic regression analysis to calculate adjusted and unadjusted odds ratios (AORs, ORs) with 95% confidence intervals. Analysis was performed to examine the association between maternal and paternal age across seven different adverse outcomes, including low birthweight, low Apgar score, early term pregnancies, abnormal newborn conditions and presence of congenital anomalies. Results: The risks for most outcomes paralleled with advanced maternal age and paternal age. Logistic regression models demonstrated that maternal age groups 40-44, 45-49 and 50-54+ were at highest risk for an adverse pregnancy outcome compared to the 30-34 year old reference group. Abnormal newborn conditions including assisted ventilation, NICU admission and use of antibiotics were significant for all age groups 40 and older. Low Apgar score, low birthweight and early term pregnancies were significantly higher among mothers as well as fathers with advanced age. Conclusions: These findings suggest that advanced maternal age is a risk factor for a variety of adverse pregnancy outcomes. Women aged 35-39 have a similar risk of an adverse outcome as their younger counterparts. This suggests that perhaps we should begin assessing high-risk pregnancies as starting at an older age versus the de facto standard of 35.

Many women aged 20-30 are postponing their first pregnancies until their mid 30s and beyond, which has resulted in compressed childbearing years and/or infertility. Little is known about the knowledge and understanding that Canadian women of advanced age (age 35-45) possess of their reproductive capacity. This phenomenological study sought to explore these women's knowledge and perception of their reproductive capacity in relation to the timing of first pregnancy. Research questions using the constructs of Ajzen's theory of planned behavior were developed to explore how the behavioral, normative, and control beliefs of women's childbearing behaviors were based on their perceptions of their reproductive capacity. A purposeful sample of 10 participants provided data in semistructured interviews about their lived experiences of being pregnant for the first time at an advanced age. Thematic analysis was used to analyze interview transcripts. Emergent themes derived from the data included being naïve about natural conception, use of fertility specialist, discussions of childbearing plans by family doctors, lacking energy to care for young children, and feeling judged by others. Results indicated inaccuracies in the women's factual knowledge in terms of the narrow window for fertility, chances of natural conception, the impact of long-term use of contraception, and the use of artificial reproductive technologies to compensate for age-related fertility decline. This study may promote positive social change by offering healthcare providers information that assists them in tailoring reproductive messages for patients that dispel misconceptions regarding women's reproductive potential, which may reduce the number of women experiencing involuntary childlessness and infertility

Muitas mulheres estão adiando a maternidade até a 4ª ou 5ª década de vida, um fenômeno mundial. O objetivo do estudo foi avaliar resultado da gestação em 281 mulheres com 40 anos ou mais, atendidas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre Julho de 1998 e Julho de 2005. A incidência de diabetes gestacional e doença hipertensiva específica da gestação (DHEG) foi de 14,6% e 19,6%, respectivamente. Dezessete (6,0%) mulheres tiveram abortamento e 4 (1,4%) óbito fetal. Três recém-nascidos apresentavam síndrome de Down e 6 outras malformações (índice de detecção de 88,9%). Mulheres com DHEG tiveram maior risco para fetos com baixo peso. História prévia de hipertensão não foi fator de risco para DHEG. Gestantes com DHEG ou diabetes gestacional não apresentaram risco maior para parto pré-termo. Obesidade foi fator de risco para diabetes gestacional. Mulheres sem companheiro e nulíparas tiveram maior incidência de malformações e baixos índices de Apgar. Mulheres com idade materna muito avançada (maior ou igual a 45 anos) apresentaram incidência maior de óbito fetal e de índice de Apgar baixo. A assistência pré-natal específica possibilita a detecção das complicações maternas e a instituição precoce do tratamento / Many women are delaying childbearing until the fourth or fifth decade in life, and it has become a common and worldwide phenomenon. The aim of this study is to evaluate pregnancy outcome in women of 40 or older who were care at our institution. During the period from July 1998 to July 2005 a total of 281 women with advanced maternal age presenting at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were studied. The incidence of gestational diabetes and preeclampsia was 14.6% e 19.2%, respectively. Seventeen women had miscarriage (6.0%) and four presented fetal death (1.4%). There were three infants with Down syndrome and six with other anomalies (detection rate of 88.9%). Women presenting preeclampsia were at higher risk for presenting low birthweight. Previous history of hypertension was not a risk factor for preeclampsia. Pregnant women with gestational diabetes or preeclampsia did not carry a higher risk for preterm delivery. Obesity was a significant prognostic factor for gestational diabetes. Nulliparous and single women had higher incidence of fetal anomalies and low Apgar score. Women with very advanced maternal age (>= 45 years old) had higher rate of fetal death and low Apgar score. Prenatal care devoted for women with advanced maternal age allows an early detection and treatment of adverse maternal-fetal outcomes.

Muitas mulheres estão adiando a maternidade até a 4ª ou 5ª década de vida, um fenômeno mundial. O objetivo do estudo foi avaliar resultado da gestação em 281 mulheres com 40 anos ou mais, atendidas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre Julho de 1998 e Julho de 2005. A incidência de diabetes gestacional e doença hipertensiva específica da gestação (DHEG) foi de 14,6% e 19,6%, respectivamente. Dezessete (6,0%) mulheres tiveram abortamento e 4 (1,4%) óbito fetal. Três recém-nascidos apresentavam síndrome de Down e 6 outras malformações (índice de detecção de 88,9%). Mulheres com DHEG tiveram maior risco para fetos com baixo peso. História prévia de hipertensão não foi fator de risco para DHEG. Gestantes com DHEG ou diabetes gestacional não apresentaram risco maior para parto pré-termo. Obesidade foi fator de risco para diabetes gestacional. Mulheres sem companheiro e nulíparas tiveram maior incidência de malformações e baixos índices de Apgar. Mulheres com idade materna muito avançada (maior ou igual a 45 anos) apresentaram incidência maior de óbito fetal e de índice de Apgar baixo. A assistência pré-natal específica possibilita a detecção das complicações maternas e a instituição precoce do tratamento / Many women are delaying childbearing until the fourth or fifth decade in life, and it has become a common and worldwide phenomenon. The aim of this study is to evaluate pregnancy outcome in women of 40 or older who were care at our institution. During the period from July 1998 to July 2005 a total of 281 women with advanced maternal age presenting at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo were studied. The incidence of gestational diabetes and preeclampsia was 14.6% e 19.2%, respectively. Seventeen women had miscarriage (6.0%) and four presented fetal death (1.4%). There were three infants with Down syndrome and six with other anomalies (detection rate of 88.9%). Women presenting preeclampsia were at higher risk for presenting low birthweight. Previous history of hypertension was not a risk factor for preeclampsia. Pregnant women with gestational diabetes or preeclampsia did not carry a higher risk for preterm delivery. Obesity was a significant prognostic factor for gestational diabetes. Nulliparous and single women had higher incidence of fetal anomalies and low Apgar score. Women with very advanced maternal age (>= 45 years old) had higher rate of fetal death and low Apgar score. Prenatal care devoted for women with advanced maternal age allows an early detection and treatment of adverse maternal-fetal outcomes.

Bakgrund: Förstföderskors ålder ökar i höginkomstländer och med stigande ålder ökar risken för graviditetsrelaterade komplikationer. Även andelen interventioner som avser att sätta igång, förstärka progressen och övervaka den fysiologiska förlossningsprocessen ökar. Syfte: Syftet med examensarbetet var att undersöka om antalet interventioner och förlossningsutfall vid ett medelstort sjukhus i västra Sverige skiljer sig mellan äldre förstföderskor (≥35 år) och yngre förstföderskor (20–24 år) med spontan värkstart. Metod: Examensarbetet var en kvantitativ retrospektiv tvärsnittsstudie där data samlats in under ett år. Materialet som bestod av 232 förstföderskor bearbetades med deskriptiv och jämförande statistiska analyser. Resultat: Det var vanligare att äldre förstföderskor fick utökad fosterövervakning och att de födde barn som vägde 4500 gram eller mer jämfört med yngre förstföderskor. Oavsett ålder födde förstföderskorna vanligtvis vaginalt och interventioner som värkstimulerande dropp och skalpelektrod användes vid runt hälften av förlossningarna. Slutsats och klinisk tillämpbarhet: Få signifikanta skillnader fanns mellan de jämförda åldersgrupperna. Examensarbete visade att det behövs en individuell bedömning av varje kvinna eftersom åldersförändringar sker gradvis. Som barnmorska måste man beakta att ålder bara är en faktor i bedömningen av den födande kvinnan och vara medveten om att man påverkas av den kulturella kontexten och organisationen. / Background: The age of first-time mothers increases in high-income countries and with increasing age, the risk of pregnancy related complications gets more common. The proportion of interventions that are needed to initiate, strengthen and monitor the psychological birth process is also increasing. Aim: The aim of this study was to investigate if interventions and delivery outcomes differ between older nulliparous women (≥35 years) and younger nulliparous women (20–24 years) with spontaneous onset of labor. Method: We conducted a quantitative retrospective cross-sectional study where data were collected from a hospital in Sweden. The material, which consisted of 232 nulliparous women, was processed with descriptive and comparative statistical analyzes. Results: In our study, we found that older nulliparous women more often received extended fetal monitoring and gave birth to babies weighing 4,500 grams or more compared to younger nulliparous women. Regardless of age, nulliparous gave birth vaginally and interventions such as administration of oxytocin and fetal scalp electrodes were used in around half of the births. Conclusion and clinical implications: There were few significant differences between the compared age groups. Our study didn’t show large differences between the age groups, however, research shows that age is a risk factor. As a midwife, you must consider that age is only one factor in assessing the woman giving birth.

Des études récentes ont démontré une augmentation de la prévalence de l’infertilité au Canada ainsi qu’une augmentation fulgurante de l’utilisation de la procréation assistée. Le Québec s’est doté en 2010 d’un programme de financement de la procréation assistée visant un accès universel ainsi que la protection de la santé des mères et des enfants. Les diverses parties prenantes attribuent un certain nombre de lacunes à ce programme, incluant l’absence de mesures de prévention et de promotion de la santé visant à réduire la prévalence de l’infertilité. En effet, une proportion significative de cas d’infertilité découle de facteurs modifiables et relatifs aux modes de vie tels que le tabagisme, les infections transmises sexuellement et par le sang, les problèmes de poids, les toxines environnementales et l’âge. De plus, l’âge maternel avancé ainsi que l’usage de la procréation assistée comportent des risques pour la santé des mères et des enfants au sujet desquels la population ne possède pas une connaissance suffisante. Des approches en amont ont été proposées par diverses organisations et dans divers pays, toutefois, peu ont été adoptées. Force est de constater que ces initiatives représentent de grands défis au point de vue de l’acceptabilité sociale, en raison de la nature sensible du sujet et d’une grande valorisation sociale de l’autonomie reproductive. L’éthique des communications en santé permet d’identifier ces défis qui touchent l’usage de tactiques persuasives, le risque de stigmatisation et l’attribution indue d’une responsabilité. Si leur élaboration tient compte de ces enjeux, les campagnes de communications en santé ont le potentiel d’informer adéquatement la population afin de favoriser l’autonomie et la santé reproductive des individus, sans causer de dommage iatrogénique. L’éthique de l’ « empowerment », qui requiert l’attribution d’une responsabilité individuelle de nature prospective, l’apport de ressources concrètes et l’implication des communautés, permet d’identifier les besoins en termes de solutions législatives favorisant des contextes socioéconomiques qui soutiennent la santé reproductive et l’autonomie reproductive. / Recent studies have demonstrated an increased prevalence of infertility in Canada and a tremendous growth in assisted reproductive technologies use. In 2010, the Quebec government launched a public funding program for assisted reproductive technologies, which aims to provide equitable access and to protect the health of mothers and children. Various stakeholders have identified a number of shortcomings to this program, including the absence of prevention and health promotion measures aimed towards reducing the prevalence of infertility. Indeed, a significant proportion of infertility cases is attributable to modifiable and lifestyle related factors such as smoking, sexually transmitted infections, weight problems, environmental toxins and age. In addition, both advanced maternal age and assisted reproductive technologies utilization pose risks to the health of mothers and children, about which the population is not adequately informed. Preventative approaches have been proposed by many organizations in various countries but few have been implemented. A reason for this might be that these initiatives represent major challenges in terms of social acceptability, due to the sensitive nature of the subject and the strong social respect for reproductive autonomy. Health communication ethics highlights these issues such as the use of persuasive tactics, the risk of stigmatization, and undue attribution of responsibility. If designed effectively with these challenges in mind, health communication campaigns for infertility prevention have the potential to adequately inform the public, thus fostering reproductive autonomy and health, without causing iatrogenic damage. The ‘ethics of empowerment’, with its requirements for assigning only prospective individual responsibility, providing concrete resources and involving communities in social change, helps in identifying the needs for policy solutions that address the social context in order to enhance reproductive health and reproductive autonomy.

Des études récentes ont démontré une augmentation de la prévalence de l’infertilité au Canada ainsi qu’une augmentation fulgurante de l’utilisation de la procréation assistée. Le Québec s’est doté en 2010 d’un programme de financement de la procréation assistée visant un accès universel ainsi que la protection de la santé des mères et des enfants. Les diverses parties prenantes attribuent un certain nombre de lacunes à ce programme, incluant l’absence de mesures de prévention et de promotion de la santé visant à réduire la prévalence de l’infertilité. En effet, une proportion significative de cas d’infertilité découle de facteurs modifiables et relatifs aux modes de vie tels que le tabagisme, les infections transmises sexuellement et par le sang, les problèmes de poids, les toxines environnementales et l’âge. De plus, l’âge maternel avancé ainsi que l’usage de la procréation assistée comportent des risques pour la santé des mères et des enfants au sujet desquels la population ne possède pas une connaissance suffisante. Des approches en amont ont été proposées par diverses organisations et dans divers pays, toutefois, peu ont été adoptées. Force est de constater que ces initiatives représentent de grands défis au point de vue de l’acceptabilité sociale, en raison de la nature sensible du sujet et d’une grande valorisation sociale de l’autonomie reproductive. L’éthique des communications en santé permet d’identifier ces défis qui touchent l’usage de tactiques persuasives, le risque de stigmatisation et l’attribution indue d’une responsabilité. Si leur élaboration tient compte de ces enjeux, les campagnes de communications en santé ont le potentiel d’informer adéquatement la population afin de favoriser l’autonomie et la santé reproductive des individus, sans causer de dommage iatrogénique. L’éthique de l’ « empowerment », qui requiert l’attribution d’une responsabilité individuelle de nature prospective, l’apport de ressources concrètes et l’implication des communautés, permet d’identifier les besoins en termes de solutions législatives favorisant des contextes socioéconomiques qui soutiennent la santé reproductive et l’autonomie reproductive. / Recent studies have demonstrated an increased prevalence of infertility in Canada and a tremendous growth in assisted reproductive technologies use. In 2010, the Quebec government launched a public funding program for assisted reproductive technologies, which aims to provide equitable access and to protect the health of mothers and children. Various stakeholders have identified a number of shortcomings to this program, including the absence of prevention and health promotion measures aimed towards reducing the prevalence of infertility. Indeed, a significant proportion of infertility cases is attributable to modifiable and lifestyle related factors such as smoking, sexually transmitted infections, weight problems, environmental toxins and age. In addition, both advanced maternal age and assisted reproductive technologies utilization pose risks to the health of mothers and children, about which the population is not adequately informed. Preventative approaches have been proposed by many organizations in various countries but few have been implemented. A reason for this might be that these initiatives represent major challenges in terms of social acceptability, due to the sensitive nature of the subject and the strong social respect for reproductive autonomy. Health communication ethics highlights these issues such as the use of persuasive tactics, the risk of stigmatization, and undue attribution of responsibility. If designed effectively with these challenges in mind, health communication campaigns for infertility prevention have the potential to adequately inform the public, thus fostering reproductive autonomy and health, without causing iatrogenic damage. The ‘ethics of empowerment’, with its requirements for assigning only prospective individual responsibility, providing concrete resources and involving communities in social change, helps in identifying the needs for policy solutions that address the social context in order to enhance reproductive health and reproductive autonomy.