INTRODUCTION:

In today’s society and present generations, many women are delaying childbearing into their later reproductive years for various reasons; these include late marriage, higher education and career pursuit, longer life expectancy, social and (probably the most important) economic status, more effective contraceptive techniques, and modern infertility treatment. These pregnancies are only partially the results of planned postponement of motherhood, as a good percentage are secondary to infertility (20%) or to previous fetal losses (40%). Live births in women 35 years of age increased from 5% in 1970 to 13% of all live births in 2000.Between 1977 and 1998, the number of women giving birth at 35 to 39, 40 to 44, and >45 years increased 9.9, 9.1, and 49.9 times, respectively.

In 1999, the birth rate for women aged 40 to 44 years was the highest in almost two decades. Over 10 years, the average age at ﬁrst delivery increased from 25.9 to 27.5 years and at any delivery from 27.3 to 29.7. This trend of postponing childbearing has not yet shown any tendency to decrease. Recent studies on large cohorts of older women have shown more favorable maternal and perinatal outcomes.¹

1. Definition:

Advanced Maternal Age (AMA): Obstetric literature is variable. Advanced maternal age has been traditionally deﬁned as age >35 years at delivery, although some authors have used the age limits of 40 and even 44 years. Regardless of what the cut off for deﬁning advanced maternal age is, pregnancies in women aged >35 years are considered at risk of both obstetric complications and interventions.¹

Medicinenet.com:

Advanced maternal age is usually defined as age 35 or more at delivery.²

Wikipedia:

Advanced Maternal Age (AMA), in a broad sense, is the instance of a woman being of an older age at a stage of reproduction.³ Previously, this population has been described as “elderly primips”, “elderly or older moms”, “elderly multips”, “delayed pregnancies”, or “late maternal age”. This older terminology is no longer considered to be supportive or appropriate for this growing population.⁴

2. Advanced Maternal Age: Health Advantages: Women who are pregnant over the age of 35 have some distinct health advantages.

2.1 Increased use of folic acid:

Women age 30 and older are more likely to have taken folic acid supplements in the preconception period. Health professionals recommends that all women who are pregnant or planning a pregnancy take a daily folic acid supplement, starting 3 months before conception and continuing throughout the first trimester of pregnancy, to decrease the risk of neural tube defects (Van Allen, McCourt and Lee, 2002).⁵

2.2 A purposeful approach:

The women becoming pregnant after age 35 are more likely to carefully plan their pregnancy, which has some clear health advantages. Women can improve their health in the preconception period, and can start to prepare themselves for parenthood. They likely to look for information prior to pregnancy, to talk with a health care provider before pregnancy, and to make health changes at least 3 months before they hope to be pregnant (Best Start, 2002).⁶ Women with advanced maternal age also actively seek information about pregnancy, and they feel established in their personal and professional lives. It gives positive impact on women participation in their prenatal care. An US study reveals that, women over the age of 35 were more likely to seek early prenatal care and to continue with regular prenatal visits throughout pregnancy (Fonteyn and Isada, 1988).⁷Women who are pregnant after age 35 are also more likely to report having a positive experience with service providers in prenatal care, labour and birth (Windridge and Berryman, 1999).⁸ Statistics for births in India show that the birth rate per 1,000 women⁹ is:

· 157 births between 25 and 29 years of age.

· 66 births between 30 and 34 years of age.

· 30 births between 35 and 39 years of age.

· 9 births between 40 and 44 years of age and

· 4 births between 45 and 49 years of age

A national survey in India showed that the women who failed to seek antenatal care tended to be older (ages 35 to 49), with a high number of previous pregnancies, and to be illiterate and socioeconomically disadvantaged.^{10, 11}

2.3 Psychological Preparation for Parenthood: Postponing childbearing until after age 35 is associated with a sense of readiness for becoming a parent. In a Toronto study, women who were pregnant after age 35 were more likely to report feeling settled, stable, personally secure, prepared for the challenge, emotionally ready, adaptable and flexible in regards to childrearing (Dion, 1995).¹²Knowledge, maturity, high degree of personal control and the belief in advanced maternal age helps in coping with parenthood and its stress (Dion, 1995).¹²Older parents report that they feel less confident in their parenting knowledge and skills (Invest in Kids, 2002).¹³

2.4 Higher Breastfeeding Rates:

Breastfeeding is the optimal method of infant feeding. Benefits to the infant include protection from gastrointestinal infections, respiratory infections and otitis media. Benefits to the mother include reduced postpartum bleeding, earlier return to pre-pregnancy weight, and a decreased risk of both breast and ovarian cancers. A Canadian survey reported the percentage of women of different ages who breastfed for 3 months or longer. Breastfeeding rates increased with the age of the mother/rate of breastfeeding 3months and more: 25 to 29 years - 60%, 30 to 34 years - 67%, 35 and older 76 %. (Health Canada, 2003).¹⁴

2.5 Socio-economic Influences on Physical Health: Women, who have delayed pregnancy until after age 35, tend to have a higher level of education and a higher income (Health Canada, 2005).¹⁵Education and income are key determinants of health. There are positive health implications for women who have a higher than average education and income, as well as for their children. Women who delay their first pregnancy may have more resources available to support their growing family.

3. Advanced Maternal Age: Overview of Health Concerns:

Women over the age of 35 generally consider the risks when making the decision to become pregnant (Pers com, 2007).¹⁶However, they often have an incomplete understanding of the range of potential risks (Tough, Benzies et al, 2006).¹⁷There are some clear health disadvantages to delaying a first pregnancy until after 35.

3.1 Declining Fertility:

Age alone is the most important factor in declining fertility. For women, fertility begins to decrease significantly in the early 30s and continues to drop with increasing age. Fertility starts to dramatically decrease at age 35 (Institute for Clinical Evaluative Sciences (ICES), 2006).¹⁸ While 91% of women are physiologically able to become pregnant at age 30, this drops to 77% at age 35, and 53% by age 40 (Health Canada, 2005).¹⁵Some women assume that with advances in assisted reproductive techniques (ART), they can solve/overcome the declining fertility problem. While advances in ART do allow many women with fertility problems to conceive, the success rates decrease with the age of the mother. The financial cost of ART is prohibitive for many women.

3.2 Increased Use of Alcohol in Pregnancy:

The use of any alcohol in pregnancy puts a fetus at risk for Fetal Alcohol Spectrum Disorder (FASD). FASD describes a series of birth defects and neuro developmental disorders caused by alcohol consumption in pregnancy. Children with FASD may have difficulties with learning, memory, attention span, communication, vision and hearing. In modern society over the age of 35 have a higher self-reported rate of alcohol use in pregnancy.

3.3 Risks Associated with Work:

Working long hours (more than 8 hours/day), standing for longer than 4 hours at a time, stress at work and doing strenuous work can increase the risk for preterm labour and low birth weight (SOGC, 2005).¹⁹ Women who are pregnant over age 35 are more likely to be professionals employed in a career that regularly involves an increased number of work hours and a stressful work environment. Women who work in positions such as teaching or health care may be required to stand for extended periods of time.

3.4 Greater Likelihood for Pre-existing Medical Conditions:

As all people age, the likelihood for developing medical conditions increases. Medical conditions that are more common with age include cancer, diabetes, hypertension and arthritis. A pre-existing medical condition may impact fertility, a pregnancy and/or the developing fetus, as may the associated treatments or medications. Cancer is another factor to consider. Breast cancer is the most common cancer in young women. As women pass age 35, their chance for developing breast cancer increases significantly (Cancer Care Ontario, 2006).²⁰

3.5Environmental Toxins:

There are an increasing number of environmental toxins present in our communities, homes, food and water. They come from sources such as industrial pollution, pesticides, personal care products, home cleaning products etc. These chemicals include known or suspected teratogens as well as chemicals that may disrupt reproductive health in other ways. Some toxins bio-accumulate over time, and women over age 35 may have higher levels of some environmental toxins than younger women.

3.6 Increased Chance for Complications in Pregnancy:

There are a number of complications in pregnancy that are associated with advanced maternal age. These include an increased risk for fetal loss, chromosome anomalies such as Down syndrome, multiple pregnancy, hypertension, diabetes, placenta previa, placental abruption, Caesarean birth, preterm labour and low birth weight.

4. Advanced Maternal Age: Specific Prenatal Risks: Certain prenatal complications occur more frequently in pregnant women over age 35. With the excellent prenatal care available, most of these pregnancy complications can be successfully addressed to minimize the risk for the pregnant woman and the fetus. The risks for specific prenatal concerns include fetal loss, chromosome anomalies, multiple births, maternal medical risks and complications in labour and birth. Age alone is an important risk factor for chromosome anomalies in pregnancy. For some pregnancy complications, the level of risk depends on whether the mother is giving birth to a first baby or has given birth previously.

4.1 Greater Risk of Fetal Loss:

For all pregnant women, the risk of fetal loss is approximately 14%. The rate of fetal loss increases with age and there is a steep increase after age 35 (Nybo Anderson et al, 2000).²¹Fetal loss can result from a number of different causes including genetic factors (i.e. chromosome anomalies), anatomic factors (i.e. abnormalities of the uterus),endocrine factors (i.e. diminished progesterone secretion), immune factors (i.e. generation of auto-antibodies), microbiologic factors (i.e. group B streptococcus, toxoplasmosis or rubella), environmental factors (i.e. alcohol, tobacco and drug use), diminished ovarian reserve and nutrition issues (i.e. folic acid deficiency and elevated homocysteine) (Heffner, 2004).²²Fetal loss can be devastating to a mother of any age. Fetal loss can be complicated by the concurrent reality of declining fertility. It takes longer for women over the age of 35 to conceive. In addition, women who have conceived using ART may be grieving a pregnancy loss while undergoing another series of ART. Fetal loss can occur through miscarriage, ectopic pregnancy or stillbirth.

Miscarriage:

Miscarriage (spontaneous abortion) is the loss of pregnancy before 20 weeks gestation. In a Denmark study the rate of miscarriage was shown to increase with maternal age (Fig 1):

Maternal Age

Figure 1: Age of Mother and Risk for Miscarriage, Denmark, 1978-1992 (Nybo Anderson et al, 2000).²¹

In all ages of pregnant women, most miscarriages occur within the first trimester of pregnancy. The risk for miscarriage increases with age - In their 20's 10%, between ages 35-39, 20%, between ages 40-44, 35% and in Age 45, over 50% of diagnosed pregnancies ends in miscarriage.²³The rise in chromosomal anomalies with increasing maternal age likely leads to the rise in miscarriage rates. In addition, advanced paternal age (>45 years) is associated with abnormal sperm (Heffner, 2004).²² Abnormal sperm - increased risk for some single gene and epigenetic mutations.

Ectopic Pregnancy:

Ectopic pregnancy leads to fetal loss and may result in maternal death. The rate of ectopic pregnancy in Canada is 13.8 per 1000 reported pregnancies (Health Canada, 2003).¹⁴The incidence of ectopic pregnancy increases with maternal age. Because of increased prevalence of fallopian tube scarring as women age (Nybo Anderson et al, 2000).²¹

Stillbirth:

Stillbirth, or fetal demise, is the intrauterine loss of a fetus after 20 weeks gestation or a fetus weighing 500 grams or more. The overall stillbirth rate in Canada is 6.1 per 1000 births (Statcan, 2002b).²⁴Studies show that stillbirth rates rise with maternal age (Nybo Anderson et al, 2000; Reddy, 2006).^{21, 25}India shares the highest burden of stillbirths (75%) as compared to other South-East Asian countries. The rates range from 20 to 66 per 1000 births in different states.^{26, 27}

4.2 Higher Chance of Chromosome Anomalies:

Major congenital anomalies are detected in 2 to 3% of all births. It can be structural or due to chromosomal anomalies. The chance for a pregnancy in which the fetus has a chromosome anomaly increases with maternal age (Hook, 1981).²⁸The most common chromosome conditions associated are: Down syndrome, trisomy 18, trisomy 13, or an extra X chromosome such as in Klinefelter syndrome (SOGC, 2007).²⁹

4.3 Greater Chance of Conceiving Multiples:

For every 100 births, approximately 3 of these are multiple births (Health Canada, 2003).¹⁴Although multiples represent only 3% of births, they account for 20% of preterm births, 25% of low birth weight births and 29% of very low birth weight births (Best Start, 2005).³⁰ Multiple births are more frequent among women in their 30s and 40s. In 2002, approximately 55% of multiples were born to women over the age of 30 (Statcan, 2004).³¹Twin birth rates increased for women of all ages over the three decades, with the largest increases among women aged 30 and over. From 1980 to 2009, rates increased 76 percent for women aged 30-34, nearly 100 percent for women aged 35-39, and more than 200 percent for women aged 40 and over(Fig 2).Fertility treatments contribute major for multiple births and 30-50% of twin pregnancies and at least 75% of triplets result from ART (Health Canada, 2003).²⁷Risks associated with a pregnancy with multiples - perinatal death, preterm birth, low birth weight, infant death, and intellectual, social or physical disabilities. The stillbirth rate for multiple birth pregnancies is 20 per 1000 births compared with the stillbirth rate for singleton pregnancies of 5.7 per 1000 (Statcan, 2002b).²⁵Also an increased risk for pregnancy complications for the mother including gestational hypertension, proteinuria, anemia, gestational diabetes, premature rupture of membranes (PROM) and postpartum haemorrhage.

4.4 Increased Risk for Maternal Medical Complications:

Women over the age of 35 are at higher risk for some maternal medical complications including hypertension and diabetes.

Hypertension:

There are various types of hypertension to consider in pregnancy - Pre-existing hypertension and gestational hypertension. Hypertension in pregnancy occurs in about 6-8% of all pregnancies.³²For all women, the chance of developing hypertension increases with age. Pre-existing hypertension in pregnancy is high among older women (Cleary-Goldman et al, 2005; Joseph et al, 2005).^{33, 34}

Very Preterm Birth:

Very preterm babies are born before 32 weeks completed gestation. The provincial study in Nova Scotia found that rates for very preterm birth were higher for women of advanced maternal age and also for women having their first baby (Fig 5).Very preterm birth is associated with even higher risk for perinatal mortality and morbidity. The risk of long-term intellectual, emotional or physical disabilities is directly related to the gestational age of the infant (SOGC, 2000).⁴³

Placental Abruption:

Placental abruption is the separation of the placenta from the wall of the uterus during pregnancy. Women of advanced maternal age are at an increased risk for placental abruption (Cleary-Goldman et al, 2005; Joseph et al, 2005; Sheiner et al, 2003).^{33, 34, 44}In a national U.S. study, placental abruption was found to increase as maternal age increased. Placental abruption can have serious consequences including fetal death and maternal hemorrhage.

Low Birth Weight: A weight of less than 2500 grams at birth is considered low birth weight. Very low birth weight is a weight of less than 1,500 grams at birth. Women at advanced maternal age are at higher risk for low birth weight and very low birth weight (Statcan, 2006a).⁴⁵In particular, women over age 40 are at a greater risk (Cleary-Goldman et al, 2005).³³

Low birth weight is associated with specific conditions in pregnancy including multiple pregnancies, hypertensive disorders in pregnancy, preterm birth and very preterm birth. Some known risk factors for low birth weight include occupational stress in pregnancy and pregnancy achieved through ART (Tough et al, 2002).⁴²

Supportive research findings

Louise C. K et al, 2013⁴⁶conducted a population-based cohort at the University of Manchester, UK, revealed the results as follows: Women aged 40+ at delivery were at increased risk of stillbirth (RR=1.83, [95% CI 1.37–2.43]), pre-term (RR=1.25, [95% CI:1.14–1.36]) and very pre-term birth (RR=1.29, [95% CI:1.08–1.55]), Macrosomia (RR=1.31, [95% CI: 1.12–1.54]), extremely large for gestational age (RR=1.40, [95% CI: 1.25–1.58]) and Caesarean delivery (RR=1.83, [95% CI: 1.77–1.90]). The study concludes that, advanced maternal age is associated with a range of adverse pregnancy outcomes.

Sahu T Meenakshi, Agarwal Anjoo, Das Vinita, 2007⁴⁷done a retrospective study states that: Women aged 35 years or more constitute a high risk group but they can expect a good pregnancy outcome with careful and watchful antenatal care and delivery.

Sohani Verma, 2009⁴⁸did a retrospective study reveals that - The women aged 35 years and above have obstetric complications, similar to the high risk pregnancy group in younger women and increased rates of operative deliveries.

5. Advanced Maternal Age: Considerations for Emotional Care:

Pregnancy after age 35 can be emotionally challenging. The emotional concerns related to pregnancy over the age of 35 help the nurse/midwifes to address these concerns.

5.1 Emotional Concerns

· Fertility - more concerns, more stress and worry - because possibility of complications

· Fetal Loss -loss rate is higher, fear, heart-breaking

· Difficult Decisions - During pregnancy or about their ability to parent. Use of donor versus non-donor eggs, decisions about multi-fetal pregnancy, reduction in a higher order multiple pregnancy, decisions about diagnostic tests that are associated with increased chance of miscarriage, and decisions about termination of the pregnancy.

· Perinatal Mood Disorders - The most common concerns in pregnancy and postpartum. Affect up to 20% of pregnant and postpartum mothers. Risk factors include depression or anxiety in pregnancy, history or family history of depression, recent stressful life events and lack of social support (Ross et al, 2005).

· Lack Social Support

· Unintended Pregnancy or mistimed pregnancy - additional stress

· Low Socio-economic Status⁴⁹

· Referrals - Women dealing with difficult aspects of pregnancy after age 35 need support and information. Some possible partners in supporting women are genetic counsellors, bereavement counsellors, adoption services, organizations for parents of multiples, psychologists, support groups that focus on perinatal loss or infertility, or associations such as Down Syndrome Association.

5.2 Points for Midwives/Service Providers: Emotionally Difficult Aspects

1. Present information in a factual way. Repeat information if needed. Allow sufficient time.

2. Ask what the information means to the person involved. Listen with sensitivity.

3. Offer options in a non-directive manner. Women need to make decisions based on their own goals and values.

4. Make appropriate referrals for counseling.

5. Be supportive and non-judgmental as women work through their options.

6. Link women to available supports.

7. Develop a plan for follow-up.⁴⁹

6. Advanced Maternal Age: Considerations for Preconception Care:

Preconception care is important for all men and women for planning a pregnancy. It has significant benefits for women over age 35, especially in relation to higher risk of fertility concerns, pre-existing health concerns, teratogenic exposures and chromosome anomalies. The preconception period gives the opportunity for midwife/nurse to provide information about planning a healthy pregnancy and to determine any potential risks.⁴⁹

· Declining Fertility - The decreased chance for conceiving and increased chance of fetal loss - can make informed choices about planning the timing of future pregnancies.

· Folic Acid for Women at Risk – AMA mothers likely with pre-existing Type 1 or Type 2 diabetes - 3 to 4 times higher risk for neural tube defects (Macintosh et al, 2006).⁴⁷

· Workplace Reproductive Risks - Encourage women to reduce or eliminate workplace risks where possible. Advocate for pregnancy friendly workplace.

· Alcohol Use - ask all women who are planning a pregnancy about their alcohol use.

· Pre-existing medical conditions - Ask for Use of prescription medications, OTC medications and herbal remedies. Reduce, remove or substitute harmful medications as needed.

7. Advanced Maternal Age: Considerations for Prenatal Care:

Specific considerations in prenatal care for pregnant women – Midwives/Nurses may have a role in providing support, referrals or written information. For the most part, prenatal care is the same for women of all ages. However, there are a few differences, especially in the area of screening tests and diagnostic tests.⁴⁹

Health care provider/Midwife - spend an increased amount of time on specific health concerns that are more frequent in this population, for example diabetes and hypertension. The care provided for each of these concerns would be the same for all pregnant women, regardless of age.

Women who are pregnant over the age of 35 are at higher risk for many prenatal complications - miscarriage, ectopic pregnancy, stillbirth, multiple births, hypertension, placenta previa, Caesarean birth, preterm birth, placental abruption and low birth weight. For each of this complication the management is same for all pregnant women, regardless of age. The one aspect of prenatal care that does change for women pregnant after age 35 is information and referral regarding chromosome anomalies and prenatal screening tests.⁴⁹

7.1 Screening Tests⁴⁹

1. Explain to women that screening tests are not the same as diagnostic tests.

2. Screening tests estimate the chance that a fetus may have for Down syndrome, Trisomy 18 or open neural tube defects based on a number of risk factors. Tests with the highest detection rates and the lowest false positive rates are the most reliable.

3. Women need timely information about screening tests and enough time to make an informed decision about whether or not to have a screening test.

4. Women who choose to have screening tests need preparation for the possibility of a positive screen.

5. For women who have screen positive results, re-stating the results in an alternate way can offer reassurance. For example, a “1 in 100 chance” of an affected baby means a 99% chance for a healthy baby.

6. Women with screen positive results can be referred for balanced genetics counselling.

7. When talking to women about the risk of having a child with a specific disability, do so in a way that respectful of individuals with disabilities.

8. Counseling should be non-directive and should not be framed from the provider’s personal beliefs.

7.1.1 First Trimester Screening (FTS)⁴⁹

1. The First Trimester Screening test (FTS) combines NT with the measurement of maternal serum markers.

2. FTS has the advantage of results early in pregnancy, 13-14 weeks gestation.

3. NT and serum markers for the FTS have to be completed by 11 weeks, 0 days and 13 weeks, 6 days of pregnancy. This requires an early visit with a service provider.

4. FTS does not screen for open neural tube defects. A follow-up screening test measuring maternal serum AFP is recommended between 15-22 weeks gestation.

Nuchal Translucency (NT)⁴⁹

· NT is an ultrasound examination, which measures the amount of fluid behind the neck of the developing fetus.

· NT is completed as one aspect of a screening test protocol that also includes measurement of serum markers. (SOGC, 2007). ²⁹

· NT is measured in the first trimester between 11 weeks, 0 days and 13 weeks, 6 days.

· The NT measurement is used primarily to assess the chance of Down syndrome. Detection rate for Down syndrome of 69 to 75% with a false positive rate of 5 to 8% (SOGC, 2007). ²⁹

· NT measurements that are larger than 3.0 or 3.5 mm (depending on the testing facility) indicate a fetus that has an increased chance of chromosome anomalies and other congenital anomalies, especially congenital heart defects.

7.1.2. Second Trimester Screening Tests ⁴⁹

Second trimester screening tests include

a. Triple and quadruple maternal serum screening.

b. An ultrasound scan of fetal anatomy can also serve as a screening test.

a. Triple and Quadruple Maternal Serum Screening (MSS):

It is useful for determining risk for Down syndrome, trisomy 18 and open neural tube defects. The MSS screening test consists of 1 blood test done between 15-22 weeks gestation. The MSS triple screen measures 3 maternal biochemical serum markers: Alpha fetoprotein (AFP), human chorionic gonadotrophin (hCG) and unconjugated estriol (uE3). (SOGC, 2007). ²⁹

The MSS quadruple screen (Quad screen) adds a 4th marker, dimeric inhibin-A (DIA). Improves the detection rate and lowers the false positive rate compared to MSS triple screen. The Quad screen has a detection rate for Down syndrome of 77% (SOGC, 2007).²⁹The advantage of Quad screening - Women who present late for prenatal care can still have prenatal screening. Disadvantages of Quad screening compared to FTS are; Lower detection rate, Results in later pregnancy, the results of quad screening between 17-22 weeks of pregnancy. The elevated markers (AFP is elevated - >2.0 Multiples of the Median (MoM) or 2.5 MoM) can help predict the conditions of IUGR, PROM, preeclampsia, preterm labour and preterm birth (Dugoff, Saadeand Malone et al, 2003)⁵⁰

b. Fetal Anatomy Ultrasound:

An ultrasound of fetal anatomy between 18 and 20 weeks of gestation is regarded as standard practice. The anatomic scan is recommended by the SOGC (SOGC, 2005).¹⁹The anatomy scan at 18 to 20 weeks gestation is useful for detecting: neural tube defects, heart defects and abdominal defects. It can detect many minor anomalies - cleft lip and limb deformities. Fetal anatomy ultrasound is also useful for the assessment of placental location and amniotic fluid volume. Not all abnormalities can be detected with an 18 to 20 week scan. “Soft markers” are associated with an increased risk for Down syndrome. Soft markers findings are often not anomalies, but variations of normal. (SOGC, 2007).²⁹

7.1.3 Two-Step Integrated Screening Tests

1. The Integrated Prenatal Screening (IPS) improves performance by combining first and second trimester screening tests.

2. Women need to complete the NT and the first maternal serum test between 11 weeks 0 days and 13 weeks, 6 days of pregnancy. This requires an early prenatal visit with a service provider.

3. IPS and Serum IPS results are received later in pregnancy compared to first trimester screening tests (17-22 weeks gestation).

4. IPS and Serum IPS include screening for open neural tube defects.

7.2 Diagnostic Tests

1. Diagnostic tests karyotyping the fetus to identify chromosome anomalies.

2. Women who screen positive on screening tests, or women pregnant after age 40 may choose to have a diagnostic test.

3. Since Chorionic Villus Sampling CVS is completed in the first trimester of pregnancy; early discussion is required in order for women to make an informed decision about CVS.

4. Diagnostic test results are specific and women and their partners need to be prepared for the results.

5. Women need to be informed of the risks specific to each diagnostic test.

7.3 Genetic Pre-implantation Test:

In some ART clinics it is now possible for women undergoing IVF to choose to have the embryos tested for chromosome anomalies prior to implantation in the uterus.

8. Advanced Maternal Age: Preparation for Parenting:

The needs of new parents (who are over 35years of age) should be considered while planning services related to parenting. Older first time mothers may experience transition to parenting differently than younger first time parents. Unique stressors for older first time mothers can affect transition - higher perception of risk for the baby, lower levels of confidence, high expectations of motherhood, and transition from the work environment.⁴⁹

· Perception of Risk - Think of their baby as precious and irreplaceable, more aware of possible concerns for the baby and more likely to believe their baby's life could be at risk.

· Work and Social Support - may lack social support in the postpartum period. May miss the challenges of work, the social connections and the sense of satisfaction they felt on the job. May move from feeling knowledgeable and confident in their work environment, to feeling not at all confident or competent as new parents. Being at home full time with a new baby may be isolating.

· Realities of Parenting - May eagerly anticipate their role as a mother, early parenting brings joy and satisfaction, however, the postpartum period is also characterized by unpredictable demands, disorder and fatigue. Can cause anxiety. Parenting multiples can bring more stress and challenges. “Sandwich generation”- caring for aging parents, simultaneously caring for young children.

· Confidence in Parenting - showed higher rates of much positive parenting behaviour. As compared to younger first time parents, first time parents over the age of 35 were:

• Less confident in their knowledge of factors influencing healthy child development

• Less confident in their parenting ability

• More likely to rate parenting as the most important thing they can do

• Equally likely to rate parenting as enjoyable most of the time

• Less likely to feel they spent enough time with their children

· Supporting the Transition to Parenting - number and timing of children, stress the importance of health assessment and healthy choices prior to conception, as well as the importance of early prenatal care, early prenatal classes and parenting services. Prenatal classes, parenting programs Children with Special Needs

· Children with Special Needs

· Concerns in Early Parenting - Possibility of postpartum mood disorders.

9. Advanced Maternal Age: Looking Forward:

The trend of increased average maternal age is expected to continue. The increased prevalence of pregnancies over age 35, and the unique needs of this population, has implications for service providers and the health care system. Let us review, some of these implications.⁴⁹

· Preconception and Prenatal Care - Improve the services provided to women in this population. Women over the age of 35 needs to be aware of the benefits of preconception care and early prenatal care. Health care providers need to make preconception care and early prenatal care a priority for this population. • The health care system needs to have the capacity to accommodate these services.

· Social Cost - Health promotion and prevention strategies designed to reduce the risks have a positive impact on women and their growing families, and are often successful in reducing associated health care costs. Health care providers are encouraged to consider changes that they can make in their practices and programs, as well as at a broader level, in response to the growing trend of advanced maternal age.

· Policy - New policies regarding the use of screening and diagnostic tests, Pregnancy friendly employment policies, at the central, local or individual workplace level, help to support all women in having the healthiest pregnancy possible, and may also make women feel that they have more choice in the timing of their pregnancies.

· Research - Need more information about the health risks and benefits of late maternal age, considerations for the physical and mental health of women, research on effective care for this population, information from the perspective of women - experience of preconception, pregnancy, labour and birth, as well as their satisfaction with the services they received. It would be helpful to hear how women in this population would like to be cared for, prior to and during pregnancy.

SUMMARY:

The trend of pregnancy after age 35 has become well established in worldwide and in India too. This trend deserves the attention of policy makers, service providers who work with pregnant women, public health departments, prenatal care providers and the health care system as a whole. The Nurse/Midwifes place an important role in all these aspects.

REFERENCES:

1. Usta IM, Anwar H, Nassar. Advanced Maternal Age. Part I: Obstetric Complications. American Journal of Perinatology.25(8);2008: 521-534.

2. www.medicinenet.com

3. www.wikipedia.org

4. A collaborative project of: Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource Centre and the Halton Region Health Department. Reflecting on the trend: Pregnancy after age 35. 2007.

5. Van Allen MI, McCourt C, Lee NS. Preconception Health: Folic Acid for the Primary Prevention of Neural Tube Defects. A Research Document for Health Professionals. Ottawa: Minister of Public Works and Government Services Canada.2002.

6. Best Start Resource Centre. Ontario Health before Pregnancy Survey. Unpublished.2002

7. Fonteyn VJ, Isada NB. Nongenetic implications of childbearing after age 35. Obstetrical and Gynecological Survey.43(12); 1988:709-720.

8. Windridge KC, Berryman JC. Women's experiences of giving birth after 35. Birth. 26(1); 1999: 16-23.

9. http://www.babycenter.in/a538711/how-age-affects-pregnancy

10. Saumya RR, Leila C, Khan ME, and Townsend JW. Safer Maternity in Rural Uttar Pradesh: Do Primary Health Services Contribute? Health Policy and Planning. 16(3); 2001: 256-63.

11. Planning Commission. Government of India. Annual Report 2001-2002, accessed online at http://planningcommission.nic.in/sitemap/search.htm, on June 20, 2003.

12. Dion KK. Delayed parenthood and women's expectations about the transition to parenthood. Int J Behav Dev, 18(2); 1995: 315-333.

13. Invest In Kids. A National Survey of Parents of Young Children. Canada: Invest In Kids. 2002.

14. Health Canada. Canadian Perinatal Health Report. Ottawa: Minister of Public Works and Government Services Canada, 2003. www.hc-sc.gc.ca/pphb-dgspsp/rhs-ssg/index.html

15. Trends and Implications, health policy research bulletin, Health Canada, 2005. Available at: http://hc-sc.gc.ca/sr-sr/pubs/hpr-rpms/bull/2005-10-chang-fertilit/index_e.html

16. Personal Communication, Joyce Engel, Niagara College.2007.

17. Tough SC, et al. What do women know about the risks of delayed childbearing? Canadian Journal of Public Health. 97(4); 2006: 330-334.

18. Institute for Clinical Evaluative Sciences (ICES). Egg race: Assessing fertility in older women. Informed.12 (2); 2006. from www.ices.on.ca/informed/periodical/issue/3515-vol12 issue 2 Art5.pdf

19. SOGC. Healthy beginnings. Ottawa: SOGC.3rd ed. 2006.

20. Cancer Care Ontario. Cancer in Young Adults in Canada. 2006: P.49, 82. www.cancercare.on.ca/pdf/CYAC2006E.pdf

21. Nybo Anderson AM, et al. Maternal age and fetal loss: Population based register linkage study. BMJ. 3(20); 2000:1708-1712.

22. Heffner LJ. Advanced maternal age - How old is too old? New England Journal of Medicine.351(19); 2000: 1927-1929.

23. http://www.bandbacktogether.com/pregnancy-advanced-maternal-age-resources/#sthash.EEoB9RW7.dpuf

24. Statistics Canada. Stillbirths 1999. The Daily, 2002b. www.statcan.ca/Daily/English/020507/d020507c.htm

25. Reddy UM, Ko CW, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy in the United States. American Journal of Obstetrics and Gynecology. 195(3); 2006: 764-70.

26. World Health Organization. Global database on births attended by skilled health personnel. Geneva: WHO. 2009.

27. Divya KB. Still Births: A high magnitude public health issue in India. South East Asia Journal of Public Health.3(1); 2013:3-9.

28. Hook EB. Rates of chromosomal abnormalities at different maternal ages. Obstetrics and Gynecology.58(3); 1981: 282-85.

29. SOGC. Prenatal screening for fetal aneuploidy. SOGC Clinical Practice Guidelines. 187; 2007:146-160.

30. Best Start Resource Centre. Low Birth Weight and Preterm Multiple Births. Ontario: Best Start Resource Centre. 2005.

31. Statistics Canada 2004. Births. Ottawa: Minister of Industry. 2006. www.statcan.ca/english/freepub/84F0210XIE/84F0210XIE2002000.htm

32. www.heartandstroke.ca

33. Cleary-Goldman J, et al. Impact of maternal age on obstetric outcome. Obstetrics and Gynecology. 105(5); 2005: 983-990.

34. Joseph KS, et al. The perinatal effects of delayed childbearing. Obstetrics and Gynecology. 105(6); 2005: 1410-1418.

35. www.diabetes.ca

36. Macintosh MCM et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales and Northern Ireland: population based study. BMJ. 2006:333, 177

37. Johns K et al. Gestational Diabetes Mellitus Outcome in 394 Patients. Journal of Obstetrics and Gynaecology of Canada. 28(2); 2006: 122-127.

38. www.thehealthsite.com

39. Lorenz PM, Kisly A. Pregnancy outcome in nulliparous women 35 years and older. Obstetrics and Gynecology. 85(1); 1995: 65-70.

40. Bobrowski RA, Bottoms SF. Underappreciated risks of the elderly multipara. American Journal of Obstetrics and Gynecology. 172(6); 1995: 1764-70.

41. www.babycentre.in

42. Tough SC et al. Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth and preterm delivery. Pediatrics. 109(3); 2002: 399-403.

43. SOGC. Management of the woman with threatened birth of an infant of extremely low gestational age. A joint statement with SOGC and CPS. Canadian Medical Association Journal. 151(5); 2000: 547-551,553.

44. Sheiner E et al. Placental abruption in term pregnancies: Clinical significance and obstetric risk factors. Journal of Maternal Fetal and Neonatal Medicine. 13(1); 2003: 45-9.

45. Statistics Canada 2006a. Births. 2004.TheDaily,2006.www.statcan.ca/Daily/English/060731/td060731.htm

46. Louise CK et al. Maternal Age and Risk of Adverse Pregnancy Outcome. 8(2); 2013.www.plosone.org

47. Sahu TM, Agarwal A, Das V. Advanced maternal age and obstetrical outcome. J ObstetGynecol India. 57(4); 2007: 320-323.

48. Sohani V. Advanced Maternal Age and Obstetric Performance. 6(3); 2009: 258–26.

49. A collaborative project of: Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource Centre and the Halton Region Health Department. Reflecting on the Trend: Pregnancy after Age 35. Halton Publications. 2007.

50. Dugoff L et al. The quad screen as a predictor of adverse pregnancy outcome: a population-based screening study (The FASTER trial). American Journal of Obstetrics and Gynecology.(2003); 189, S79.

Received on 12.06.2015 Modified on 26.06.2015

Asian J. Nur. Edu. and Research 6(1): Jan.- Mar.2016; Page 138-148

DOI: 10.5958/2349-2996.2016.00027.6