Age at first birth, mode of conception and psychological wellbeing in

Hum. Reprod. Advance Access published March 25, 2011
Human Reproduction, Vol.0, No.0 pp. 1– 10, 2011
doi:10.1093/humrep/der076
ORIGINAL ARTICLE Psychology and counselling
Age at first birth, mode of conception
and psychological wellbeing in
pregnancy: findings from the parental
age and transition to parenthood
Australia (PATPA) study
1
Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia 2School of Psychology, Cardiff
University, Cardiff CF10 3AT, UK 3Institute of Early Childhood, Macquarie University, Sydney, NSW 2109, Australia 4Centre for Women’s
Health, Gender and Society, Melbourne School of Population Health, The University of Melbourne, Melbourne, VIC 3010, Australia
5
University of Sydney, Sydney, NSW 2006, Australia 6IVF Australia, Sydney, NSW 2065, Australia
*Correspondence address. E-mail: [email protected]
Submitted on September 27, 2010; resubmitted on February 15, 2011; accepted on February 21, 2011
background: It is increasingly common for women in high-income countries to delay childbearing. We aimed to describe the context
of pregnancy for first-time mothers of different ages and examine relationships among maternal age at first birth, mode of conception and
psychosocial wellbeing in pregnancy.
methods: Using stratified sampling, we recruited similar numbers of women conceiving through assisted reproductive technology (ART;
n ¼ 297) or spontaneously (n ¼ 295) across three age groups: younger, ≤20–30 years; middle, 31 –36 years; older, ≥37 years. Women
participated in a structured interview and completed validated questionnaires assessing socio-economic status, personality, quality of partner
relationship, state and trait anxiety, pregnancy-focused (P-F) anxiety and maternal –fetal attachment.
results: Older maternal age was associated with lower depression and anxiety symptoms, lower maternal –fetal attachment (P , 0.05),
greater psychological hardiness (resilience) (P , 0.001) and lower ratings of control in the partner relationship (P , 0.05) at a univariate level.
ART conception, but not older maternal age, was associated with more P-F anxiety. Although most main effects of age and mode of conception became non-significant after controlling for contextual/reproductive history variables, a significant association between ART conception and more intense fetal attachment emerged (P , 0.05).
conclusions: Women having their first baby when older appear to have some psychological advantages over their younger counterparts; they are more resilient, report their partners as less controlling and report lower symptoms of depression and anxiety during pregnancy. However, women conceiving through ART have a more complex experience of pregnancy, simultaneously experiencing more P-F
anxiety and more intense emotional attachment to the fetus.
Key words: maternal age / ART conception / pregnancy / psychological wellbeing
Introduction
Older maternal age at first birth is now a well-established demographic trend in high-income countries. Older women are more
likely to experience fertility problems and require assisted reproductive technology (ART) to conceive. Data from ART clinics in
Australia (Wang et al., 2009), Europe (Ziebe and Devroey,
2008), the USA (Gleicher et al., 2007) and Canada (Reproductive
Health Working Group, 2006) confirm increases in both the
number and average age of women receiving ART. This paper presents the first report from a prospective Australian study that aims
to provide contemporary evidence on the experience of first-time
pregnancy and parenthood at an older age. An important contribution is the inclusion of both women who conceive spontaneously (SC women) and women conceiving through ART at
different ages.
& The Author 2011. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
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C.A. McMahon 1,*, J. Boivin 2, F.L. Gibson 3, K. Hammarberg 4,
K. Wynter 4, D. Saunders5,6, and J. Fisher 4
2
women conceiving through ART frequently exclude women with multiple pregnancies and/or donated gametes (Hammarberg et al., 2008).
Few studies, to date, have focused explicitly on the impact of
maternal age on psychological adjustment during pregnancy. Berryman
and Windridge (1996) reported that after controlling for parity, education and occupational status, older mothers (.35 years) reported
lower levels of maternal –fetal attachment than did younger mothers
(women in their 20s) at mid-pregnancy, but these differences were
no longer apparent in late pregnancy. No measures of pregnancyfocused (P-F) anxiety, pregnancy complications or prior pregnancy
loss were included in this study, and infertility history and mode of
conception were not reported. More recently, McMahon et al.
(2007) compared older (≥38 years) and younger (≤35 years)
women conceiving with ART on various indices of adjustment
during pregnancy. There were no age differences for mood state
and, contrary to prediction, no age differences were observed in
anxiety about the pregnancy outcome or fetal attachment, assessed
in the third trimester. This may have been related to limited statistical
power in this small sample (n ¼ 67) and the relatively small age difference between the age groups. Further, since all women in the
McMahon et al. (2007) study conceived using ART, it is possible
that the impact of infertility and ART outweighed any age differences.
The current study therefore addresses a gap in the literature by examining maternal age effects in SC women as well as those who conceive
through ART.
The role of psychosocial factors in attenuating the impact of biological risk for older mothers has not yet been empirically investigated.
Although several studies of parenting have demonstrated that psychological maturity (generally conceptualized as adaptive competence and
flexibility) is associated with more sensitive child-centred parenting
(see Belsky and Barends, 2002, for a review), few have examined
associations between maturity and maternal age, and studies have
not yet explored whether psychological maturity influences the
relationship between age and pregnancy adjustment. McMahon et al.
(2007) found that compared with their younger counterparts (aged
,35 years), older mothers (aged 38 years and older) conceiving
through ART scored higher on psychological hardiness (Maddi and
Khoshaba, 2001), a measure that assesses adaptive flexible responsiveness to stress, characterized by commitment, a sense of control
and enjoyment of challenge.
It is well recognized that stable supportive intimate relationships are
advantageous during the transition to parenthood (Belsky and
Barends, 2002). However, the relationship context of pregnancy, presumed to be more stable, may in fact be more complicated for older
compared with younger women. Given trends to delay partnering
(Birrell et al., 2004), older first-time parents may embark on pregnancy
after a relatively short time together or while in a de facto relationship.
Further, older women having first babies are more likely to be in a
second marriage and/or have a partner who already has children,
factors which may increase relationship tension during the transition
to parenthood (Khesgi-Genovese and Genovese, 1997). One study
notes that older mothers conceiving through ART and their partners
(with children aged 4 –9 years) reported less expressive warmth in
their partner relationship compared with younger mothers and their
partners (Boivin et al., 2009).
This paper is the first report from the Parental Age and Transition
to Parenthood Australia (PATPA) study, a prospective study that
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Definitions of ‘older’ mothers vary in the research literature. Some
studies focus on chronological age and the social meanings and consequences of having a baby at different ages (Billari et al., 2010), whereas
others focus on biological ageing and reproductive consequences. A
cut-off of .35 years, when age-related infertility becomes more
common, is used to define ‘older’ in many studies with a biological
focus (Collins and Crosignani, 2005), whereas recent studies of
psychological adjustment related to maternal age in women conceiving
through ART have defined older mothers as 38 years or older
(McMahon et al., 2007; Boivin et al., 2009). Gleicher et al. (2007)
argue that ‘the age of 37–38 years, when the female fertility decline
accelerates, would appear a more logical point of definition for the
beginning of advanced reproductive age’ (p. 640). Mirowsky and
Ross (2002) analysed age-related associations between depression in
women and parenthood in a large sample (n ¼ 2592) and found a
parabolic association with higher depression scores reported by
women who had first babies at younger and older ages, and optimal
scores for those giving birth at 30 years. They noted that the psychosocial benefits of older maternal age may cease to apply after the age
of 36 years.
In this prospective study, we used projected age at the expected
date of delivery to derive age groups to enable comparisons with
other large databases of published maternal age data in Australia
(e.g. Births, Australia, 2009) and defined older mothers as 37 years
or older and younger mothers as 20–30 years of age for descriptive
purposes; however, we test our study hypotheses using age as a continuous variable.
The biological context of pregnancy changes with increasing
maternal age. As they age, women are more likely to experience fertility difficulties and need ART to conceive (Collins and Crosignani,
2005). There is a linear decline in live birth rates per ART cycle
with increasing age as well as greater likelihood of conception using
donated eggs or embryos, and multiple pregnancies (Wang et al.,
2009). Furthermore, rates of miscarriage and pregnancy complications, such as hypertension, diabetes, placental abruption and placenta previa, increase with older maternal age (Heffner, 2004,
Joseph et al., 2005).
Understanding the impact of this biological risk context on general
mood, specific anxiety about the pregnancy and feelings of attachment
towards the unborn baby is important given growing research evidence of associations between anxiety in pregnancy and less optimal
cognitive, temperamental and behavioural outcomes in infants during
the first post-natal year (see Talge et al., 2007, for a review). A systematic review of psychological aspects of pregnancy after ART
(Hammarberg et al., 2008) concludes that compared with SC women,
women conceiving through ART consistently report fewer depressive
and general anxiety symptoms, but higher anxiety about the pregnancy
outcome and fetal health. Study findings regarding fetal attachment
after ART are inconclusive with some studies reporting no differences
compared with SC women from a similar socio-economic background
(e.g. McMahon et al., 1997; Hjelmstedt et al., 2006) and others (Fisher
et al., 2008) reporting higher scores on a measure of maternal–fetal
attachment for women pregnant as a result of ART compared with
data from a normative sample. Studies of women conceiving
through ART typically control for maternal age, however, and most
have not taken adequate account of the psychosocial and reproductive
history factors associated with ART conception. Further, studies of
McMahon et al.
3
Age, conception mode and wellbeing during pregnancy
seeks to examine the impact of maternal age and mode of conception
on adjustment during the transition to parenthood. The study design
acknowledges the complex interactions among age-related biological
and socio-economic factors and their likely influence on the magnitude
and nature of age effects on the outcomes of interest. First, we
describe relationships between maternal age, mode of conception
and demographic and psychosocial factors that may influence adjustment during pregnancy. Next, we test a model to investigate
whether age and mode of conception effects are mediated by these
contextual factors. Given considerable medical concern regarding
delayed childbearing (e.g. Bewley et al., 2005), we have chosen to
test the proposition that adjustment during pregnancy for older
mothers will be more problematic.
Materials and Methods
The ethics committees at Macquarie University, University of Melbourne,
relevant hospitals and the participating ART clinics provided approval for
the study. Our stratified sampling strategy involved recruiting approximately equal numbers of women who were in the third trimester of pregnancy and had either conceived through ART or SC across three age
groups based on expected age at delivery: ‘younger’, 20 – 30 years;
‘middle’, 31–36 years; and ‘older’, ≥37 years. Inclusion criteria were
intentionally broad (e.g. women with donor eggs, embryos, twin pregnancies, single women using donor sperm and ART were included) to ensure
a representative sample of older mothers and women using ART to conceive. Nulliparous women aged 20 years or older in metropolitan Sydney
and Melbourne were informed of the study through ART clinics and
through antenatal clinics and classes in public and private hospitals
co-located or associated with the ART clinics. Only women with
inadequate English to complete the study measures were considered ineligible. Participation involved a computerized telephone interview and the
completion of questionnaires in pregnancy (current paper) and at 4
months after the birth. A priori power calculations focused on group
differences between age groups. For the present analyses, a power calculation using G*Power (Buchner et al., 1997) based on the regression effect
size and 18 potential predictors (effect size f2 ¼ 0.15, a ¼ 0.05, power ¼
0.95) demonstrated a minimum total sample size of 213, which was
exceeded.
Participants
The participation rate was 67% (793 of 1179 women approached), and
78% (619 of 793 consenting women) completed both interview and questionnaire measures during the third trimester of pregnancy. The 98
women who were interviewed and subsequently did not return questionnaires were significantly less socio-economically advantaged (less likely to
have private health insurance and university education, P ¼ 0.000). Mean
gestational age at interview was 31.6 weeks, SD ¼ 2.5 weeks, range ¼
25 – 40 weeks.
Participants were socio-economically advantaged as is typical in volunteer samples; most were university educated (66%), in professional occupations (75%) and from English-speaking backgrounds (82%). With regard
to the relationship context, 78% of participants were married, 23% had
been previously married and 5% had stepchildren. All women classified
as conceiving through ART had experienced oocyte retrieval and
embryo transfer (with fresh or frozen embryos) after IVF or ICSI. Some
had also used donor gametes: 18 had used donor sperm, 9 donor eggs
and 2 donor embryos. Women classified as SC had conceived without
Materials
Interview: pregnancy context variables
Socio-economic and reproductive history variables. During a computerassisted telephone interview conducted in the third trimester, participants
provided information on education, current employment and occupational
status, language spoken at home, marital status, whether previously
married, whether they had stepchildren and home ownership. They
were also asked about time to conceive, number of ART attempts,
whether the pregnancy was intended, multiple pregnancy, prior miscarriages or induced abortions, and presence of gestational complications,
such as hypertension, gestational diabetes and bleeding. Data regarding
the use of donor gametes were collected from medical records at the
ART clinics.
Questionnaires
Anxiety. Anxiety was assessed with the State-Trait Anxiety Inventory
(STAI; Spielberger et al., 1983). The STAI consists of two 20-item parts
addressing current (state) and general (trait) feelings of anxiety and
worry. Scores for each item range from 1 to 4 with higher total scores indicating greater anxiety. Cronbach’s a coefficients in this sample were 0.86
and 0.91 for the state and trait measures, respectively. Previous Australian
research with pregnant women has confirmed that a score of .40 on the
A-Trait and A-State measures is indicative of clinically significant anxiety
(Grant et al., 2008).
Depression. Depression was assessed using the 10-item Edinburgh Postnatal Depression Scale (Cox et al., 1987). Scores for each item range
from 0 to 3, yielding a possible total score between 0 and 30. Higher
scores denote more depressive symptoms. The measure has also been
validated for use in pregnancy, where scores ≥13 and ≥15 indicate
minor and major depression, respectively (Murray and Cox, 1990). In
pregnancy, and in this paper, the measure is referred to as the Edinburgh
Depression Scale (EDS). Cronbach’s a in the current study was 0.86.
P-F anxiety. Participants completed the five-item ‘Anxiety concerning
Health and Defects in the Child’ scale from the Baby Schema questionnaire (Gloger-Tippelt, 1983). Responses are rated on a six-point scale
ranging from 1 (strongly disagree) to 6 (strongly agree), with higher
scores indicating more anxiety. The scale has good reliability, with Cronbach’s a ¼ 0.89 in the current sample. Previous research shows a low
but significant correlation with the A-state measure (McMahon et al.,
2007).
Maternal –fetal attachment. The extent to which pregnant women engage
in behaviours and thoughts that represent an affiliation with their unborn
child was measured using the Maternal– Fetal Attachment Scale (MFAS;
Cranley, 1981). Items are scored on a five-point Likert scale ranging
from 0 (definitely no) to 4 (definitely yes) with higher scores indicating
more intense attachment (but note transformation in data analysis).
One item ‘I keep wondering what sex the baby is’ was removed as
many contemporary mothers would know the sex of their baby. The
Cronbach a coefficient for the amended scale was 0.81.
Proposed mediator variables
Hardiness. The Personal Views Survey (3rd edn, rev., or PVS-III-R; Maddi
and Khoshaba, 2001) is an 18-item measure designed to assess
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Procedure
any medical assistance. It should be noted that in Australia, ART is well
subsidized by the national universal tax-payer funded Medicare and
Pharmaceutical Benefit Schemes and therefore more affordable than in
most other countries.
4
psychological hardiness, a construct similar to resilience which taps the
ability of individuals to turn stressful circumstances into growth-inducing
experiences. Items are rated on a four-point scale from 0 (not at all
true) to 3 (very true). Higher scores indicate more hardiness (resilience).
Reliability for the total questionnaire was 0.80 in the current sample.
Quality of intimate partner relationship. The 24-item Intimate Bonds
Measure (IBM; Wilhelm and Parker, 1988) assesses two dimensions of
the perceived quality of the partner relationship: the care dimension
(IBM Care) gauges expressed warmth and affection, whereas the control
dimension (IBM Control) assesses the extent to which the partner tends
to control or criticize. Items are rated on a Likert scale (0 – 3) and
higher scores indicate higher perceived care (more optimal) and control
(less optimal), respectively (but see transformation in data analysis). The
Cronbach a’s were 0.93 and 0.83 for IBM Care and IBM Control,
respectively.
Less than 5% of questionnaire items were missing. We prorated when
there were fewer than 10% of items missing and for the P-F anxiety
measure where one-fifth of the items was missing; however, reliability
for this scale was high (a ¼ 0.89).
As data screening revealed significant skewness (≥2.58, P , 0.001)
towards more positive adjustment on EDS depression, STAI anxiety and
MFAS attachment, a square root transformation was applied to these variables. IBM Care and IBM Control variables were more extremely skewed
(also towards favourable adjustment) and a logarithmic transformation was
applied. Because IBM Care and MFAS attachment were negatively skewed
(most scores at the top end of distribution), scores were reflected before
transformation such that higher scores on transformed variables indicate
less favourable adjustment. These variables have been relabelled R-IBM
Care and R-MFAS to remind the reader of reverse scoring. Three outliers
(extreme low scores) detected on hardiness were changed to scores
within three SDs of the mean (i.e. Winsorized). The A-State and
A-Trait measures were highly correlated (r ¼ 0.75) so analyses used
only the state measure. P-F anxiety had a low but significant correlation
with A-State (r ¼ 0.28), P , 0.05. All data analyses are calculated on
transformed scores. To allow cross-study comparisons, data values in
tables were untransformed. For all analyses, probability values P ≤ 0.05
were considered significant.
Results
After recruitment, 27 women (8 aged 20 –30 years; 10 aged 31 –36
years and 9 aged ≥37 years) reported fertility treatment (ovulation
induction or artificial insemination without IVF) and were excluded
as they did not meet criteria for either ART (Zegers-Hochschild
et al., 2006) or SC. Thus, the final sample for this paper comprised
592 women: 178 in the younger age group (mean ¼ 28.4 years,
SD ¼ 2.0, range ¼ 20–30); 218 in the middle age group (mean ¼
33.6 years, SD ¼ 1.8, range ¼ 31 –36) and 196 in the older age
group (mean ¼ 39.4 years, SD ¼ 2.2, range ¼ 37– 51). We had
aimed to sample approximately equal numbers of ART and SC
women in each age group. This objective was achieved for the
middle age group (47% ART); however, the younger age group comprised 31% and the older age group 71 % of women, respectively, who
conceived through ART.
Socio-economic context
x 2 analyses were used to compare the three age and two mode of
conception groups for categorical variables and one-way analysis of
variance and t-tests were used for continuous variables. There were
few between-group differences and significant differences are summarized below.
Age group differences
Younger mothers were less likely to have purchased a home (61%
compared with 75 and 77% in the middle and older age groups,
respectively), and less likely to be employed in a professional occupation (65% compared with 76 and 83% in the middle and older
groups, respectively). Older mothers differed from the other two
age groups with regard to the relationship context: they were the
least likely to be married (70% compared with 83% in the middle
and 81% in the younger age groups). Forty per cent of mothers in
the older age group had been previously married compared with
22% in the middle and 7% in the younger age groups. Mothers in
both the middle and older age groups were more likely than
younger mothers to have stepchildren [all x 2 values (df ¼ 2) were
.10.0; all P , 0.025].
Mode of conception differences
Eighty-five per cent of women conceiving through ART had purchased
a home compared with 63% of SC women. Women conceiving
through ART were more likely than SC women to be married
(85 versus 73%, respectively) and less likely to be in the paid workforce in the third trimester of pregnancy (70% ART versus 88% SC)
[all x 2 values (df ¼ 1) were .4.0; all P , 0.025].
Reproductive history
Age group differences
Time to conceive the pregnancy increased across the young, middle
and older maternal age groups, irrespective of mode of conception
(SC: 3, 6 and 14 months, respectively; ART: 30, 35 and 39 months,
respectively), F(2,591) ¼ 10.7, P , 0.001. Older women were more
likely to have experienced prior miscarriage compared with women
in the middle and younger age groups (36% versus 22 and 19%,
respectively) with similar results for termination (22% versus 12 and
10%, respectively). Among SC women, those from the younger
(28%) and older age groups (26%) were more likely than those in
the middle age group (16%) to have an unintended pregnancy
[all x 2 values (df ¼ 2) were .6.0; all P , 0.025].
Among women conceiving through ART, those in the older age
group required more treatment cycles to achieve a pregnancy
(older: mean ¼ 4.3 cycles, SD ¼ 4.7; middle: mean ¼ 3.1 cycles,
SD ¼ 2.8; younger: mean ¼ 2.4 cycles, SD ¼ 1.9), F(2,295) ¼
6.21, P , 0.001. Older mothers were also more likely than their
younger counterparts to conceive using donor gametes (older 18%,
middle 3% and younger 2%). All x 2 values (df ¼ 2) were .12.0; all
P , 0.001.
Mode of conception differences
As expected, women conceiving through ART took longer
(mean ¼ 35.22 months, SD ¼ 25.47) to conceive than SC women
(mean ¼ 7.91 months, SD ¼ 15.60), t(590) ¼ 25.80, P , 0.001.
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Statistical analyses
McMahon et al.
5
4.1a (4.3)
3.9 (4.7)
4.2 (3.8)
4.6a (5.0)
4.8 (5.3)
3.9 (4.4)
IBM Control‡,1
ART, assisted reproduction techniques; SC, spontaneous conception; STAI, State-Trait Anxiety Inventory; EDS, Edinburgh Postnatal Depression Scale; P-F anxiety, pregnancy-focused anxiety; MFAS, Maternal Fetal Attachment Scale.
‡
Analyses were conducted using transformed values but means are from untransformed data.
*Women without a partner did not complete IBM Care (n ¼ 581) and IBM Control (n ¼ 572).
1
Age groups differ at P ≤ 0.05; cells with different superscripts are significantly different.
2
Mode of conception groups differ at P ≤ 0.05.
4.3 (4.9)
3.7 (3.8)
3.5 b (4.0)
4.1 (4.8)
31.8 (6.0)
30.8 (6.9)
3.2 (3.6)
40.7 (5.6)
30.6 (7.7)
30.9 (6.6)
31.8 (6.0)
31.7 (6.6)
31.9 (5.2)
32.6 (4.5)
32.6 (4.4)
32.6 (4.7)
IBM Care *
38.4 (5.8)
Hardiness1 (n ¼ 583)
Psychosocial mediator variables (mean, SD)
30.9 (6.6)
41.5b (6.0)
40.3b (5.5)
39.9 (5.6)
40.7 (5.3)
38.9 (5.3)
38.8a (5.5)
68.9 (9.1)
69.4a (9.6)
68.6 (9.9)
71.1 (8.7)
MFAS‡,1 (n ¼ 592)
‡,
66.8 (10.1)
67.1b (9.7)
41.7 (4.9)
41.6 (7.2)
39.8 (5.9)
67.4 (10.4)
68.5 (9.4)
66.9b (10.3)
66.4 11.7
66.4 (11.6)
5.8 (4.6)
17.9 (6.1)
19.3 (6.3)
18.8 (6.5)
17.8 (6.7)
19.2 (6.3)
18.1 (6.1)
P-F anxiety2 (n ¼ 592)
17.6 (6.3)
17.7 (6.1)
20.1 (5.9)
18.3 (6.2)
19.2 (6.1)
4.6 (4.1)
4.6b (4.1)
5.4 (4.3)
32.7 (9.6)
30.4 (7.4)
31.0 (8.6)
32.7 (11.6)
30.0 (7.0)
4.4 (4.1)
5.1b (4.3)
31.5 (9.0)
32.2 (9.7)
5.6 (4.3)
4.5 (4.3)
30.8 (8.9)
32.4 (8.0)
6.0a (4.5)
6. 3 (4.7)
5.3 (4.0)
SC
Total
SC
33.1 (8.6)
31.0 (7.0)
Total
SC
..............................................
ART
ART
Total
............................................
ART
EDS depression1,2 (n ¼ 591)
SC (total)
ART (total)
>37 years, M 5 39.4, SD 5 2.2
(37 –51)
..........................................
STAI2 state anxiety (n ¼ 590)
Dependent variables
Women conceiving through ART had lower (more optimal) scores for
EDS depression [F(1,589) ¼ 13.45, P ¼ 0.001] and STAI state
anxiety [F(1,588) ¼ 9.14, P ¼ 0.003]. Ten per cent and 17% of SC
women compared with 6 and 13% of women conceiving through
ART reported clinically elevated scores for depression and anxiety,
respectively, but these differences were not significant (P . 0.10).
ART women differed, however, in reporting higher (less optimal)
scores for P-F anxiety [F(1,590) ¼ 7.40, P ¼ 0.007] compared with
SC women (Table I).
ART mothers did not differ from SC mothers on R-MFAS fetal
attachment, hardiness or perceived care (R-IBM Care) and control
(IBM Control) in the partner relationship (P . 0.10).
..........................................................................................................................................................................................................................................................
Mode of conception differences
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Overall, 8% of women reported EDS depression scores .13,
suggesting possible clinical depression and 15% reported A-State
scores in the probable clinical range. There were no significant age
group differences in the proportions of women with EDS and
A-State scores in the clinical range (P . 0.10). There were,
however, age group differences for EDS symptom scores
[F(2,588) ¼ 5.13, P ¼ 0.010], with women in the younger age
group reporting higher depression scores than those in the middle
and older age groups. It should be noted, however, that mean
scores were well below the clinical cut-off, indicating marginally
higher distress but not more clinically significant depression
(Table I). Age groups did not differ on state anxiety symptom
scores or P-F anxiety (P . 0.10).
There was a significant age group difference on R-MFAS fetal attachment [F(2,589) ¼ 3.12, P ¼ 0.048], with transformed scores indicating that women in both the older and middle age groups reported less
intense emotional attachment to the fetus than did younger women.
Age groups differed on two of the proposed mediator variables, the
personality variable hardiness [F(2,589) ¼ 11.03, P , 0.001] and
one of the partner relationship factors, IBM Control [F(2,578) ¼
2.98, P , 0.05]. The younger age group reported lower (less
optimal) scores for hardiness compared with mothers in the middle
and older groups, whereas older women reported lower (more
optimal) scores than those in the middle and younger age groups
for perceiving their partner as controlling.
31 –36 years, M 5 33.6, SD 5 1.8
(31–36)
Age group differences
≤30 years, M 5 28.4, SD 5 2.0
(20– 30)
Pregnancy adjustment
Age group at expected date of delivery (range)
Women conceiving through ART were also more likely to have
experienced a previous miscarriage (ART 33%; SC 19%) and to
report at least one gestational complication (e.g. bleeding, hypertension, gestational diabetes) in the current pregnancy (ART 36%; SC
27%); all x 2 values (df ¼ 1) were .5.0; all P , 0.025. As these differences in reproductive history may influence the overall experience of
pregnancy and particularly may impact on anxiety about the pregnancy
outcome, they were examined as potential mediators in multivariate
analyses. See Supplementary data, Tables S1 and S2, for full details
on age and mode of conception differences in demographic variables
and reproductive history.
Table I Results from study of age at first birth, mode of conception and psychological wellbeing in pregnancy, showing mean (SD) values for dependent and
mediator variables according to age group and mode of conception.
Age, conception mode and wellbeing during pregnancy
6
Multivariate analyses
Next, we examined relationships between age (as a continuous variable) and the dependent variables (i.e. EDS, STAI, P-F anxiety and
R-MFAS attachment), as well as the potential mediator variables
(demographic variables, reproductive history variables, hardiness,
R-IBM Care and IBM Control). In order to test for mediation, predicted age at birth should be related to the dependent variables and
to the potential mediators (i.e. mode of conception and other demographic, psychosocial and reproductive history variables) and these
mediators should be significantly related to the dependent measures
(Baron and Kenny, 1986).
Mediation and moderation
Hardiness/resilience and perceived care (IBM Care) in the partner
relationship were significantly related to better adjustment on all
dependent variables, whereas greater reported partner control (IBM
Control) in the relationship was associated with more depression.
Of the demographic and reproductive history variables, only three
were significant. Living in rented accommodation was associated
with more depression, having stepchildren was associated with
more P-F anxiety and a short time to fall pregnant was associated
with less P-F anxiety.
Discussion
The results of this study show that personality and context factors
(mainly the quality of the relationship with the intimate partner) are
more important than age in predicting pregnancy mood (both
depression and anxiety symptoms) and also pregnancy-specific adjustment (P-F anxiety, fetal attachment). The favourable factors are having
a hardy (resilient/adaptive) personality and a less controlling partner,
and together these attenuate most age effects on global emotional
adjustment during pregnancy.
ART conception, however, sets the stage for a more complex
experience of pregnancy with women conceiving through ART simultaneously experiencing more P-F anxiety and more intense feelings of
attachment to the growing fetus. Although P-F anxiety was no longer
significantly higher for ART women when reproductive history factors
were controlled for, the association between ART conception and
more intense fetal attachment can be attributed directly to having
required fertility treatment to conceive rather than to personality, contextual or age factors. Despite reporting higher P-F anxiety, women
conceiving by ART reported lower symptoms of depression and
anxiety than did SC women. Taken together, these results indicate
that if a pregnancy is achieved, childbearing at an older age
(whether using ART or not) is not associated with more problematic
anxiety and depression symptoms during pregnancy and therefore
unlikely to lead to adverse effects reported in association with
effects of maternal mood on the developing fetus (Talge et al., 2007).
The relatively low correlation between P-F anxiety and state anxiety
in this study confirms that P-F anxiety needs to be considered as a separate construct from more generalized anxiety. Indeed, women conceiving through ART reported higher P-F anxiety alongside more
positive mood, a finding consistent with previous research suggesting
that the experience of pregnancy is qualitatively different in this
context (Hammarberg et al., 2008). Further research on the implications of P-F anxiety in women conceiving through ART is needed.
As noted earlier, associations between anxiety in pregnancy and less
optimal cognitive, temperamental and behavioural outcomes in
infants during the first post-natal year have been reported in a
number of studies and these effects are hypothesized to result from
physiological influences of maternal stress hormones on the developing fetus (see Talge et al., 2007, for a review). However, the mixed
emotions (low depression and state anxiety, but high P-F anxiety)
characterizing ART pregnancies and the fact that P-F anxiety may be
based on a particular reproductive history rather than intrapsychic
(trait) factors may differentiate these pregnancies from other stressful
pregnancy contexts.
In the current study, it should be noted that once reproductive
history factors were included as control variables, the difference
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As we wanted to disaggregate the effects of predicted age at birth
from mode of conception as well as from the more generic mediators,
we built a hierarchical regression model using the following sequence
of entry: predicted age at first birth (Step 1), mode of conception
(Step 2), interaction between age at birth and mode of conception
(Step 3a) and mediators (Step 3b). Only mediators that showed marginal or significant associations with the dependent measure at the univariate level were included. Table II shows correlations between
predicted age at first birth (column one) and mode of conception
(column two) and proposed mediator variables, as well as summary
results for the hierarchical regression analyses. Age at first birth was
significantly correlated with all mediators except twin pregnancy and
the presence of one or more gestational complications. Mode of conception was significantly correlated with a subset of mediators: marital
status, previous marriage, home ownership, prior miscarriage, time to
fall pregnant, likelihood of multiple pregnancy and gestational
complications.
All regression models were significant with 7.2 –22.6% of variability
in the psychosocial adjustment measures explained by study variables.
Expected age at birth was correlated with all dependent variables
except for P-F anxiety as shown by significant standardized coefficients
for the main effect of age (Step 1). Specifically, older maternal age was
associated with lower scores on the measures of depression symptoms, state anxiety and maternal –fetal attachment. When mode of
conception was entered into the model (Step 2), it attenuated the
association between age and state anxiety, but not the associations
between maternal age and depression or between maternal age and
fetal attachment, both of which remained significant. Mode of conception was significantly related to all dependent variables and was
associated with more favourable adjustment in all cases except for
P-F anxiety, where using ART was associated with higher P-F
anxiety. The interaction between age and mode of conception (Step 3a)
was not significant for any dependent measure.
The final step of the model (Step 3b) shows changes in associations
related to contextual factors. Overall, the main effects of age and
mode of conception were attenuated, with maternal age and mode
of conception effects becoming non-significant after entry of these
variables. The only exception was for maternal– fetal attachment,
where the association with mode of conception emerged as significant
after entering mediator variables. After controlling for contextual
factors, women who used ART reported a more intense emotional
attachment to the fetus than SC women.
McMahon et al.
Variable
Age at first birth,
zero-order correlation
Mode of conception,
zero-order correlation
EDS depression
(n 5 569)
STAI anxiety
(n 5 573)
P-F anxiety
(n 5 574)
R-MFAS†
attachment
(n 5 580)
..........................................................................................................................................................................................................................................................
Step 1: Main effect age
Predicted age at first birth
R 2△ ¼ 0.01*
R 2△ ¼ 0.00
R 2△ ¼ 0.01*
20.15***
20.09*
0.07
0.10*
R △ ¼ 0.01**
R △ ¼ 0.01**
R △ ¼ 0.01*
R 2△ ¼ 0.01*
(20.12**)
(20.06)
(0.03)
(0.13**)
20.11**
20.11**
0.11**
20.10*
R 2△ ¼ 0.00
R 2△ ¼ 0.00
R 2△ ¼ 0.00
R 2△ ¼ 0.00
2
Step 2: Main effect age in presence of ART
Predicted age at birth
Mode of conception (0 ¼ ART, 1 ¼ SC)
R 2△ ¼ 0.02***
0.33***
Step 3a: Interaction of age and mode of conception
2
2
Age × mode of conception
20.03
20.05
20.02
0.00
Step 3b: Age and ART in presence of mediators
R 2△ ¼ 0.15***
R 2△ ¼ 0.22***
R 2△ ¼ 0.07*
R 2△ ¼ 0.06***
Predicted age at birth
(20.00)
(0.05)
(20.00)
(0.16)
Mode of conception
(20.07)
(20.08)
0.07
20.09*
—
—
—
—
20.02
20.01
—
—
University education (0 ¼ no, 1 ¼ yes)
0.09*
20.05
Language spoken in home (0 ¼ mixed, 1 ¼ English
only)
0.10*
0.07
Marital status (0 ¼ not married, 1 ¼ married)
0.09*
20.04
—
—
—
Previous marriage (0 ¼ no, 1 ¼ yes)
0.34***
0.11**
—
—
—
—
Stepchild(ren) (0 ¼ no, 1 ¼ yes)
0.11**
0.04
—
—
0.10**
—
20.01
—
—
—
20.11**
20.05
0.07**
—
Occupational status (1 ¼ professional, 2 ¼ other)
Purchased home (0 ¼ no, 1 ¼ yes)
20.11**
20.19***
0.16***
20.06
0.29***
Age, conception mode and wellbeing during pregnancy
Table II Summary statistics for hierarchical regression testing mediation and moderation in adjustment to pregnancy.
Psychosocial
Hardiness/resilience
0.17***
0.08
20.26***
20.35***
20.14***
20.18***
R-IBM Care†
0.08*
0.02
0.09*
0.16***
0.09*
0.11**
0.14***
0.07**
—
—
—
—
0.06
—
—
—
—
—
R-IBM Control†
20.11**
20.06
Reproductive history
Previous miscarriage (0 ¼ no, 1 ¼ yes)
0.18***
Previous termination (0 ¼ no, 1 ¼ yes)
0.14***
a
0.17***
20.03
Time to pregnancy (months)
0.32***
0.57***
0.02
20.00
20.10*
—
Twin pregnancy (0 ¼ singleton, 1 ¼ twins)
0.06
0.14***
—
—
—
—
One or more gestational complications
0.07
0.11***
—
—
0.06
20.07
R 2 ¼ 0.17***
R 2 ¼ 0.23***
R 2 ¼ 0.08***
R 2 ¼ 0.07
Overall model significance
(—) indicates variable not meeting the threshold for inclusion in model in bivariate analyses.
a
Women with unplanned pregnancies assigned a time to pregnancy ¼ 0. Sample size varies owing to missing data.
†
Because IBM Care and MFAS attachment were negatively skewed, scores were reflected before transformation such that higher scores on transformed variables indicate less favourable adjustment. These variables have been relabelled R-IBM
Care and R-MFAS, as a reminder of reverse scoring.
*P , 0.05.
**P , 0.01.
***P , 0.001.
7
Downloaded from http://humrep.oxfordjournals.org/ by guest on June 11, 2014
8
understand the complex psychological construct of maturity and implications for adjustment to parenting.
Study strengths and limitations
This large prospective study represents a significant advance in examining both age and ART effects on adjustment during pregnancy, while
taking account of the many confounding variables that are associated
with but not caused by age. The sample was recruited systematically
from a range of clinical services in two Australian states and was of sufficient size to allow us to take account of a large number of potential
age-related confounds, most notably mode of conception. Importantly, our sampling strategy allowed us to consider separate and combined effects of maternal age and ART conception.
The step-wise approach in multivariate analyses showed that mode
of conception explained some but not all of the age effects and there
was no evidence that the effect of age differed according to mode of
conception, nor that their effects were additive. This lack of interaction between age and mode of conception may be attributable to
the fact that those contextual factors that may make the transition
to parenthood easier (e.g. high socio-economic status) or more difficult (e.g. time to conceive, pregnancy complications) are present for
both older women and those conceiving through ART, and therefore,
joint effects are minimal.
Nonetheless, some limitations need to be acknowledged. First, the
participants were for the most part highly educated and well
resourced financially. Although this may be typical of samples of
older mothers and those using ART (Hammarberg et al., 2008), the
women having a first baby in their 20s who participated in this study
are unlikely to be representative of younger mothers in the population.
This suggests that findings regarding overall positive adjustment in
older mothers may be conservative, as they were compared for the
most part with younger mothers with similar socio-demographic
advantages. However, the comparability of the age groups in this
regard allowed a more robust test of pure age effects. We acknowledge that our sample spanned a broad age range with very small
numbers of women in their early 20s and mid-late 40s, respectively.
Future studies may like to consider a more detailed analysis of the
socio-economic and psychological characteristics of women in their
early versus late 20s, or late 40s versus late 30s, but meaningful comparisons would require sampling adequate numbers of women in
these more ‘atypical’ age groups for childbearing.
We also note as a limitation that our sampling goals regarding comparable numbers of young women conceiving through ART and older
SC women were not achieved, as these are both relatively rare
phenomena in the community. Nevertheless, this sample represents
the largest prospective cohort, to date, of older and ART mothers.
Finally, we included women expecting twins, women conceiving
using donor gametes, single women and women with same sex partners, to accurately reflect the diverse pregnancy context for older
first-time mothers. However, the sample sizes for these subgroups
were small and did not allow detailed analysis of the impact of these
characteristics on adjustment during pregnancy.
Conclusions
Our study findings are reassuring regarding the psychosocial wellbeing
of older mothers once a pregnancy is achieved and suggest that the
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between ART and SC women was no longer significant for P-F anxiety.
Oates (2002) cautions against making pregnant women worry about
worrying, and this may be particularly pertinent for women conceiving
through ART. These women often have complex histories of pregnancy loss and may need to be reassured by health-care providers
as their pregnancy progresses that most pregnancy losses occur in
the first trimester of pregnancy and that the risk of pregnancy loss is
low in later pregnancy.
Empirical evidence, to date, regarding maternal –fetal attachment in
women pregnant after ART conception is equivocal (Hammarberg
et al., 2008). In the current study, although univariate analyses
showed no differences in fetal attachment according to the mode of
conception, the multivariate analysis revealed that when the impact
of age was taken into account, a robust association between mode
of conception and more intense maternal –fetal attachment emerged.
Fisher et al. (2008) have reported intense protective and affectionate pre-occupation with the fetus in women conceiving through ART
compared with normative community data and suggested that the
combination of high fetal attachment and positive mood noted in
their sample (pregnancy-specific anxiety was not assessed) may indicate elation about the prospect of parenthood after a long period of
anticipation and effort to conceive. They caution that idealized expectations in pregnancy may contribute to vulnerability in adjusting to
early parenthood in women conceiving through ART. Assessing
mother to fetus attachment is important because it is associated
with self care in pregnancy and also predicts quality of parent to
infant attachment (Van den Bergh and Simons, 2009). Identification
of groups who might be vulnerable to either delayed or overly idealized fetal attachment has implications for targeted clinical care in pregnancy. Longitudinal data from the current prospective study may more
fully elucidate the relationship between a high intensity of fetal attachment in pregnancies conceived using ART, later parent–infant
relationships and the experience of parenthood.
Older maternal age was associated with socio-demographic factors
likely to contribute to optimal adjustment (home ownership, professional occupation), but associations between age and relationship
status were more complex. Although older mothers were less likely
to be married, more likely to be in a second marriage and more
likely to have stepchildren, all variables that may be presumed to
make relationship adjustment more challenging, they perceived their
partners as less controlling (more optimal) than women in the other
age groups. Expected age-related reproductive history factors were
confirmed, with older mothers taking longer to conceive and having
a history of more pregnancy loss, irrespective of mode of conception.
Of particular interest was the finding that psychological hardiness (an
index of adaptive personality functioning) was positively associated with
maternal age, confirming in this larger more representative sample
earlier findings reported by McMahon et al. (2007) that were specific
to women conceiving through ART. Further, hardiness was the variable
most strongly associated with positive indices of pregnancy adjustment.
This finding provides the first direct empirical support for largely speculative comments across a range of studies that psychological maturity
may be an advantage for older parents (e.g. Berryman et al., 1999; Bornstein et al., 2006). The hardiness construct has been shown to be closely
related to ego resilience (Gramzow et al., 2000), previously identified as
a predictor of positive adaptation across the transition to parenthood
(Heinicke, 1984). Further longitudinal research is needed to better
McMahon et al.
Age, conception mode and wellbeing during pregnancy
greater psychological hardiness among older women may be protective. Results confirm previous reports that women conceiving
through ART may have a qualitatively different experience of pregnancy: with higher pregnancy-specific anxiety juxtaposed with more
intense maternal –fetal attachment and lower levels of depression
and general anxiety symptoms. More research on the implications of
mixed emotions in pregnancy is needed using instruments that
capture both the highs and the lows of pregnancy and the fact that
these may co-occur (DiPietro et al., 2004). Finally, given the demographic shift to older first-time parenthood, it is also important to
acknowledge that this study has assessed wellbeing only in those
women who successfully achieved a pregnancy that survived until
the third trimester. Bearing in mind the compelling evidence of
age-related declines in fertility (Collins and Crosignani, 2005), it is
also important, therefore, to study psychosocial wellbeing in those
women who, having delayed parenthood for a variety of reasons,
are not able to achieve a pregnancy.
C.A.M. contributed to conceptualization, study design, to the first
draft and revisions of the manuscript and supervised data collection
in North South Wales; J.B. contributed to the conceptualization,
study design, data analysis and interpretation, first draft and revisions;
F.L.G. contributed to conceptualization and study design, drafting and
revisions; K.H. contributed to conceptualization and study design,
drafting and revisions; K.W. contributed to data analysis and interpretation, drafting and revisions; D.S. contributed to conceptualization,
study design, drafting and revisions; J.F. contributed to conceptualization and study design, drafting and revisions of the paper and supervised data collection in Victoria.
Supplementary data
Supplementary data are available at http://humrep.oxfordjournals.
org/.
Acknowledgements
The authors are grateful for assistance from IVF Australia and Melbourne IVF in identifying ART conceiving women and informing
them about the study, to Helene Seddon-Glass (NSW) and Turi
Berg (Victoria) who managed recruitment and data collection and to
the 619 participants who contributed their time and experiences.
Funding
This study was funded through an Australian Research Council (ARC)
Linkage Grant with contributions from Industry Partners IVF Australia
and Melbourne IVF.
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