In many countries, including the UK, a large proportion of care for women during pregnancy, labour and the postnatal period is provided by practising midwives (International Confederation of Midwives (ICM), 2011). While complications may occur in any pregnancy, there are specific risks to both mother and baby associated with advanced maternal age, defined as 35 years or older at the time of delivery (Cleary-Goldman et al, 2005). Primagravid women of advanced maternal age have a higher chance of experiencing complications during delivery due to rigidity of the birth canal, and women of any parity have an increased chance of having a baby with a chromosomal abnormality as they age (Munné et al, 2007). The risks of other complications such as placental abruption, placenta praevia and postpartum haemorrhage are also increased in older mothers, while their offspring are more likely to be stillborn or die in the neonatal period than babies of younger mothers (Royal College of Obstetricians and Gynaecologists (RCOG), 2013). However, the number of childbearing women of advanced maternal age is increasing globally; for example, birth rates in Canada are continuing to rise from 4.9% in 1981 to 19.2% in 2011 for this age group (Milan, 2013). In comparison, there is wider variation in European countries where birth rates for women of advanced maternal age in 2010 ranged from 10.9% in Romania to 34.7% in Italy (European Perinatal Health Report 2010). For the first time, the average age of mothers having their first child in Japan has risen above the age of 30, from 25.7 in 1975 to 30.1 in 2011 (Ministry of Health, Labour and Welfare 2013). In the UK the average age of first time mothers in England and Wales rose to 28.1 in 2012 from 26.8 in 2002 (Office for National Statistics (ONS), 2013a). Birth rates of mothers aged 35 years or over in England and Wales has continued to grow steadily from 13.7% of all births in 1997 to 19.8% in 2012 (ONS, 2013a).
Background
Women of advanced maternal age may feel additional concern about themselves and their baby during and after pregnancy because of the risks associated with childbearing in the late 30s and 40s. In Canada, Bayrampour et al (2012) compared perceptions of risk in mothers aged 35 years and over with their younger counterparts. The older women were more concerned about both themselves and their babies, with higher perceptions that they might die during pregnancy and that their children were more at risk of preterm birth and congenital abnormalities. In another study, women over 35 years were more likely to believe their infants had been at risk during labour than younger women (Windridge and Berryman, 1999). Lampinen et al (2009) reported that some pregnant women over 35 years did not have a supportive person to talk with about their concerns, which may place a greater emphasis on their relationship with the midwife.
One of the decisions facing women of advanced maternal age is whether to undergo screening or invasive testing (or both) to detect whether the baby has an abnormality (Fuchs and Peipert, 2005; Reid et al, 2009). In the past, the offer of testing for fetal abnormality was focused on women of advanced maternal age, who, for example, may have been offered amniocentesis or chorionic villus sampling because of the greater risk of having a baby with a chromosomal abnormality at that age (Bernhardt et al, 1998). In some regions, screening and testing is still based on advanced maternal age (Verma et al, 2003, Muhsen et al, 2010); however, in many others universal serum and ultrasound screening is offered to all women, regardless of age, as is the case in England and Wales (National Institute for Health and Care Excellence (NICE), 2008). This may have altered the focus on women of advanced maternal age and reduced the level of information and care offered to them during pregnancy.
The role of the midwife in the UK is regulated by the Nursing and Midwifery Council (NMC): his or her responsibility is primarily to meet the needs of the woman and her baby and to work in partnership with the woman and her family, providing care which is safe, responsive and compassionate throughout childbirth (NMC, 2012). In England and Wales, the National Screening Committee (NSC, 2011) programme for antenatal screening requires that midwives discuss the options for screening with all pregnant women, including those over 35 years. However, while midwives are provided with guidance and education on these issues (NSC, 2013), Skirton and Barr (2010) found that women and their partners were not sufficiently educated on screening issues to make an informed decision about the options available, while other authors suggested that routinisation of the screening tests by midwives reduced the emphasis on the need for parents to make a decision (Tsouroufli, 2011).
In many countries, the introduction of universal screening has shifted attention away from mothers of advanced maternal age with regard to fetal screening and testing. However, no studies that focus on this group were identified to ascertain whether their needs are currently being met by midwives. Therefore, this empirical study determined to explore this issue.
Aims and objectives
The aim of this study was to focus on the experiences of a particular subset of mothers who were 35 years and over at the time of the birth of their baby. While a number of issues were explored, this paper will report women's experiences of care provided by health professionals throughout their pregnancies.
The objectives were to:
Method
Participants
A cross-sectional survey design was used to gather both qualitative and quantitative data from women, who were eligible to participate in the study if they were aged 35 years and over at the time of birth and had given birth in the UK during the previous year.
Data collection
In order to recruit mothers from across the UK, the data were collected via an online questionnaire hosted on the Survey Monkey website between May and August 2012. Topics for inclusion within the questionnaire were developed in discussion between the authors and based on previous research (Skirton and Barr, 2007; Skirton and Barr, 2010; Barr and Skirton, 2013). A total of six questions concerned demographic data of participants, while a further 34 questions covered topics such as: ‘how you felt during your pregnancy’, ‘your care by midwives’, ‘perceptions and understanding of Down syndrome or similar conditions’, and ‘future care by midwives’. While there were a number of closed response questions, there were also multiple questions where the respondents could insert their own free text.
All questions and topics were refined and discussed with midwife colleagues and several recently delivered mothers over the age of 35 years. In order to enhance access by women from a wide geographical area who would have experienced care from a range of providers, the questionnaire was posted online, using a recognised data collection site Survey Monkey. The link to the online survey was then circulated via the use of the social media site Twitter.
Recruitment method
Twitter is a social networking site that allows users to send short messages publicly to other users, which are known as Tweets. Twitter was used to advertise the study (O'Connor et al, 2014). Tweets with brief details of the study were targeted at Twitter users who were likely to have followers who were childbearing women and asked them to retweet: (i.e. share the tweet with their own list of followers) the information and the link to the online survey.
Ethical considerations
Ethical approval was given by the NHS National Research Ethics Service Committee South West–Cornwall and Plymouth and the Plymouth University Research Ethics Committee. A website containing further information about the study, including a video of the participant information and contact details of the researchers was made available. Participants were assured that their responses would be confidential and not identifiable, in any way, in any future dissemination of the findings. After reading the explanation of the research study, participants were only able to proceed to take part in the online survey after they had indicated their consent to be involved.
Data analysis
Demographic information and responses of participants to quantitative questions were analysed using descriptive statistics. Analysis of the free-text data gathered via the open ended questions was undertaken using Thematic Analysis (Braun and Clarke, 2006). Each individual comment was coded independently by two researchers. These were then discussed in detail, grouped under categories and finally organised under themes (some of which are presented in Table 2). Any areas of divergence in the analysis were discussed until consensus was reached.
Rigour
Triangulation was achieved through the collection of both quantitative and qualitative data. Without reference to the quantitative results, analysis of the qualitative data was conducted, which enabled the results to be confirmed or refuted. To ensure trustworthiness and reduce the opportunity for subjectivity, the qualitative data were analysed independently by two researchers and then discussed until a consensus on the key themes was reached.
Results
A total of 529 women of advanced maternal age, who had given birth in the UK within the previous year, accessed the survey. The study initially aimed to recruit 100 mothers of advanced maternal age, but this figure was far exceeded. Of these, a total of 397 answered the relevant questions, a response rate of 75%. The quantitative and qualitative data will be presented in an integrated format, under the key themes identified during data analysis, supported by quotes from the women. The participant number is included in brackets after each quote.
For the purpose of this study, the main question focused on the care that participants had received from health professionals. Thematic content analysis revealed four main themes: 1) maternal concerns; 2) attitudes of health professionals; 3) disparities in care; and 4) health service organisation. Table 2 shows the themes and codes that were identified from within the data.
Demographic characteristics
The demographic characteristics of the participants are shown in Table 1. Approximately half (50.4%; n=200) of the respondents were aged 35–37, with the remainder aged 38–46 years. The majority (92.4%; n=367) stated that they were either married or living with their partner and the majority were in paid employment (72%; n=286). Over two thirds of the participants (66.8%; n=241) were educated to degree level.
| Age (in years) on the birth date of your (last) baby (or babies) | n=397 (%) |
| 35–37 | 200 (50.4) |
| 38–40 | 131 (33.0) |
| 41–43 | 59 (14.9) |
| 44–46 | 7 (1.8) |
| 47–49 | 0 (0.0) |
| Marital status | n=397 (%) |
| Married | 297 (74.8) |
| Living with your partner | 70 (17.6) |
| Single | 17 (4.3) |
| Divorced or separated | 13 (3.3) |
| Widowed | 0 (0.0) |
| Employment status | n=397 (%) |
| Working full time | 98 (24.7) |
| Working part time | 128 (32.2) |
| Not in paid employment | 85 (21.4) |
| Have a job but on maternity leave | 60 (15.1) |
| Other | 26 (6.5) |
| Education | n=361 (%) |
| Secondary school (GCSE) | 28 (7.8) |
| Apprenticeship | 1 (0.3) |
| A-Level, BTEC, HND or equivalent | 60 (16.6) |
| Diploma | 31 (8.6) |
| Degree | 241 (66.8) |
| Number of babies in last pregnancy | n=396 (%) |
| One baby | 375 (94.7) |
| Twins | 18 (4.5) |
| Triplets | 3 (0.8) |
| Care theme | Codes identified from data |
|---|---|
| Maternal concerns | Concerns for own health |
| Attitudes | Midwives had own agendas |
| Disparities in care | Lack of information given/poor advice given |
| Health service organisation | Busy hospitals/understaffed/no time |
Maternal concerns
Over half (56%) of the mothers said that they did not have thoughts about their own health in relation to their age during pregnancy; however, 62.8% did have specific concerns about their baby's health because of their own age. With regard to how much information mothers were given about the chances that their baby might have Down syndrome or other similar conditions, 55.5% said they received ‘some’ information while 22% received either none or very little information. Midwives predominantly (74.6%) discussed this information with mothers, with only 13.3% of participants receiving this information from their obstetrician and 3.4% from their general practitioner.
‘My wonderful community midwife batted my concerns away telling me 35 was no longer old to have a baby.’ (P51)
‘Everything you read is biased against older mothers. It makes you feel guilty for being pregnant and as if you are irresponsible.’ (P49)
‘…concerned baby would have medical issues/defects often associated with later pregnancies in life.’ (P54)
Information about screening (for conditions that could affect the baby), other than that provided by health professionals, was sought by 45.3% of mothers, with 88.3% using the Internet and 64.8% using books and leaflets. Other sources of information for mothers were friends and relatives (27.6%) and other parents (26.2%), only 5.5% sought information from support groups.
Attitudes of health professionals
The attitudes of health professionals towards mothers of advanced maternal age were frequently commented on by participants, with some experiencing negative comments relating to their age:
‘One midwife thought it was unusual that I was 38! Told me I was “no spring chicken”!’ (P30)
‘[I experienced] constant threats about my age and the impact on my unborn child. None factually based.’ (P136)
‘…was made to feel bad I was pregnant at 40, every single person asked if I conceived naturally…whole experience was made awful for no reason.’ (P202)
Other mothers reported that they or their partners felt patronised by midwives:
‘A bit controlling over options for birthing and quite patronising to my partner.’ (P39)
There were also accounts where mothers felt midwives had their own agenda about their antenatal care and birthing options, with instances of what they termed ‘scaremongering’ by midwives:
‘She [midwife] didn't listen to anything I said, had no regard for my preferences, was rude and unprofessional, would only consider her own point of view and said everything I wanted was wrong, she dismissed my plans for a home birth out of hand, and accused me of endangering my child when I went against her bogus advice.’ (P86)
‘Midwives have their own agenda and are led by their own views rather than considering what's best for the individual. I found and still find them rather bullying in nature.’ (P119)
Mothers also commented that they felt midwives assumed they had some ‘prior knowledge’ either because of previous pregnancies or because of their advanced maternal age. A concern was that this led to a difference in the type and quality of care they received:
‘As it was my second pregnancy even though older. They were a bit “well you've done this before so we really don't need to see you.”’(P174)
‘…had amazing midwife and doctors in labour ward but after-care on the ward left a lot to be desired. No help first day on ward and lots of assumptions made about what you knew.’ (P203)
Disparities in care
The overwhelming disparity of care received by mothers of advance maternal age, both pre- and postnatal, in community and hospital settings was evident throughout the data. Some participants reported having a positive experience and felt they had experienced excellent care from health professionals:
‘(midwife) was amazing, gave all antenatal care at home, gave her home number, attended the birth and has been fantastic postnatally too.’ (P198)
‘…same midwife all the way through. Had plenty of time with me. Helpful advice and I never felt under pressure.’ (P40)
However, many of the mothers felt that they received inadequate and poor care throughout their pregnancy: many of the concerns related to a lack of information provided by the midwife, along with inconsistent advice:
‘…midwife during pregnancy very poor, asked if I was doing a NCT course, when I said yes, she then said I should refer my questions to them.’ (P25)
‘My antenatal care was pretty bad. A lot of assumptions were made based on my weight, age and medical history.’ (P29)
While some mothers had supportive and caring midwives, others felt they had no confidence in their health professionals, creating anxiety in their pregnancy and leading some to consider alternative arrangements such as private health care or to change their primary care practice. There was evidence of mothers feeling that their concerns were ignored:
‘The midwife during the majority of my pregnancy was not approachable and never seemed to listen, resulting in my baby being born at 37 weeks due to gestational diabetes not being diagnosed until week 32.’ (P54)
Others felt that midwives were trying to do a good job, but that lack of staff ultimately led to inadequate care:
‘When I gave birth the unit was chronically understaffed (the midwives were lovely but over worked) after I gave birth my legs were ‘washed’ with paper towels.’ (P176)
This differing level of care was experienced by mothers both pre- and postnatally and in both hospital and community settings and is illustrated in Table 3, where examples from the data can be seen.
| Antenatal care (participant no.) | Postnatal care (participant no.) | |
|---|---|---|
| Community | ‘I was fortunate to live in an area where a community midwife scheme is available (midwife visited me at home throughout the pregnancy)’ (31) |
‘Post-birth health visitor visit was brilliant but home midwife care (2 visits) were hasty and rushed’ (151) |
| Hospital | ‘…however, though I had a number of appointments with a consultant, I only met with him twice, having to see a number of different registrars instead’ (128) |
‘Postnatal care was fantastic by staff nurses and clinical support workers. Didn't see a midwife on postnatal ward until discharge’ (106) |
When asked whether they felt their care differed in any way from previous pregnancies, 36.6% of mothers felt that it did:
‘As good if not better actually–more close care.’ (P40)
‘Very different, I was belittled and treated very much like I was a naughty girl for being pregnant.’ (P32)
However, only 45.1% felt that midwives could do something to improve their care of mothers over 35 years of age:
‘Yes, be more receptive to the fact they are dealing with grown-ups. I found them quite dismissive.’ (P25)
‘I think all midwives should improve their care for all mothers, but we need more midwives to enable this to happen.’ (P150)
With particular regard to screening for fetal abnormalities, 71.1% of mothers felt that they were supported in the decision-making process by health professionals.
Health service organisation
Mothers were asked to rate their overall care by health professionals during their last pregnancy on a scale of 1 to 7 scale, with 1 indicating poor care and 7, excellent care. In total, 32.4% of participants rated the care they received as 6, with 73.7% of mothers rating their care between 5 and 7. However, 26.3% of mothers rated their care as either equivocal or poor.
Many of the respondents referred to a lack of continuity of care. This was frequently because of appointments with different midwives in the community or due to mothers seeing different consultants at hospital throughout their consultant-led care:
‘No consistent pattern…saw loads of different people. Time between appointments was quite long.’ (P108)
‘Generally fine, but some consistency issues—never saw the same midwife twice.’ (P199)
‘Midwives were constantly changing in visits, different opinions, worried me for no reason.’ (P156)
In addition, there were frequent references to health professionals being rushed and overworked, resulting in a lack of care:
‘The maternity ward was extremely busy for the first two nights I was in…[I] had limited help.’ (P187)
‘Maternity ward was full so spent most of my labour in an antenatal ward. Was wheeled down for the last hour.’ (P191)
There were fewer examples of positive experiences by mothers with regard to organisation of the health service:
‘…same midwife all the way through. Had plenty of time with me. Helpful advice and I never felt under pressure.’ (P40)
Discussion
Although there were many positive responses regarding the care by health professionals of mothers of advanced maternal age, some women felt they had inadequate care. In some, but not all cases, women perceived inadequate care to be related to understaffing of maternity services. In particular, mothers reported that midwives employed in hospital settings often appeared to be too busy to offer appropriate levels of support. Some participants reported increased levels of anxiety due to a lack of consistency in care, lack of information and inconsistent advice, in both the hospital and community settings. The NMC (2013) provides clear guidance for nurses and midwives on raising concerns if they believe that care is being compromised. However, it was not within the remit of this study to report whether managers of these health professionals were made aware of the shortcomings in the care of these participants. In some cases, these shortcomings were more about loss of dignity or personal choice than risk of physical harm, but it is possible that harm could have occurred. It is also possible that some women were discouraged from acting on their own choices for care, due to the midwife's awareness of staff pressures.
While it is evident that women required information and support, many resented being patronised or subjected to ‘scaremongering’. These may have been the attitudes of a few individual midwives, but it breaches the boundaries of professional care by being too protective or by trying to influence women to adopt certain behaviours. The Code (NMC, 2008) sets the standards of care to which all midwives working in the UK are subject, and demands that women are treated with dignity, that midwives respond to their concerns and that they advocate for those in their care. This has been emphasised in the discussion around compassionate care and the values of care, compassion, competence, communication, courage and commitment (the 6 Cs) (Department of Health, 2012). However, some women in the study felt that their own choices (such as home birth) were ignored by midwives. It may be that midwives are genuinely concerned for the safety of women, but while risks do increase for older women, Carolan and Frankowska (2011) suggest that midwives should bear in mind that perinatal outcomes are generally good, even in pregnancies in women over 40 years of age. In a qualitative study conducted in South Africa, Mathibe-Neke (2008) discovered that while women perceived that their general healthcare needs were met by midwives, they were dissatisfied with care related to interpersonal relationships, specifically in the areas of choice, information giving, individualised care and continuity of care. Although that study was confined to a region of the country and the cohort were not all women of advanced maternal age, it was conducted in a country with a national health system and regulation of midwives and the results are very similar to this study.
With regard to screening for fetal abnormalities, it was apparent that the majority of mothers did feel supported by their health professionals in the decision-making process. Participants reported that it was predominantly midwives who discussed the information relating to the chances that the baby might have Down syndrome or a similar condition. However more than 88% of mothers also used the internet to source alternative information from that provided by their health professional. It is becoming increasingly common for individuals to source healthcare information online, and share this information with others on social networking sites (Fox, 2011). This trend, possibly due to smartphones and internet accessibility, means that health professionals will need to have a growing role in educating mothers and helping them to evaluate information that they have sourced in this way (Gilmour et al, 2012).
Despite the range of experiences of mothers in this study, it was surprising to find that less than half felt that midwives could, in some way, improve the care of mothers aged 35 and over. It was evident that mothers felt that care—both pre-and postnatal—could be improved for mothers of all ages, not just those of advanced maternal age. More than 73% of mothers rated the care that was provided by their health professionals as high, even though the overwhelming theme was of a lack of continuity of care, and a sense of being rushed by understaffed and overworked health professionals.
This study has indicated women's experiences of midwifery care are highly varied. Further studies are required to identify how the needs of women of advanced maternal age can be specifically addressed in a way that enables the normality of pregnancy to be preserved, while addressing the increased risks to both mothers and babies.
Limitations
As may be the case with any questionnaire, it is possible that those who responded to the study were not mothers of advanced maternal age and verifying personal information can often be difficult, whether research takes place face-to-face or online. However, we interrogated the free text data and were convinced that, due to the level of detail involved, the majority of responses were made by those who had experienced midwifery care during a recent pregnancy.
Although selection bias of a sample recruited online using social media should be acknowledged, it is not dissimilar to other forms of sampling conducted on the internet. The majority of women in the study sample were educated to degree level and therefore the findings may not reflect the experiences and attitudes of women of advanced maternal age in general. However, studies indicate that women who have a child at advanced maternal age are more likely to be better educated than those who have their children at a younger age and have higher family incomes (Sutcliffe et al, 2012). In addition, the study required women to have the ability to use the internet to answer the questionnaire. As the ONS (2013b) states that only 2.8 and 6.9% of women aged 35–44 and 45–54 years, respectively had never used the internet by the beginning of 2013, it is unlikely that a significant number of women were excluded for this reason. Although young people account for the highest numbers of social media users e.g. Twitter and Facebook, it is estimated that 62% of people aged 35–44 and 40% aged 45–54 used social networking sites in 2012 (ONS, 2013c).
While this study explored the experiences of mothers of advanced maternal age, it did not however, investigate the views of midwives. With this in mind, further research conducting observational studies or ethnographic studies involving midwives discussing experiences of care is recommended, to explore the midwives' perspectives and identify specific situations in which care is unsatisfactory. In addition, further research regarding the experiences of younger mothers would also be beneficial in order to make comparisons with those experiences of mothers of advanced maternal age; however, this was not the focus of the present study.
The study was able to provide a range of diverse data. It was conducted online and therefore was able to collate data nationally and explored the experiences of mothers of advanced maternal age within community and hospital settings, both pre- and postnatal.
In addition, over 90% of mothers in this study were married or living with a partner. This is directly comparable to figures given by the ONS, where almost 92% of mothers aged 35–39 and 89% of mothers aged 40–44 years were married, in a civil partnership or cohabiting (ONS, 2013a).
Conclusion
While there are examples of exemplary midwifery care of women of advanced maternal age, there is clearly room for improvement. Whether the issues reported by mothers reflect the situation across midwifery care generally is unknown. However, it is essential that in order to fulfil the expectations of women, their families and the bodies governing healthcare, undergraduate and continuing education for midwives and leadership at both local and national level needs to support practitioners to develop those skills essential to care for women with dignity and compassion.