Which career first?

We were encouraged by the general and medical media interest
generated by our editorial. Although some was critical, we were simply
drawing attention to a population trend with serious medical implications
and the well-known, if uncomfortable, hazards of later reproduction. The
novel emphasis picked up by Tan(1) was the public ill-health implications
of a recent, marked and unexplained social trend for later reproduction

We did not postulate a single explanation for the change in
childbearing, nor prescribe solutions. It is inappropriate to defend
propositions we did not make: such as advising women not to get pregnant
before 20 or after 35(2,3), singling out women alone when pointing to
problems with delaying pregnancy(4), ignoring financial and social
reasons(5), branding women as selfish(6), presenting well established
facts as headline news(7) or successful older motherhood as
problematic(8), or portraying IVF as an easy option(9).

Other adverse factors exist, including social disadvantage(10), poor
clinical care, smoking(11) and alcohol(6) but are no reason to ignore age.
We concur that the medical endeavour is intrinsically “nature
defying”.(9,12) Town-planning also defies nature, yet we doubt that
warnings about the risk of building cities below sea level with poor levee
maintenance would be branded as “sinister”(13) or “a biased crusade”.(3)
Obstetricians and gynaecologists are well placed to comment on the nature
of the risks in reproduction and the shortage of effective treatments.
Although improved general health is associated with a fall and rise in the
ages of menarche and death respectively, the age of menopause (and prior
decade loss of fertility) remains absolutely unchanged. It relates to the
inevitable biological loss of oocytes from prenatal life onwards. This
loss of ovarian function is likely to remain stubbornly resistant to
medical treatments.

We disagree that women are well aware(9) of the fantastic failure
rates of IVF or that it is condescending(7) to suggest that the existence
of IVF, or even celebrity older mothers, may lull women into age-related
infertility; Our patients may not be so well read as BMJ respondents and
they tell us repeatedly that they receive mixed messages from the media,
they do not receive appropriate advice from their doctors, and nor did
they appreciate fully the facts about fertility despite information in the
public domain.

We agree that women are on the horns of a dilemma(14) and look
forward to a time when having children will not be perceived as an
impediment to women’s career advancement (as it rarely has been for men).
Like Batra(15) we believe it timely that health authorities look
particularly at medical careers. Miller’s denunciation(12) of a
dysfunctional ob/gyn profession failing to modernise may reflect issues
pertinent to the USA but she must be unaware of the primary-secondary GP-
specialist split and increasing subspecialisation that characterises
obstetrics and gynaecology in the UK.

It has long been known that the rate of ectopic rises with age(16);
this was recently confirmed in a study of 2,617 ectopics among 126,451
pregnancies(17). We are grateful for detailed information about perinatal
mental illness(18); particularly referring to lack of social support and
previous psychiatric problems as risk factors for postnatal depression. It
has been suggested that it is the lack of social support that has led to
the trend of older mothering (19), so this may be a complex issue to
untangle. It is difficult to study the effect of age as an independent
factor, for as women get older they have had more opportunity to obtain a
psychiatric diagnosis or treatment (which predicts postnatal depression).
In addition, women who do not have children through infertility and
miscarriage (which rise with age) can be very distressed. We are grateful
for the information about a small but definite (1.3%) rise in perinatal
mortality that would not have taken place had there been no change in
maternal age (20). The term epidemic does not apply solely to infectious
disease(6) but is an “occurrence in a community or region of cases of an
illness, specific health-related behaviour, or other health-related events
clearly in excess of normal expectancy…”(21). We need a new taxonomy for
pregnancies in older women; middle age, in particular, means “over 40”.
(22)

Neither age nor pregnancy are diseases of themselves, but the
combination can and does lead to dis-ease; age-related involuntary
childlessness, infertility, recurrent miscarriage, fetal anomaly and
pregnancy complications are the stuff of our daily work. The purpose of
the editorial was to remind doctors, particularly GPs, of important
medical information, both for their patients who request advice about
reproductive health when attending for contraception, pregnancy or smears)
and for themselves. Whilst young men may also need and want advice about
reproductive health, generally they do not attend doctors for this. We
were not criticising women who either choose or find themselves of
advanced maternal age or childless and are well aware of the pain that
‘women-blaming’ brings. Doctors are in a good position to lead healthy
social trends(15), such as stopping smoking ahead of the rest of the
population.

The scientific question as to why maternal age is rising remains
unasked and unanswered. From the private, BMJ and media responses to our
editorial we have identified a host of theories; women’s inability to find
suitable partners, men being less interested in settling down and
fatherhood, increased divorce, excessive effective contraception, an
exploitative capitalist need for more women in the workplace, women
wanting careers, more further education, ignorance about fertility, more
youth travelling and enjoyment, high student debt, more acceptance of male
homosexuality and fashion (amongst others). We do not subscribe to any
particular theory. They remain entirely speculative but deserving of
urgent research. Meanwhile, we reiterate our standard obstetric and
gynaecological advice that the securest time for childbearing remains 20-
35.

References

1. Tan KH. Maternal age and low fertility rate: Anecdotal and
epidemiological viewpoints. (BMJ rapid response 24 September 2005)

2. Faisal H, Lindsay P. Is it justified to reduce the reproductive
period by half? (BMJ rapid response 26 September 2005)

3. Tomlinson K. Is this a biased crusade? (BMJ rapid response 28
September 2005)

4. Sullivan K. Waiting for nothing (BMJ rapid response 17 September
2005)

5. Harris LC. Who funded this study and why? (BMJ rapid response 18
September 2005)

6. Noble R. Women don’t want it all, but they may want children. (BMJ
rapid response 19 September 2005)

7. Gupta S, Manyonda I. Which career first? BMJ 2005;331:558-9 (BMJ
rapid response 20 September 2005)

8. Donnelly S. Splitting hairs. (BMJ rapid response 23 September
2005)

9. Wilson C. Nature schmature (BMJ rapid response 16 September 2005)
10. Gamble SM. Take a population perspective (BMJ rapid response 7
October)

11. Forbes L, Blackwood R. Take a population perspective (BMJ rapid
response 30 September)

12. Miller KS. Which career first? The obstetricians’. (BMJ rapid
response 22 September 2005)

13. Nabi S. A sinister article. (BMJ rapid response 21 September
2005)

14. Lindenmayer A. Horns of a dilemma (BMJ rapid response 19
September 2005)

15. Batra S. Which career first? BMJ 2005;331:558-9 (rapid response
23 September 2005)

16. Baird D, Hytten FE, Thomson AM. Age and human reproduction. J
Obstet Gynaecol Br Emp 1958;65:865-76

17. Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy
rate and treatment utilization in a large managed care organization.
Obstet Gynecol 2005;105:1052-7

18. Marsh MS, O’Keane V, Seneviratne G. Delaying pregnancy and
perinatal mental illness. (rapid response 19 October 2005)

19. Watson M. The trouble with men. Spectator 2005 (15 October)

20. Bell R. Rising maternal age has had little impact on perinatal
mortality (rapid response 30 September 2005)

21. Last JM (ed). A Dictionary of Epidemiology. International
Epidemiological Association/ World Health Organization handbooks, USA
1983:32

22. Concise English Dictionary. Wordsworth Editions Ltd, Herts.
1994:323

Competing interests:
None declared

Editor-

Although the editorial by Bewley et al 1 has many merits and has
prompted valuable discussion about the risks and benefits of
delaying childbirth we feel that the comments concerning mental
illness in pregnancy and maternal age may be misleading and
could lead to confusion in the minds of women who may be
deciding when to have their family .

In the context of depression in pregnancy the authors claim that
postnatal depression rises with age. This is not a consistent finding
in published studies. They quote the study of Chaudron et al 2 who
reported an association between maternal age and postnatal
depression using logistic regression analysis in 465 women of
whom 27 became clinically depressed postpartum. In this report
the division into age groups for the purpose of analysis appears to
have been made arbritarily. In fact, the number of women who
became depressed using the mean age of the group as a division
(29yr) is remarkably similar (12 of 239 versus 15 of 226).
Furthermore, in this study 64 % of women had one or more
children at home and the authors acknowledged, but were not
able to statistically eliminate, the obvious relationship between
age and number of children. The findings of Chaudron et are
notably different from most other reports, including 2 large
metananalyses 3,4 and recent studies from Europe and elsewhere
5,6,7,8 which have not shown advancing maternal age to be a risk
factor for postpartum depression.

Important predictors of postnatal depression include depression
during pregnancy, past history of psychiatric illness and poor
social support 9. In approximately fifty percent of women who
have postnatal depression it is evident that this depression
commenced during the antenatal period. Younger, rather than
older, age is a risk factor for antenatal depression. It would be
unfortunate if women reading this article, or hearing other's
accounts of it, who are considering delaying pregnancy for
whatever reason, gained the impression that age alone will
substantially increase the risk of them becoming depressed for the
first time in their life after childbirth. In fact, it could be argued
that a
number of psychosocial risk factors for depression such as lack of
preparedness for motherhood, poor ability to support a new child,
lack of support and financial difficulties may be improved if a
mother delays pregnancy.

Although we acknowledge that it is common in the clinical setting
to find women of over 35 in their first pregnancy who are worried
about their pregnancy, the literature does not support an effect of
age on anxiety in pregnancy. To support their statement that
"anxiety in pregnancy" increases with age the authors mention the
1979 paper of Standley K et al 10 who studied only 73 women
using assessment and statistical methods that were of that time.
More recent and larger studies using current methodology 11
report that either anxiety (as measured either by Beck Inventory or
Social Interaction Anxiety Scale scales) is not clearly related to
age.

Presumably Drs Bewley and colleagues cite the well established
risk of increased risk of schizophrenia in children of older men
because they feel that this is a relevant factor that should influence
women in their decision concerning the timing of childbearing.
Although considerable data certainly support such an increased
risk this effect is most evident when the father is over 50 years of
age. It is also less likely in longer partnerships. Using data from a
recent study 12 that may have been fundamentally biased 13 it
has been postulated that the increase in the mean age of fathers
in the population that has occurred over the last 20 years may lead
to an increase in the number of offspring developing
schizophrenia. However, the numerical differences in risk for an
individual mother whose partner is aged 25-29 yr compared with,
for example, 35-39 y, is tiny, if such a difference exists at all, and it
is doubtful whether such a factor should be introduced into the risk
equation when women are making the difficult decisions they have
to concerning the timing of their families.

Your sincerely

Michael S Marsh, Honorary Senior Lecturer,

Veronica O'Keane, Senior Lecturer, Head of the Section of
Perinatal Psychiatry,

Gertrude Seneviratne, Consultant Psychiatrist

Institute of Psychiatry,
De Crespigny Park,
London SE5 8AF

Competing interests: None

References

1 Bewley S, Davies M, Braude P. Which career first? BMJ 2005;
331: 588-9.

2 Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex
MJ. Predictors, prodromes and incidence of postpartum
depression. J Psychosom Obstet Gynaecol. 2001;22:103-12

3 O'Hara MW, and Swain AM. Rates and risk of postpartum
depression - A meta-analysis. Int Rev Psych 1996; 8:37-54, .

4 Bect CT. Predictors of Postpartum Depression: An Update. Nurs
Res 2001; 50: 275-285

5 Yonkers KA, Ramin SM, Rush AJ, Navarrete AJ, Carmody T,
March D, et al. Onset and persistence of postpartum depression in
an inner-city maternal health clinic system. American Journal of
Psychiatry 2001; 158: 1856-1863.

6 Josefsson A , Angelsioo L, Berg G, Ekstrom C-M, Gunnervik C,
Nordin C, and Sydsjo G. Obstetric, Somatic, and Demographic
Risk Factors for Postpartum Depressive Symptoms. Obstet
Gynecol 2002; 99(2): 223 - 228.

7 Inandi T, Elci OC, Ozturk A, et al Risk factors for depression in
postnatal first year, in eastern Turkey. Int J Epid 2002; 3: 1201 -
1207.

8 Lee DTS, Yip ASK, Leung T Y S, et al Ethnoepidemiology of
postnatal depression: prospective multivariate study of
sociocultural risk factors in a Chinese population in Hong Kong.
Brit J Psych 2004; 184: 34-40

9 Gotlib IB, Whiffen VE, Mount JH, et al.. Prevalence rates and
demographic characteristics associated with depression in
pregnancy and the postpartum. J Consult Clin Psychol. 1989
;57(2):269-74.

10 Standley K, Soule B, Copans SA. Dimensions of prenatal
anxiety and their influence on pregnancy outcome. Am J Obstet
Gynecol. 1979;135:22-6

11 Wenzel A, Haugen EN, Jackson LC, Brendle JR. Anxiety
symptoms and disorders at eight weeks postpartum. J Anxiety
Disord. 2005;19(3):295-311.

12 Sipos A, Rasmussen F, Harrison G, Tynelius P, Lewis G, Leon
DA, Gunnell D. Paternal age and schizophrenia: a population
based cohort study. BMJ. 2004 Nov 6;329(7474):1070.

13 Procopio M Paternal age and schizophrenia One swallow
does not make a summer BMJ 2005;330:147-148

Competing interests:
None declared

Lindsay J Forbes, and Rosalind Blackwood's welcome Rapid Response
might usefully be supplemented by consideration of some of the most
disadvantaged women in our community here who never enter the labour
market at all, much less insist on remaining in it. We have the second
highest rate of teenage pregnancy in the industrialised world, runners up
to USA. For unmarried women this may well be a prelude to a life of
grinding poverty, but what is often overlooked is that it may not be much
fun for married women either. The family formation patterns in England of
women born in Pakistan and Bangladesh typically involve little access to
higher education, much less a career. As Roger Berthoud has noted:

'early motherhood can be seen as part of a pattern of family life
characterised by a large number of children, exclusion from the labour
market and high rates of child poverty.'

These highly disadvantaged women can't bring forward their
childbearing to earlier years, as Bewley et al suggest, because they are
already bearing children in those earlier years.

Roger Berthoud's research showed that births to Pakistani and
Bangladeshi born mothers were consistently higher ithan all other ethnic
groups in all age groups, but were much higher in the oldest ranges of 34-
9 and 40-4 by comparison with all other ethnic groups, where rates of
births drop much faster. (1)

A measure of the deprivation suffered here in England and Wales is
that in the year 2000 infant mortality rates for women born in Pakistan
were 12.2 per 1000 live births, more than twice the overall infant
mortality rate of 5.5. (2)

It is easy for the privileged to imagine that their own rather cosy
lives typify the lives of others. Some of us, at least, seem to be in
danger of reverting to the fantasy of women working for pin money, and I
am heartened by the Rapid Responses of those with a better grasp of
realities of life as it is lived today.

Stevie Gamble

(1) Population Trends, no 104, pp 6. see in particular table 3
http://www.statistics.gov.uk/articles/population_trends/teenbirthsethnic...

(2) “Ethnic Disparities in Health and Health Care”
http://www.lho.org.uk/Publications/Attachments/PDF_Files/Ethnic_Disparit...

Competing interests:
None declared

Bewley et al highlight concerns about the potential public health
impact of delayed childbearing, drawing attention to the fact that ‘small
shifts in population curves affect large numbers of women’(1). Whilst the
rise in mean maternal age, and consequent increase in the proportion of
pregnancies occurring in older women, are undisputable, it is less evident
that this has translated into poorer outcomes at a population level.

We conducted a population based study of the effect of secular trends
in birth population risk factors on perinatal mortality in the Northern
region of England (2). This investigated outcomes in nearly 700,000
births over a nineteen year period; data on stillbirths and neonatal
deaths were obtained from the Northern Perinatal Mortality Survey (3).
Between 1982 and 2000, the proportion of mothers aged over 35 more than
doubled, from 5.3% to 12.9%. Over the same time period, extended
perinatal mortality (stillbirths at 28 weeks gestation or more, plus
neonatal deaths) fell by more than a third, from 12.1 per 1000 total
births in 1982 to 7.9 in 2000. By directly standardising for maternal age
structure, we were able to quantify any adverse impact of increasing
maternal age on perinatal mortality rates. The perinatal mortality rate
for 2000, standardised to the maternal age structure observed in 1982, was
7.8 per 1000 births, compared with an unadjusted rate of 7.9 – in other
words, the observed perinatal mortality rate was about 1.3% higher than
might have been expected if there had been no change in maternal age since
1982. This indicates that the adverse impact on perinatal mortality of
the shift in maternal age is minimal at a population level, in the context
of globally improving perinatal mortality rates. Indeed, we observed a
greater reduction over time in perinatal mortality in older mothers than
in younger mothers, which mitigated the effect of rising maternal age.
Our data suggest that, for those women aged over 35 who achieve and
maintain a pregnancy to delivery, mortality outcomes have improved
substantially. The public health implications of rising maternal age may
be more significant for other adverse outcomes such as subfertility, early
pregnancy loss and chromosomal abnormalities, which are less amenable to
intervention.

References

1.Bewley S, Davies M, Braude P. Which career first? BMJ 2005;331:588-9.

2.Glinianaia SV, Rankin J, Bell R, Pearce MS, Parker L. A
retrospective cohort study found changes in risk factors attenuated
temporal trends in perinatal mortality. J Clin Epi 2005 (in press).

3.Hey EN, Welch RG, Lawson JB, Barron SL, Bullough CHW, Morris D,
McNay RA. Perinatal mortality: a continuing collaborative regional survey.
British Medical Journal 1984;288:1717-1720.

Competing interests:
None declared