Delay In Childbearing Research Articles

Projecting the Contribution of Assisted Reproductive Technology to Completed Cohort Fertility

Assisted reproductive technology (ART) is increasingly influencing the fertility trends of high-income countries characterized by a pattern of delayed childbearing. However, research on the impact of ART on completed fertility is limited and the extent to which delayed births are realized later in life through ART is not well understood. This study uses data from Australian fertility clinics and national birth registries to project the contribution of ART for cohorts of women that have not yet completed their reproductive life and estimate the role played by ART in the fertility ‘recuperation’ process. Assuming that the increasing trends in ART success rates and treatment rates continue, the projection shows that the contribution of ART-conceived births to completed fertility will increase from 2.1% among women born in 1968 to 5.7% among women born in 1986. ART is projected to substantially affect the extent to which childbearing delay will be compensated at older ages, suggesting that its availability may become an important factor in helping women to achieve their reproductive plans later in life.

Association between ICSI cycle outcome and response in women with infertility

Background: Infertility is the inability to achieve a clinical pregnancy after 12 months of regular and unprotected sexual activity. Increases in child-bearing delay and maternal age at first pregnancy significantly impact the rise of age-related infertility and the demand for treatment using assisted reproduction techniques (ART). As a result, many women with a low ovarian reserve and a poor ovarian response (POR) to conventional stimulation seek medical assistance at infertility clinics. Aim: The study aimed to evaluate the quality of oocytes and embryos, as well as the rates of conception, in infertile women who were candidates for fresh intracytoplasmic sperm injection between good and poor-responder women (ICSI). Patients and methods: The study was conducted on 45 infertile women undergoing ICSI at the High Institute for Infertility Diagnosis and Assisted Reproductive Technologies/ Al-Nahrain University/ Baghdad/ Iraq from October 2021 to April 2022, regardless of whether they had previously undergone ICSI. The morphology of the oocytes and the quality of the resulting embryos were assessed. The patients' ages ranged from 20 to 42 years old. There was primary and secondary infertility ranging from one to 20 years. Every couple had a basic reproductive assessment. The antagonist protocol was used for all infertile females. All females had their serum levels of AMH, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and oestradiol (E2) measured on the second or third day of their cycle. The serum oestradiol (E2) level was re-measured on the day of the hCG injection. Results: The participants in the study were 32.6 ± 5.3 years old. The findings showed that 57.8% of the patients had a well response, and 24.4% of the women were pregnant. In those who became pregnant, anti-müllerian hormone (AMH) levels were significantly higher, and follicle-stimulating hormone (FSH) levels were noticeably lower (p> 0.05). The E2, LH, prolactin, and progesterone levels were not statistically different (P> 0.05). Conclusion: In conclusion, the findings revealed a positive relationship between response and ICSI outcomes in infertile women.

Residential proximity to a fertility clinic is independently associated with likelihood of women having ART and IUI treatment.

Is geographic proximity to a fertility clinic associated with the likelihood of women of reproductive age undertaking different forms of medically assisted fertility treatment? After adjusting for socioeconomic status (SES) and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI treatment than those who lived further than 60 km away. In most countries, patients living outside of metropolitan areas are more likely to be more socio-economically disadvantaged and to have less equitable access to healthcare. However, how a woman's residential proximity to fertility clinics predicts utilization of high-cost/high-technology treatment (ART) and low-cost/low-technology treatment (IUI) is limited, and whether socio-economic disadvantage explains much of the hypothesized lower utilization is unknown. Australia's universal insurance scheme provides supportive reimbursement for almost all ART and IUI treatment regardless of age or number of cycles, providing a unique setting to investigate disparities in access to infertility treatment. National population-based observation study of ART and IUI treatment utilization by women across socio-economic gradients and Australian residential locations between August 2015 and December 2017. Universal insurance claims information on female patients who underwent ART or IUI were provided by Services Australia, comprising 67 670 female patients who accessed 162 795 ART treatments, and 10 211 female patients who accessed 19 615 IUI treatments over a 29-month period. Incidence rates by SES and proximity to fertility clinics were calculated to describe the number of women undergoing at least one ART or IUI treatment cycle per 1000 women of reproductive age (25-44). Treatment frequencies were calculated to describe the average number of ART or IUI treatment cycles per woman of reproductive age who had undergone at least one ART or IUI treatment during the study period. Poisson regression analyses were used to estimate the independent effect on accessibility to infertility treatment by geographic proximity (based on small area locations) to the closest fertility clinic after adjusting for SES, childbearing delay, remoteness area, and marital status. On average, 19.1 women per 1000 women of reproductive age underwent at least one fresh or frozen ART cycle, with an average 2.3 ART cycles each, while 3.0 women per 1000 women of reproductive age received at least one IUI cycle, with an average of 1.6 IUI cycles each. After adjusting for SES and other confounders including a proxy for the need for infertility treatment, women who lived within 15 km of a fertility clinic were 21% more likely to undergo ART treatment and 68% more likely to undergo IUI than those who lived over 60 km away. Regardless of geographic location, there was a steady and independent gradient in access to ART treatment based on increasing SES, with women residing in the most advantaged residential quartile having a 37% higher rate of receiving ART treatment compared to those in the most disadvantaged quartile. The negative effect of social disadvantage on ART use became more pronounced as distance from a fertility clinic grew, indicating that the barriers to access to ART care caused by distance were further compounded by the level of socioeconomic advantage of the women's residential location. In contrast, socioeconomic status did not modify the likelihood of using IUI over and above the distance from a fertility clinic. In relation to IUI treatment, differences in utilization by SES disappeared after adjusting for geographic proximity to a fertility clinic, childbearing delay, remoteness area, and marital status. Information is aggregated by small geographic areas and it therefore may not reflect individual characteristics. Australia provides partial but comparably supportive reimbursement for both ART and IUI through its universal healthcare system and thus the results may not be fully generalizable to other settings. Residential proximity to a fertility clinic is a persistent barrier to accessing ART and IUI treatment, regardless of SES, even in countries characterized by supportive public funding, such as Australia. SES is less of a barrier to accessing IUI than ART, presumably driven by the lower cost and fewer clinic visits required with IUI treatment. Safe and effective fertility treatment should be available to all women regardless of where they live. This work was supported by the Australian National University Research scholarship and by the Higher Degree Research Fee Merit Scholarship. The authors have no conflict of interest. N/A.

Pathways into childbearing delay of men and women in Australia.

Childbearing delay is a pervasive feature of Australian society, but little research has been conducted to examine how socio-economic factors are linked to childbearing timing among Australian men and women. This paper addresses this by analysing the timing of first childbirth for a large sample of Australian residents (N = 4,444). The findings indicate that childbearing delay is socially patterned and that life course experiences shape the risk of delaying childbearing across genders. Having a tertiary qualification delays the transition to parenthood, especially for women. An uninterrupted career prolongs time to parenthood for women but accelerates it for men. Low occupational prestige, being married and having been in only one co-residential union are associated with earlier parenthood for both men and women. For each increase in education level, not being married is associated with increasing levels of childlessness. Clear-cut gender differences are found in the relationship between childlessness and childbearing delay.

Caesarean Myomectomy: Safety and Feasibility of The Procedure

Introduction: Frequency of uterine myomas has increased these days with factors like delayed child bearing and IVF conception in elderly pregnant women. The vascularity of uterus increased and thus myomectomy during caesarean was considered a risk. With advanced surgical techniques the risk has become minimal these days. Case Report: 42 year G4P3L3 presented with 36 weeks gestation with USG s/o 3 large uterine fibroid, 2 subserosal fibroids with largest of size 7.1 x 6.3 x 7.2 cms, and 1 intramural fibroid. Emergency LSCS was done for her due to fetal indication. Due to emergency nature of surgery the option of preoperative uterine artery embolisation was not feasible and hence decision of stepwise de-vascularisation was taken. The de-vascularisation was done at the level of B/L uterine arteries, utero ovarian anastomosis bilaterally followed by removal of the three myomas. Discussion: Majority of myomas do not require surgical intervention during pregnancy or delivery. It has been repeatedly stated in the literature that routine myomectomy during cesarean section should be avoided and should only be carried out in carefully selected patients. In our case, stepwise devascularisation was required to control the bleeding. Proper devascularization and experienced obstetricians can reduce the incidence of haemorrhage and hysterectomy. The approximate blood loss was only 400 ml signifying the importance of this approach to myomectomy during caesarean section.

Pregnancy in physicians: A scoping review

BackgroundThe personal health and professional impact of physician pregnancy requires further study. We performed a comprehensive scoping review of physician pregnancy to synthesize and assess the evidence to aid decision-making for relevant stakeholders. MethodsA search of 7 databases resulted in 3733 citations. 407 manuscripts were included and scored for evidence level. Data were extracted into themes using template analysis. ResultsPhysician pregnancy impacted colleagues through perceived increased workload and resulted in persistent stigmatization and discrimination despite work productivity and academic metrics being independent of pregnancy events. Maternity leave policies were inconsistent and largely unsatisfactory. Women physicians incurred occupational hazard risk and had high rates of childbearing delay, abortion, and fertility treatment; obstetric and fetal complication rates compared to controls are conflicting. ConclusionsComprehensive literature review found that physician pregnancy impacts colleagues, elicits negative perceptions of productivity, and is inadequately addressed by current parental leave policies. Data are poor and insufficient to definitively determine the impact of physician pregnancy on maternal and fetal health. Prospective risk-matched observational studies of physician pregnancy should be pursued.

Vanilla bisquits and lobola bridewealth: parallel discourses on early pregnancy and schooling in rural Zambia

BackgroundAdolescent pregnancy is a complex socio-economic phenomenon ranking high on the global health policy agenda. Early childbearing is associated with early marriage and school drop-out, and is defined as a problem to the health and development of girls. This paper reports from formative research. The formative research aimed to explore socio-cultural and structural dynamics at work behind early pregnancy and school drop out in rural Zambia. The study findings have been used to inform a school based intervention to reduce early pregnancy (RISE: ‘Research Initiative to Support the Empowerment of Girls’). Theoretically the study is informed by social constructionism.MethodsA qualitative approach was employed. Semi-structured qualitative interviews (61) and focus group discussions (7) were carried out with girls (in and out of school), boys, parents, teachers, health workers and community- and district leaders in 2014–15. Systematic text condensation was drawn upon in the analysis of the material.ResultsThe study findings indicate that the official Zambian discourse that presents early pregnancy as a serious challenge and schooling as the prime way to confront the problem enjoy substantial support at community levels. However, a parallel discourse on fertility, early marriage and childbearing as social and economic security surfaced and was articulated by the same study participants. The latter contrasting discourse questioned schooling as the only solution to secure a girl’s future arguing that there are many reasons why early pregnancy may emerge as rational.ConclusionsGrasping the complexity of local discourse is vital in planning health interventions. The present study revealed that although delayed child bearing and schooling among girls enjoyed high status and legitimacy in the study area, the social and economic context worked to reward early marriage. Interventions to reduce early pregnancies in rural Zambian communities need to fundamentally address the material constraints that condition and reinforce a culture of early childbearing.

Brazil's Missing Infants: Zika Risk Changes Reproductive Behavior.

Zika virus epidemics have potential large-scale population effects. Controlled studies of mice and nonhuman primates indicate that Zika affects fecundity, raising concerns about miscarriage in human populations. In regions of Brazil, Zika risk peaked months before residents learned about the epidemic and its relation to congenital anomalies. This spatiotemporal variation supports analysis of both biological effects of Zika infection on fertility and the effects of learning about Zika risk on reproductive behavior. Causal inference techniques used with vital statistics indicate that the epidemic caused reductions in birth cohort size of approximately one-quarter 18 months after Zika infection risk peaked but 10 months after public health messages advocated childbearing delay. The evidence is consistent with small but not statistically detectable biological reductions in fecundity, as well as large strategic changes in reproductive behavior to temporally align childbearing with reduced risk to infant health. The behavioral effects are larger for more-educated and older women, which may reflect facilitated access to information and to family planning services within high-risk, mosquito-infested urban locations as well as perceptions about the opportunity costs of risks to pregnancy and infant survival.

Determinants of Under-Five Mortality in Ghana: Evidence from the Ghana Demographic and Health Survey

Background and Objectives: This study aims to investigate the strength of the association between socio-economic, maternal and environmental determinants and under-five mortality in Ghana.
 Methods: We utilized data from the 2014 Ghana Demographic and Health Survey, a population-based cross-sectional study, which included 4151 children born alive to women aged 15-49 years. The primary outcome variable was under-five mortality. Descriptive statistics and multivariate logistic regression were applied to assess the relationship and relative association of the independent variables with the outcome variable.
 Results: Children of women with secondary education and above and women within the middle wealth status were 0.593 and 0.886 less likely to experience under five deaths compared to women with no education and women of low wealth status (OR=0.593; 95% CI 1.690 to 2.063; p< 0.01) (OR =0.886; 95% CI 1.48 to 1.63; p<0.01). Women who had their first birth at age 20-29 years were 0.764 less likely to experience under-five deaths compared to those aged 15-19 years (OR= 0.764; 95% CI 0.994 to 1.191; p<0.01). Children born in households with pit toilets were more likely (OR= 1.51; 95% CI 1.20 to 2.30; p<0.01) to die before age five compared to children born in households with flushed toilet. Women who used bore hole /well water were more likely (OR= 1.686; 95% CI 2.94 to 3.01; p< 0.05) to experience under-five deaths compared to women who used piped water.
 Conclusion and Implications for Translation: This study identified the determinants that significantly predicted under-five deaths and the magnitude of the influence on under-five deaths in Ghana. It accentuates the need for increased maternal education, delayed child bearing, provision of improved drinking water and toilet facilities to reduce under-five deaths in Ghana.
 Key words: • Socio-economic • Maternal health • Child health • Environmental factors • Under-five mortality • Ghana • Demographic and Health Survey • DHS
 
 Copyright © 2020 Nyaaba, et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

A CLINICAL STUDY ON MATERNALAND PERINATAL OUTCOME OF MULTIPLE PREGNANCIES IN PATNA MEDICAL COLLEGE & HOSPITAL, PATNA, BIHAR

The occurrence of two or more foetuses simultaneously in the uterus is referred to as multiple pregnancy. Teleologically, multiple pregnancy in humans can be regarded as an atavistic trait to which the mother is not optimally suited, with consequent increase in the risks for both the foetuses and the mother. The past few years have shown a considerable rise in the incidence of multiple pregnancies largely attributed to the advent of assisted reproduction, use of ovulation inducing drugs and an increased trend towards delayed child bearing. This cross –sectional study was carried out to find the maternal and perinatal outcome in multiple pregnancies in Patna Medical College and Hospital, Patna, Bihar over a period of July 2018 to April 2019. The incidence of multiple pregnancies was found to be 1.27%.53.6% cases were booked and 43.6% were unbooked. Preterm labour was the commonest complication (74.2%), anaemia being the second most common (45.16%). The maternal morbidity was higher in caesarean section than in vaginal delivery. There was one case of maternal mortality due to septicaemia and peritonitis with severe PIH, who underwent LSCS due to prolong labour and retained second twin. Judicious use of assisted reproductive technology including ovulation induction can reduce the incidence of multiple pregnancies. Proper antenatal care, health education, prevention of preterm birth, better facilities for premature babies, skilled obstetrician and anaesthetist can improve the maternal and perinatal outcome in multiple pregnancy. As such early detection of multiple pregnancies is an important parameter which enables proper antenatal care and subsequent delivery.

Pregnancy Outcome in Patients with Placenta Praevia with Delayed Child Bearing Age

This is a hospital-based cross sectional descriptive study was carried out during January 2015 to June 2015 in the Department of Obstetrics and Gynaecology of Rajshahi Medical College Hospital to determine pregnancy outcome in placenta praevia cases with delayed child bearing age. Total 8107 patients were admitted during the study period and among them 82 patients were diagnosed as placenta praevia. Patients were categorized into two groups as above 35 years & below 35 years and relationship between advanced maternal age and placenta praevia was seen. Socio-demographic condition, clinical condition, course of management, maternal and perinatal outcome were observed and recorded. Proportion of placenta praevia was 1.01% during the study time. Among 82 patients of placenta praevia, 25 were advanced maternal age group (30.49%). Prevalence of placenta praevia in advanced maternal age group in comparison to below 35 years among total admitted patient was seen 9.73% and 0.73% respectively. So, incidence is more in advanced maternal age group which is statistically significant (p<0.05). Most of the patients of placenta praevia came from middle class family 42(51.21%) and most women were multi gravida 75(91.5%). 42.68% patient had history of caesarean section and 47.56% patients had history of menstrual regulation (MR), abortion & dilatation, evacuation & curettage (DE & C). Major placenta praevia was more in advanced maternal age group (64%) which is statistically significant (<0.05) and mode of delivery was caesarean section 62(75.60%). Maternal and perinatal complications were more in advanced maternal age group. Maternal mortality rate 9(10.97%) and perinatal mortality rate 14(17.07%). Advanced maternal age has a relation with placenta praevia and associated with more adverse maternal and perinatal outcome. So, pregnancy in advanced age should be considered as a risk factor for developing placenta praevia.
 TAJ 2019; 32(2): 48-55

Delayed child bearing is a choice or a chance? Why do women delay childbearing?

Delayed child bearing is a choice or a chance? Why do women delay childbearing?

Outcome of Pregnancy-Associated Breast Cancer in Primigravid Women: A Report of 3 Cases

Incidence of Pregnancy-Associated Breast Cancer is increasing due to delay in child bearing. Management during pregnancy is challenging for the treating physicians as options like chemotherapy may put the foetus at risk. Therapeutic approach involving a multidisciplinary team, integrating surgery and chemotherapy along with patient preferences may yield a good outcome. We report the short- and long-term outcome in three women who were diagnosed to have breast cancer during their pregnancy and were managed with surgery and chemotherapy. Of the three cases, two of them are under remission at 8 and 9 years of follow-up, whereas the third lady had recurrence and died after 2 years of diagnosis. All three babies were normal without any delay in milestones on follow-up. Multidisciplinary team of specialists, integrating the various approaches with labour management, may help to optimise the outcome for the mother and her baby.

Fertility Awareness among Medical and Non- medical Undergraduate University Students in Al-Iraqia University, Baghdad, Iraq

Introduction: postponing child-bearing and its effect in declining fertility has been recognized recently as an important health, social and demographic concern in the world. Aim of the study: to determine the fertility awareness among undergraduate medical and non-medical students by their intention for parenthood, desired number, preferred age to have first and last child, to identify the major factors and their choices in case of infertility. Methodology: A descriptive cross-sectional survey study was conducted among medical and non-medical students at Al-Iraqia University, 150 students were the randomly selected sample size and data was collected using self-administrated questionnaire. Data entry and analysis was done using SPSS version 15.0. Results: The study found that parenthood was higher among non-medical students than medical students. Medical students desired to have only one child in comparison to non-medical students desire to have 4 or more children. The preferred age to have first child was 25-29 years among medical students in contrast to 21-24 years for non-medical students. Majority of medical students preferred the age of 30-39 years for the last child compared to 40-44 years for non-medical students. Smoking and alcohol were the major factors affect fertility reported by medical students compared to caffeine and diet as major factors by non-medical students. IVF with high expected success rate was the choice in case of infertility among medical students more than non-medical one. Conclusion: The students of this study plan to have children within a women’s window of fertility, however, their overestimate about the female fertility period could lead to delayed child bearing, so, it is mandatory to increase the level of awareness about this important period of life.

Targeting oocyte maturation to improve fertility in older women.

Reproductive aging is an increasingly pressing problem facing women in modern society, due to delay in child bearing. According to Statistics Canada, 52% of all Canadian births in 2011 were by women aged 30 years and older, up from 24% in 1981 ( http://www.statcan.gc.ca/pub/91-209-x/2013001/article/11784-eng.htm ). Women older than 35 years of age experience significantly increased risks of infertility, miscarriage and congenital birth defects, mostly due to poor quality of the eggs. Increasingly sophisticated, and often invasive, assisted reproductive technologies (ARTs) have helped millions of women to achieve reproductive success. However, by and large, ARTs do not address the fundamental issue of reproductive aging in women: age-related decline in egg quality. More importantly, ARTs are not, and will never be, the main solution for the general population. Here, I attempt to review the scientific literature on age-related egg quality decline, based mostly on studies in mice and in humans. Emphasis is given to the brief period of time called oocyte maturation, which occurs just prior to ovulation. The rationale for this emphasis is that oocyte maturation represents a critical window where unfavorable ovarian conditions in older females contribute significantly to the decline of egg quality, and that science-based intervention during oocyte maturation represents the best chance of improving egg quality in older women. Finally, I summarize our own work in recent years on peri-ovulatory putrescine supplementation as a possible remedy for reproductive aging.

Ultrastructural markers of quality are impaired in human metaphase II aged oocytes: a comparison between reproductive and in vitro aging.

Childbearing delay contributes to the increase of subfertile couples that require assisted reproductive technology (ART). Subfertility relates with reproductive aging (RA). In vitro aging (IvA) (due to extended culture) may also impair oocyte competence. Aims of this study were to evaluate and compare the oocyte ultrastructure after RA and IvA. Cumulus-oocyte complexes (COCs) (n = 68), with metaphase II oocyte and expanded cumulus, from consenting patients (<35years old and ≥35years old, n = 36), were selected by phase contrast microscopy and fixed at pick up, or after 24h culture. COCs (n = 44) were studied by light and qualitative/morphometric transmission electron microscopy. Two-way ANOVA, with age and culture as grouping factors, was applied for statistical analysis (p < 0.05). Metaphase II cumulus-free oocytes (n = 24) were selected for confocal microscopy observations. Significant decrease of mitochondria-smooth endoplasmic reticulum aggregates, increase of mitochondria-vesicle complexes size and amount, decrease of cortical granules and microvilli, and alterations of the spindle structure characterized both RA and IvA oocytes. These changes were significantly more evident in the RA oocytes submitted to IvA. RA oocytes also showed changes of the zona pellucida and occurrence of vacuoles after culture. Cumuli appeared re-compacted after culture, irrespective of the age of the patients. These data demonstrated that aging is related to decay of oocyte ultrastructural quality, and that oocytes from elder women are more sensitive to prolonged culture (IvA) than the oocytes from younger women. These morphological results should be considered when applying ART in aged patients, rescue ICSI, or artificial oocyte activation.

Desperately seeking parenthood: neonatal nurses reflect on parental anguish.

This paper aims to explore the ways in which neonatal nurses understand the experience of parents who have experienced infertility, conceived a baby via in vitro fertilisation and delivered an extremely premature infant. The chance of a poor long-term outcome for the baby is significant; therefore, parental anguish plays out in the neonatal intensive care. Current literature suggests that infertility is a significant issue for ageing women and many couples experience multiple cycles of invitro-fertilisation (IVF) treatment to achieve a pregnancy. Babies conceived through IVF are more likely to have genetic disorders, and be born prematurely. When the baby is born through IVF and is also born extremely prematurely, it creates a crisis situation for the parents. This paper will focus on the parental anguish of achieving a pregnancy through IVF to see the baby born extremely prematurely (defined as ≤ 24-week gestation). It will examine parental anguish from caregiver perspective of the neonatal nurse who supports the parents through this very difficult time. This study used interviews with neonatal nurses, and drew insights from interpretative phenomenology. This research used a combination of a questionnaire and a series of interviews in a qualitative study informed by phenomenology. The analysis of the interview data involved the creation of key themes following extensive coding of thematic statements and the analysis of the emerging themes. This paper outlines the neonatal nurses' understanding of parental anguish and overwhelming sadness in parents whose baby was conceived by IVF, and was also born extremely prematurely. The theme of 'seeking parenthood' was synthesised from two sub-themes - 'longing for a baby' and 'the desperation to become parents'. This study identified that neonatal nurses bear witness to parental anguish as their hopes of taking home a live baby might not be realised. The time, effort and money required to achieve a pregnancy does not mean that the baby will be spared the outcomes of extreme prematurity and the risk factors associated with IVF. The parents may be left empty handed. Therefore, the word precious becomes a metaphor for the IVF baby as the neonatal team try desperately to give the parents their much longed baby. Delayed child bearing has an impact on fertility, with maternal age having the most impact on the ability to conceive. Babies conceived through IVF technologies have a higher risk of genetic abnormalities and being born prematurely, and this will impact on the neonatal intensive care availability. Extreme prematurity and IVF can significantly impact on the baby's outcome. Witnessing parental anguish can be a major source of stress for the neonatal nurses. Neonatal nurses need to develop strategies not only to help the parents but also to prevent the parents' overwhelming sadness from affecting their ability to function in the neonatal intensive care unit.

Neonatal risks from in vitro fertilization and delayed motherhood.

Delayed childbearing (DC) is common in most Western countries. The average age of first-time mothers increased in United States from 21.4 years in 1970 to 25.0 years in 2006 and from 25.4 to 30.8 years in Australia in the same period. It is commonly believed that this has no ominous consequences. But several negative consequences of this behavior are described: stillbirth, prematurity, twins, birth anomalies. Age also decreases women's fertility, thus many couples undergo in vitro fertilization. And we highlight a paradox: medical reproduction techniques decreases their effectiveness with maternal age, but their availability can be an incentive to postpone parenthood. Of course the risks of delayed parenthood involve a minority of cases, but are parents entitled to accept any risk on the behalf of their baby A complete information would make people cautious before deciding to postpone childbearing, though this is often an obliged rather that a free choice: the consumerist society pressure and the difficulty to find an employment have their heavy weight in this choice. But if this choice is not really free, people's interest is to overcome these pressures and to claim for a real broad choice on when becoming parent, despite the pressures made by their cultural environment to postpone parenthood. Moreover, even reproductive techniques have some risks. Unfortunately, mass media often praise and endorse DC, disregarding the increase of premature babies born because of DC, a real alarm for public health. Pediatricians should discourage the culture that makes DC a normal event.

Reexamining the Impact of Family Planning Programs on US Fertility: Evidence from the War on Poverty and the Early Years of Title X().

Almost 50 years after domestic US family planning programs began, their effects on childbearing remain controversial. Using the county-level roll-out of these programs from 1964 to 1973, this paper reevaluates their shorter and longer term effects on US fertility rates. I find that the introduction of family planning is associated with significant and persistent reductions in fertility driven both by falling completed childbearing and childbearing delay. Although federally funded family planning accounted for a small portion of the post-baby boom US fertility decline, my estimates imply that they reduced childbearing among poor women by 19 to 30 percent. (JEL I38, J12, J13, J18).

Global epidemiology of multiple birth

Multiple births, which account for approximately 3% of births and 14% of infant deaths, are increasing in frequency. Multiple birth rates began to decline in the 1950s, reaching a minimum in the 1970s and rising since then. Both twin and triplet rates followed the same rising trend until 1998, after which triplet birth rates began to decline while twin birth rates continued to rise. Rising maternal age is associated with rising frequency of dizygotic twinning up to 37 years of age. Older maternal age, associated with the social trend to delayed child bearing, accounts for 25–30% of the rise in multiple birth rates since 1970. The resulting rise in the prevalence of infertility has given rise to unprecedented use of ovarian stimulation treatments that stimulate the development of multiple oocytes. Assisted reproduction technology and ovulation stimulation with clomiphene citrate or gonadotrophins without assisted reproduction account for similar proportions of both twin births (20–30%) and triplet births (30–40%). The fall in triplet rates since 2000 is reassuring, but fetal reduction of high order pregnancies may be a factor in rising twin rates. Continuing attention is needed to all possible means of minimizing triplet pregnancies.