|Vol. 10, No. 2 / May 2012
“Last-chance kids”: A good deal for older parents—but what about the children?
Clinical Assistant Professor, University of Wisconsin School of Medicine and Public Health, Department of Obstetrics and Gynecology, Madison, Wisconsin
Director, Psychological Support Services, Shady Grove Fertility Reproductive Science Center, Rockville, Maryland, Assistant Clinical Professor, Georgetown University School of Medicine, Department of Obstetrics and Gynecology, Washington, DC
Clinical Associate Professor of Psychology, Director of Psychological Services, The Perelman/Cohen Center, for Reproductive Medicine, Weill Medical College of Cornell University, New York, New York
This article is based on a symposium presented by the authors at the American Society for Reproductive Medicine Annual Meeting in Orlando, Florida, on October 19, 2011.
The authors report no commercial or financial relationships from any sources.
Society is rethinking the concept of age and, more specifically, “old age.” Images of gray-haired ladies knitting and older gentleman dozing have been replaced by images of vibrant women and men engaging in an active lifestyle, enjoying the latter third of their lives. The transformation in expectations—from inactivity to vitality—is rooted in both reality and perception. The reality is that people are living longer. White males and females born in 2007 can be expected to live approximately 17 years longer than their counterparts born in the 1930s, and black males and females can be expected to live 25 years longer than their 1930s counterparts (TABLE 1).
Life expectancy at birth, by race and sex, 1930 to 2007
Not only are people living longer, they also perceive themselves as being younger than they are. A 2009 survey by the Pew Research Center found that the nearly half of 50-year-olds report that they “feel” at least 10 years younger than they are chronologically, and nearly a third of those who are 65 to 74 years old feel 10 to 19 years younger (FIGURE).1 An extended life span together with the tendency to feel younger than one’s age may have contributed to the societal perceptions that “40 is the new 30,” “50 is the new 40,” “60 is the new 40,” and even that “70 is the new 40.”
Older reproduction by the numbers
Survey results document a growing trend: Women are giving birth in their 40s and well beyond. Data from the National Center for Health Statistics show that from 1996 to 2008, the overall birth rate in the United States increased by 9.15%. 2 During that time span:
The number of births to women aged 40 to 44 increased 47.6% (105,973 births in 2008)
In women aged 45 to 49, the increase was 133% (7109 births in 2008)
For women aged 50 to 54, the increase was 276% (541 births in 2008).
While the absolute number of births to women in these higher age groups remains comparatively low, it is clear that birth rates in older women are rising.
A notable case of older motherhood
A highly publicized example of an older woman receiving infertility treatment later in life is that of Maria del Carmen Bousada de Lara, who gave birth to twins in 2006 at the age of 66. When questioned about the moral and practical implications of becoming a mother at such an advanced age, she said, “My mum lived to be 101 and there’s no reason why I couldn’t do the same.”3
People in midlife should be counseled regarding the number of additional years of good health that they can expect. Data from the Healthy People 2010 report (National Center for Health Statistics) indicate that a 65-year-old woman can hope to expect an additional 18.8 years of life; however, only 13.4 of those years can be expected to be years of good health (TABLE 2).4 Restated, nearly 30% of a 65-year-old woman’s remaining years would be expected to be years of poorer health.
Life expectancies and expected years in good or better health and excellent health for selected ages, by sex: United States, 1995
|Sex and age (years)
||Expected years of life
||Expected years in good or better health
||Years in good or better health as a % of life expectancy
||Expected years in excellent health
||Years in excellent health as a % of life expectancy
While Ms. Bousada may have enjoyed good health at the time of the interview, she developed cancer within a year of giving birth and was dead before her sons turned 2, leaving a relative as the children’s guardian.
Two sides of the actuarial coin
Fertility specialists should also consider the actuarial projections on remaining years of life and good health when providing infertility treatment for older women. Some clinics consider a woman’s age a limiting factor for infertility treatment. For example, treatment may be offered to couples only if there is a reasonable possibility of at least 20 years of life expectancy. Presumably, this is based on the hope that these couples will be able to provide 20 years of parenting. It can be argued from the data cited above, however, that although those couples may get to be parents for 20 years, a considerable percentage of those remaining years will be characterized by poorer health. This certainly affects the parenting experience and the parent-child relationship.
It is important to note that the “hope” of an additional 20 years of life is just that, “a hope.” Not all individuals projected to have another 20 years of life expectancy will actually attain those 20 years. Using life expectancy data from the National Vital Statistics Reports US life tables (2006), our actuarial consultant calculated a child’s expected age at the time of the father’s death and the mother’s death (TABLES 3 AND 4).5 Strikingly, a woman who has a child at age 50 has a nearly 15% chance of dying by the time that child is 20 years old. A woman who has a child at age 60 has an almost 20% chance of dying by the time her child is 15. For men the results are even more startling. A man who is 50 years old at the time of his child’s birth has nearly a 15% chance of dying by the time the child is 15 years old. Meanwhile, a man who is 60 at the time of his child’s birth has an almost 30% chance of dying by the time the child is 15. This is an approximately 10-fold increased risk compared with a man half his age (ie, a 30-year-old has a 3% chance of dying by the time his child is 15).
Child’s expected age at time of father’s death
|Father’s age at child’s birth
||Father’s expected age at death, at time of child’s birth
||Child’s expected age at father’s death
||Father’s probability of death by child age 5
||Father’s probability of death by child age 10
||Father’s probability of death by child age 15
||Father’s probability of death by child age 20
Child’s expected age at time of mother’s death
|Mother’s age at child’s birth
||Mother’s expected age at death, at time of child’s birth
||Child’s expected age at mother’s death
||Mother’s probability of death by child age 5
||Mother’s probability of death by child age 10
||Mother’s probability of death by child age 15
||Mother’s probability of death by child age 20
Concerning the use of oocyte donation for women of advanced reproductive age, Paulson and Sauer noted that, “At present, it appears that oocyte donation makes pregnancy possible in virtually any woman with a uterus. No definitive physiological limit appears to exist based solely on the age of the patient. Therefore, if restrictions are to be imposed on the provision of this type of care to older recipients, these restrictions will need to be based not on physiology, but rather on the wisdom or ethics of providing this population with the opportunity for parenthood.” 6
Is reproduction a right?
So, what of the wisdom and ethics of providing infertility treatments to individuals in later life? It is helpful to first consider the concept of the right to reproduce. Both the United Nations Universal Declaration of Human Rights and the 14th Amendment to the US Constitution have been cited as discussing the right to have children. Scrutiny of these documents, however, reveals that they discuss negative rights (ie, the right to not be interfered with) rather than positive rights (ie, the right to claim entitlement to a service or means to obtain something).
The American Society for Reproductive Medicine (ASRM) has a similar perspective. According to the ASRM Ethics Committee report on child-rearing ability and the provision of fertility services,7 “Reproductive rights protected under the United States and state constitutions are rights against state interference, not rights to have physicians or the state provide requested services.” The report further notes, “It is also important to recognize that constitutional rights to reproduce are, like all rights, not absolute and they can be restricted or limited for good cause.” Since an absolute right to have children at any age does not exist, ethical principles may provide guidance.
Are age-based restrictions discriminatory?
Those who support patients having children late in life claim that any restrictions on fertility treatments based on age are sexist and ageist. The argument that it is sexist to restrict a woman’s access to in vitro fertilization (IVF) based on age proposes that, historically, because men have been able to have children late in life, to curtail a similar opportunity for women is sexist. This argument, however, fails to take into account that, historically, when men had children late in life, the mother of that child was generally younger and thus able to provide more years of parenting. The child was therefore not as likely to be without parents at a young age.
The ageist argument posits that age-based restrictions presume that older individuals have a reduced capacity to parent effectively. The argument frequently broadens to (1) point out many examples of grandparents effectively raising their grandchildren and (2) suggest that any arguments based on reduced capacity and parenting would have to be applied to individuals with disabilities.
Landau makes a cogent counterpoint to ageist argument No. 1.8 She states, “The fact that grandparents may successfully fill the role of the parent when there is breakdown in the original family is not justification for deliberately using medical technology to place a child at risk for psychological harm.” Landau also effectively counters the suggestion that people with physical disabilities should face restrictions; she argues that the attempt to equate age-related limitations with limitations due to disability “only considers physical limitations and fails to consider that young physically disabled parents are not cognitively and psychologically different from their able-bodied counterparts.” Perhaps most importantly, the ageist argument fails to honestly accept the fact that individuals who are older when they have children will, by probability analysis, not be able to provide as many years of parenting for their child as their younger counterparts. There simply is no debating this fact.
Impact on the children
As recently as 25 years ago, late childbearing and older parents were terms applied to couples between the ages of 35 and 40. The success of assisted reproductive technology (ART), however, has significantly changed our notions of parenthood, both medically and psychosocially. Now, health and mental health professionals regularly provide medical care, support, and psychoeducation to many older individuals and couples (40 to 50+ years of age) who are attempting to become parents at any cost.
But what about the children?
Limited literature on childhood outcomes
Because the uptick in older parenting is a relatively recent phenomenon made possible by IVF using donated oocytes, few studies have addressed this question. The small number of studies that have examined older parenting have defined older parents as those over the age of 35 and have not interviewed the children to assess their experience.9 Thus, there is a dearth of academic research to consult when considering how children are affected when they are born to parents aged 45, 50, and beyond.
Two books published in the late 1980s and early 1990s looked for the first time at the possible effects of older-age parents on children.10,11 The books were based on extensive interviews with almost 100 adult children who were born when their parents were 35 or older, and their findings are remarkably similar: For better or worse, the feelings and experiences of children born to older parents differed from those of children born to younger parents. On the positive side, late-comer children often noted feeling devotion and attention from their parents, and they described them as being patient and wise. These children also felt secure financially and emotionally, and they experienced their parents’ marriage as being more stable compared with the marriages of their peers’ parents.
The children interviewed also identified considerable disadvantages to being “last-chance kids.” Many expressed experiencing the following feelings:
Fear of parental death or illness
A sense of a generation gap and embarrassment relative to parents’ ages and appearance
A feeling of being “different” that continued from childhood into adulthood
A need to become mature earlier than peers (“premature maturity”)
A sense of loss that results from a lack of siblings, grandparents, and other extended family members.
These children may also grapple with complex identity issues regarding their parents’ decision to use donated gametes.
As older parents age and their health declines, new difficulties frequently emerge for their children. Children who take on a caregiver role at an early age face challenges in psychosocial development and the transition into adulthood.12,13 Researchers have found that caregiver children tend to grow up and mature more quickly than their peers. They are impacted by the uncertainty of their parents’ health and often struggle with a general lack security. They have higher rates of depression and behavioral problems and are more vulnerable to stress and anxiety.
In addition, these children have less time for themselves, which affects their ability to make friends and form relationships, and many experience career difficulties and educational problems due to missed school and lack of parental support. Ultimately, many have difficulty emancipating from home because of the need to provide continued care for their parents, and they face social exclusion and stress as young adults. Life decisions such as further education or embarking on dating, marriage, and having their own children are often delayed, if not abandoned, due to the responsibilities of caring for an ailing parent. Not much positive benefit for the children has been identified from the experience of parental caretaking.
The blow of parental death
Although caring for an ill or aging parent(s) as a child is problematic, the impact of a parent dying during childhood can be catastrophic. Losing a parent, at any age, has been identified as one of the most significant and highly stressful life events.14 If the loss occurs during childhood, the increased risks of social impairment and psychopathology extend into adulthood; in addition, this group has a greater risk of earlier mortality than the general population.15
All children are at increased risk of behavior problems for at least 2 years following a parent’s death, and risk for depression and anxiety is higher. While there is no “good age” to have a parent die, children younger than age 5 and adolescents are more vulnerable for psychological impairment. The gender of the child and parent is another risk factor when the child loses the same-sex parent, yet for all children maternal loss is more significant, often related to stronger attachment in childhood. The adjustment of a bereaved child is influenced by circumstances of the death (sudden or expected), family stability, consistency in the living environment, presence of siblings, open communication, and the relationship with the surviving parent or caregiver after the death.14
Thus, while growing up with older parents may have some advantages, these children face a greater likelihood of having to care for an ill or aging parent as well as having to deal with parental death. These children often experience lifelong challenges that impact their education, career, economic security, relationships with others, and physical and emotional health. Not surprisingly, few of them report wanting to have their own children late in life.10,11 If they do decide to have children, their children will most likely not enjoy the influence of grandparents in their lives.
Counseling and patient preparation
Health care providers and mental health professionals are responsible for educating and preparing potential older parents regarding the concerns that may arise for themselves and their child or children. Patients should be counseled about the medical and health risks for children that can be associated with having children at an advanced age. For example, there may be a higher risk of autism spectrum disorder16,17; psychiatric disorders, such as schizophrenia and bipolar disorder, which are associated with older fathers18-20; and premature birth as well as other adverse maternal and fetal outcomes.21,22
Patients should be counseled about the medical and health risks for children that can be associated with having children at an advanced age.
A number of potentially difficult psychosocial issues must also be discussed with the older potential parent. (See “Discussion points to address with the older potential parent”). Although a frank discussion of these points may be difficult, it is necessary to help prospective parents realistically appraise the potential experience for their child.
Discussion points to address with the older potential parent
The potential parents’ current age and health status, and possible implications/ impact for future child rearing
Patients’ thoughts and concerns about being older parents
Plans regarding family size
Plans for the child’s future: guardianship, legal and financial security
The importance and availability of extended family and peer support relationships for the child, and how these can be created
The importance and methods for talking with children about such topics as:
– Single parenthood and the absence of a second parent
– Disclosure of gamete donation—an ongoing process
– Acknowledging and addressing the child’s fears of parental death or illness
– Plans that are in place to protect the child
– Child embarrassed by having older parents (often mistaken as “grandparents”)
– Child teased by peers about having older parents
– Child loneliness due to lack of siblings or extended family
– Child deprived of active play (sports, dance)
– Adult child as parental caretaker, which may limit his or her personal choices or goals
– Adult child’s lack of available emotional support and understanding of unique challenges of caring for elderly parents at a younger age
An informed decision is essential
ART has made parenthood a reality for many older individuals and couples who previously may not have had an opportunity to raise and mentor a child or children. Since scientific advances have made it possible to have children at virtually any age, health care professionals must recognize the new level of responsibilities that they take on as they consider treating older potential parents. It should not be assumed that “it will all work out” for a potential child. Rather, genuine consideration must be given to the experience of the potential child that comes into a family with older parents.
Health care professionals and older potential parents alike are advised to contemplate 2 key questions: Will having a child at an older age have a good outcome for the parents? And, will it also be a good outcome for the child? In some circumstances, it is not a good outcome for the child. As Landau states, “Childlessness is a complex concept, and children are neither medicine nor therapy. They should not be used as means to other people’s ends.”8
The authors gratefully acknowledge the contribution of Lori A. Grapentine, FSA, MAAA, in the preparation of actuarial data tables.References
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