Young women's views of receiving information about the consequences of delayed childbearing: A qualitative study

About the topic

All participants were aware that increasing number of women are delaying motherhood; however, a large range existed between what participants perceived as “late childbearing;” some felt that age 35 was “getting late” whereas for others 45 constituted as late. Although there was a basic awareness of their fertility declining with age, there was an uncertainty about when this decline began, though some had an idea of when but lacked certainty about the facts. There was a consensus that pregnancy at an older age had higher risks of complications. Some perceived that good health and good fertility were closely linked, and fertility is largely controlled by their lifestyle, with factors such as obesity and alcohol being of potential detriments to it. It seemed that the media was both effective and counterproductive for this issue. There was a consensus that documentaries on television (TV) had raised fertility awareness, and both groups agreed that this could be a source of providing fertility education to young people.

About the fertility treatments

In vitro fertilization (IVF) seemed to be the fertility treatment that women in both groups were most familiar with. However, little seemed to be known about IVF, and even less about other forms of fertility assistance.

There was much uncertainty about the costs of IVF and whether or not the NHS subsidized treatment. However, a number of participants were aware that a cycle costs approximately £3000.

Factors shaping childbearing decisions

There were a number of factors that both groups considered to be important in influencing their childbearing decisions [Table 1].

Table 1 Factors shaping childbearing decisions

Changing priorities

Higher education and establishing careers were described as the important factors shaping decisions to delay pregnancy. Participants expressed strong feelings about having plans and priorities while they were “young,” such as “living life with little responsibility,” and that motherhood was something that would be a priority “later.” Many participants agreed that balancing a career with a child was perceived to be very problematic, and most felt that balancing a child with career was not possible, with several participants perceiving “motherhood as the end of their career.”

Some participants suggested that the increased opportunities now perceived to be available to women were due to the ability to delay motherhood resulting from the availability of contraception. This also brought in the idea of women having increased control over their own lives.

Some women perceived childbearing as “somewhat out with their control;” they felt that despite their plans, other factors in life may intervene and childbearing could be “something put off until a more convenient time.”

Cultural and societal expectations

Expectations of society and parents for their children to go to a university and establish a career were viewed as important; for a young woman to become pregnant relatively soon after attending university was perceived potentially as a “waste” of education and money from the perspective of parents and society.

The changing gender roles, particularly of women over the last few decades, and the opportunities and choices now available compared to their perceived historic role were also important issues to a number of participants. In the past, women were perceived as domestic homemakers and mothers, whereas now women perceive themselves to achieve many things on top of these roles. Both groups commented on how society had changed the age of perceived independence; they expressed that “university seemed to extend the teenage years,” and slow down the rate of independence and maturity. This increased age of independence leads to women feeling “too young” and not mature enough to begin a family.

Personal circumstance in childbearing years

Participants felt that a number of personal factors significantly shaped their decisions about motherhood.

Personal “readiness,” the time at which a woman feels she is “ready” for motherhood, was a factor implicated by both groups. Women felt that motherhood is a very personal decision, and no one should be told to have a child before they feel physically, psychologically, and financially ready.

All participants agreed that “financial and relationship security” was the vital factor in shaping childbearing decisions. Participants also perceived children to be extremely expensive, and felt it would not be until they were older with a secure career in place that they would be in a position to support a child.

“Preservation of physical appearance” was a topic briefly mentioned by some participants in FG1. They felt that losing control on how their body looks could be a factor in young women delaying pregnancy until their later years.

Information received from schools

There were strong opinions from both groups on the influence of the school message on childbearing intentions; they felt that school had provided them with a very strong message, promoting contraception and condemning teenage pregnancy. Neither group felt that school had provided them with information on when was the optimum time to consider pregnancy. Participants also discovered large discrepancies between schools’ provision of sex education; some seemed to have received a thorough education, whereas others did not have enough information on it.

Stigma associated with younger and older mothers

Participants unanimously agreed that stigma was a problem for both young and older mothers. Stigma seemed to be perceived as coming from society, school, and even their peers, and the stigma of being perceived as a “teen mum” had now been extended to those having children in their early twenties:

“You read the papers and magazines… if you’re below the age of 25, you’re kind of stigmatized as a ‘teen mum’, even though you’re not” - L2; FG2

“(Stigma) comes from other people the same age, like people that are at uni … see someone their age having a child; they’re judgmental about it …” - C; FG2?

They felt that mums in their early twenties are stigmatized as having little education and low intelligence:

“You do assume that when you see someone like an 18 year old… with a kid that ‘Oh, they don’t have education, they are probably not that smart’” - L; FG1

“When I see women… that have children like really young, it's just like a stereotype that's tagged onto them… I don’t think like people want that stereotype, they don’t want to be seen as… a teenage mum who looks like she's got no education, nothing going for her” - KA; FG1

There was also stigma surrounding older mothers, as they could be perceived as “selfish” or unable to meet the physical or emotional needs of childbearing.

One woman felt that with increasing frequency, motherhood at an older age would become less stigmatized and that with advancing health care leading to longer average life spans, women having children at an older age was acceptable.

Should information be provided?

The majority of women felt that fertility education should be provided to them. There were a number of different reasons behind the need for information, but the ability to make “informed” choices was particularly important.

However, a small number of women felt that fertility education did not need to be provided, since everyone has the opportunity to do research themselves, and therefore, there is no need to provide it:

“I don’t think it's as big of a deal letting people know because people can find out themselves” - Li; FG1

Participants who were unsure about whether fertility information should be provided were primarily concerned about what information would be provided and the method used. Many were worried about a potentially aggressive approach to information provision, creating added pressure for young women:

“If there was some sort of guidance that came out that said ‘You should have a child between 25 and 28’… then people would be like ‘Well the Government are telling me when I can have children and that can’t be allowed’” - F; FG2

Participants in FG1 also discussed the benefit of providing information to women in the context of dispelling fertility myths that often resulted from receiving information from a variety of unreliable sources:

“One of the things that really scared me was I heard at university… it can take up to 5 years for a woman to conceive after she got (the rod) taken out. But I went to the clinic and they said that was a load of nonsense, so it's a mix of information I’m getting” - KA; FG1.

What information has to be provided?

There was a great deal of discussion about the type of information to be provided. All participants felt that a “neutral” approach was important so that women feel informed and empowered by the information they are receiving, not dictated by it. Participants felt that providing the information as facts, without influence, would allow women to make their own decisions about motherhood:

“If you just put in a fact like that then people aren’t going to be like ‘Oh, you’re telling me to have a baby’. They’ll be like ‘Oh, you’re telling me the fact and now I’m going to decide for myself’”-Ln; FG2

Some women in FG1 specifically asked for evidence-based statistics, as they felt that this was the information that women needed to be accurately provided with:

“What is the number behind steep decline? I would also like to see behind those numbers, the IVF success rate, how much is age-related?” - L; FG1

Finally, the women wished to receive the information in a nonthreatening manner. They felt that it was a sensitive subject, and this should be considered when drafting up the information content:

“They’ve got to be really sensitive, because actually it's a sensitive issue” - Li; FG2

How to provide information?

A number of suggestions were provided by participants as to how the fertility information could be provided including NHS campaigns involving posters in public places such as bus stops, giving out leaflets in smear test appointments, online bookings to speak to a professional, leaflets in health-care waiting rooms, and as part of the national curriculum in Biology and Health classes.

Website and posters

FG1 seemed particularly enthusiastic about running an NHS campaign to advertise a fertility website. They felt that not too many facts should be provided on posters, but just enough to make people consult the website. They felt that this would not pressurise people and leave them enough room to decide for themselves whether they wished to know more. They suggested publicizing the website on bus stops, at university during Sexual Health Week and in public toilets.

Leaflets

Leaflets were another suggestion, however the two groups disagreed over where these leaflets should be available; FG1 felt that they should only be provided in healthcare-related settings, β€Šwhereas FG2 suggested that they could be left in all public places where leaflets could be provided:

(In response to the question, “If I create a leaflet today, where are the places it should be provided?”…)

“A sexual health clinic? Or maybe the doctor's surgery…. And hospital waiting rooms… I don’t think I’ve ever seen a contraception leaflet in the village hall … I think it's just sort of zoned into areas” - H; FG1

“It would be inappropriate” - E; FG1 (providing fertility leaflets in village hall)

The possibility of advertising or providing leaflets alongside smear test appointments or in public toilets was suggested by some participants.

Mobile apps and social networking websites

Women were questioned about whether they felt mobile phone apps and social networking sites could be used to provide information; however, neither group seemed enthusiastic regarding this; all felt it would be an insensitive method of providing information, and some felt that this would feel pressurizing:

“I think to have it excessively out there does hit a panic button” - C; FG2.

Communicating with health-care professionals

Mixed views were expressed regarding discussing fertility with health-care professionals. Participants felt that you should have the right to talk with a professional about the subject; however, there was a consensus that this would be seldom done by young women. FG2 seemed skeptical as to how seriously they would be taken by a doctor should they approach them with fertility concerns.

Participants felt that it was not the place of a health-care professional to bring up the topic of fertility, although some felt that it would be appropriate in the context of attending for a sexual health-related matter. Most of the FG1 participants felt that professionals approaching the topic of fertility in unrelated appointments would seem “invasive.”

“It feels quite invasive in your privacy” - R; FG1

“Maybe when you’re going in for a smear… I don’t think if you go in for a chest infection they should lecture you about your fertility” - KA; FG1

One woman suggested that there could be an option to talk about fertility provided to women when they attended the sexual health clinic, via an extra form that asked whether they would like to discuss their fertility with a health professional at the clinic.

Pill packet warnings

There were mixed feelings about the idea of labeling contraceptive pill packets with a fertility warning. FG1 felt very negatively toward this, and believed it would feel invasive on their lives or scare women away from using contraception. However, FG2 felt that this was a good idea, as they all read the side effects’ leaflets provided in their contraceptive packets and felt that this message could be provided here.

Television shows

TV shows were a suggestion that came from both discussions; participants felt that educational documentaries were a good way of reaching young people, as they had learned from documentaries they had previously seen, as well as from watching fictional dramas that covered fertility issues.

FG2 seemed particularly enthusiastic about this method of information provision; they felt that careful consideration of channel and timing of the program could help to direct it toward younger audiences.

When to provide information?

Secondary school age seemed to be the consensus among participants. They felt that providing fertility education at school age was the only opportunity available to provide everyone with the information, since not everyone will go on to higher education. With this in mind, they felt that the information had to be provided before the minimum school-leaving age:

“I think when you’re hitting mid to late teens, maybe 15, like somewhere in the middle, before you’ve left school” - C; FG2

“High school… everyone has to go whereas uni only some people will go… school is the only chance you have really to hit everyone” - E; FG1

“The information should come before the kids are allowed to leave school” - M; FG1

Participants unanimously agreed that primary school age was “too young” to receive this fertility education, and that mid secondary school age around 16 years was more appropriate. FG1 participants were asked whether they felt this information provision should be repeated, with mixed responses; only some felt that they should receive it again, perhaps again at school or in university.

There was a general agreement that school was seen as authoritative, and information provided to you at this age (i.e., in secondary school - 14–16 years) would be more beneficial than the mixture of information heard on the playground:

“At school is one of the first times you learn about sex and you learn about pregnancy… you need to hear it from an authoritative figure at a young age rather than your friends making it up to sound cool” - E; FG1

Both groups felt that secondary schools specifically should be providing a particular message; one that is not so condemning of teenage pregnancy. They felt that more supportive information should be provided to women who get pregnant, or want to get pregnant young, and that schools could provide women with the message that it was their decision when they want to have children, and a career could be picked up at any time in their lives, whereas they have a fixed fertility window. They felt that they should also be provided with information regarding the optimal age to have children because at the moment they felt there was a gap between 16 and 45 years, which they were uneducated about:

“Schools should say that… if you want to have kids when you’re younger; here are the options… It should be more positive” - KA; FG1

Finally, all participants felt that secondary school was an ideal place to provide young people with fertility education. They considered this the only stage where everyone could be provided with information (since not everyone goes to university or reads leaflets) and that children could be provided with the facts as part of the national curriculum in Biology or Health classes. They felt that providing the information in this way would ensure that it was provided in an objective manner, with minimal influence.

Would receiving information affects childbearing intentions?

Finally, the young women in both groups were asked whether they felt this provision of information would make a difference. FG1 participants felt certain that receiving information about the consequences of delayed pregnancy would encourage them to research it further.

FG2 felt that although the change was unlikely to be dramatic, it would cause them and other women to consider the timing of motherhood more carefully and could lead to a change in their childbearing intentions.

What women know?

Studies from the background literature search revealed that the majority of young women did not have a substantial basic knowledge of many aspects of sexual health.^{[12,13,14,15,16,17,18]} This was largely confirmed in our results, where uncertainty surrounded several aspects of contraception, fertility decline, fertility testing, and success rates of fertility treatment.

There was controversy among participants as to what constituted “late” childbearing; a range of approximately 10 years was discussed, with a number of women suggesting that they considered 35 years to be late to have children, but an equal number were firm in their opinions of age 45. As a “reproductively advanced age” is regarded as young as 35, and 10% of women undergo an early reproductive aging process, clearly more information is required here. Due to better health care and longer life spans, many women now regard age 40 as the “new 30.” However, when it comes to reproductive health and pregnancy, there is still a fixed optimal fertility window between 20 and 35 years, which has not changed despite changing culture and advancing health care in other sectors. This could be the reason why some young women now regard ages upward of 40 as suitable to begin childbearing.

Uncertainty and lack of information was a key theme in the results, showing that overall, our participants felt uninformed about many fertility and pregnancy issues. With regard to childbearing, uninformed decision-making can significantly impact the lives of prospective mothers and for some, lead to involuntary childlessness.

Why do women delay pregnancy?

Several factors were discussed during the group sessions, consolidating the previous evidence that higher education, establishing a career and financial security, finding a suitable partner, and a personal “readiness” are all key factors in shaping a woman's childbearing decisions. Feeling that motherhood was something that is, to an extent, out with a woman's control was a factor discussed during our study, which had been found in one another study.^[1]

Our participants seemed to view higher education and establishing a career as particularly important factors in delaying pregnancy. This could certainly be due to the sample population which was recruited; all were currently undertaking undergraduate or postgraduate degrees. If a broader representation of women had been obtained from recruitment, other factors implicated in the delaying of pregnancy may have come to light. Despite this imbalance of study participants, the study unearthed an important issue; in spite of government efforts to support new parents through measures such as increased maternity and paternity leave, young women do not perceive early motherhood as something that can co-exist with a career, and delaying pregnancy to first establish their career is seen as a necessity for many. This suggests that more support is necessary for mothers and young mothers, in particular, to allow them to focus on their career too. If more supports were in place, perhaps, more women would be encouraged to start their families at a younger age.

The “school message” condemning teenage pregnancy had a profound influence on the participants; all felt this message had been promoted aggressively in school, and agreed that this had influenced their decision to delay pregnancy. However, despite sex education being part of the national curriculum, there were large discrepancies between schools as to the standard of sex education provided, and many of the young women in our study did not feel that they were being provided with a basic knowledge about this.

Our results also revealed that the stigma associated with being labeled a “teen mum” by society has been extended to include mothers in their early twenties; this was found to be a further factor behind the rationale of delaying pregnancy, and one that had not been found in the existing literature on this topic. This is a very important fact that has come to light through this study, as it explains why those who can and wish to become mothers at an earlier age are put off. This is an area where public health message is lacking.

What information do they wish to receive?

As previously mentioned, no existing literature was found detailing how, when, and what information should be provided to young women on the consequences of delayed pregnancy, or what their perceptions of receiving this would be; therefore, no comparisons can be made regarding these results. However, as per the existing literature results, women in the current study also felt that they, and other young women, ought to be more informed about delaying pregnancy; they felt that being informed on these matters would influence their reproductive decision-making.^[15,21]

Where to provide information?

Information provision through schools as part of the national curriculum was suggested by all participants. School education was discussed in detail by both groups, and despite their issues with much of the sex education they had received there, it was clear that it had a profound effect on them.

Both groups were in unanimous agreement that this information should be provided to both genders. This was interesting since much of the existing literature on this topic had only investigated perceptions and knowledge of women, and only two background literature studies had included men in their sample population. This shows that despite changing culture and gender roles, our modern day society still does not regard the issue of childbearing as an equal responsibility between a man and a woman.

When to provide information?

A previous study found that women in their thirties felt that fertility information should be provided in their early twenties.^[21] Although our groups agreed that early twenties seemed the most appropriate and relevant time to receive this information, they did not feel that this was feasible as there is nowhere at this life stage that information could be unanimously distributed, since young people go in several different directions at this age; university, college, jobs, or already employed. This was a significant factor in our participants, suggesting secondary school as the most ideal place to provide fertility education to young people.

Although secondary-school age would allow for unanimous distribution of fertility information to young people, problems in implementing this approach have to be considered; educators would need to carefully consider how to provide delayed childbearing information in a way that did not promote having children during teenage years.