Advanced Maternal Age: A Scoping Review about the Psychological Impact on Mothers, Infants, and Their Relationship

The mean age at childbirth in Europe has gradually increased, and it is now around 29 years of age. It has been shown that older maternal age is associated with problems of fertility; in fact, with increasing age, the chance of conceiving diminishes, and fetal and obstetric complications grow. Research has focused particularly on the biological risks associated with late pregnancy, both for the child and the woman. Less space has been dedicated to the potential psychological and relational benefits of motherhood at an advanced age. The aim of this review was to summarize the existing literature on this issue. Qualitative and quantitative studies were sourced from Pubmed, Science Direct, PsycINFO, and SciELO. The selected works highlight that advanced maternal age can be associated with some advantages for both mothers and their offspring in terms of physical healthcare, parenting styles, and child developmental outcomes. Specifically, the review suggests that older mothers have greater emotional maturity and feel more prepared for motherhood; also, advanced maternal age appears to exert a protective influence on children’s behavioral, social, and emotional functioning, compensating for the biological risks.


Introduction
In recent years, the age of first-time mothers has significantly increased.Among the possible reasons for this, many researchers propose that it may be caused by the greater participation of women in higher education and in employment and in their desire to reach financial stability; indeed, these motivations may lead women to postpone the moment in which they decide to become mothers [1][2][3].In Europe, the average age of first-time mothers registered in 2021 was 29.7 years, a significant increase from previous years, as reported by Eurostat [4].
The increased maternal age carries with it problems of infertility since the ability to conceive spontaneously decreases as a woman's age advances [5].Research has shown that the optimal age range for successful conception and healthy childbirth is 20-34 years old.Fertility steeply declines over the age of 35 when conceiving a child becomes increasingly difficult [6].
In addition, giving birth at an older age is linked to psychological conditions such as autism, bipolar disorder, and symptoms of depression, anxiety, and stress, along with impaired social functioning [18].
Behav.Sci.2024, 14, 147 2 of 13 Despite the recognition of the critical importance of the early parent-child relationship quality for children's socioemotional, cognitive, neurobiological, and health outcomes, there is currently limited exploration of the psychological impacts of the advanced maternal age on mothers, infants, and their relationships.
The goals of this review are as follows: (a) To understand the perinatal psychological experience in advanced-age mothers; (b) To study the parenting behaviors of advanced-age mothers compared to younger mothers.

Materials and Methods
This research was conducted as a scoping review.A scoping review is useful to map the literature on evolving topics and identify gaps.They follow the guidelines for systematic reviews but are simplified to facilitate consultation with stakeholders [19].

Search Strategy
Pubmed, Science Direct, PsycINFO, and SciELO were searched from their inception to September 2023 using the following keywords: advanced maternal age, maternal age and offspring, pregnancy outcome, postponement of childbirth, and parenting.No time limits were set to select the studies since the main purpose of the current review was to explore all the available empirical and clinical data.Articles were included if they fulfilled the following PICOS (population, intervention or exposure, comparison, outcomes, study design) eligibility criteria.

Population
Pregnant women or those who had a child at ≥35.Additionally, women under the age of 35 are considered for the purpose of comparing pregnancy outcomes between those of advanced maternal age and younger women.

Intervention/Exposure
Studies focusing on the perinatal psychological experience and parenting behaviors in the target population were considered.

Comparison
The review aimed to compare advanced-age mothers' experiences during perinatal and those of younger mothers, both in terms of psychological functioning and parenting quality.

Outcomes
We looked at the following outcomes: parenting behaviors, perinatal distress in advanced maternal-age women, and psychological symptomatology (e.g., self-reported depression, anxiety, stress, and perception of pregnancy risks).

Study Design
We included quantitative studies, qualitative studies, literature reviews, and metanalyses.

Selection Criteria
The search had the following inclusion criteria: (1) quantitative/qualitative studies; (2) literature reviews; (3) metanalyses with advanced maternal age as their primary or secondary goal; and (4) published in English.Case studies and editorials were excluded, as well as articles that did not consider psychological aspects during pregnancy and abstracts without the full text available.
The initial search yielded 184 articles.Following the exclusion of duplicates and papers lacking the full text, 72 potentially relevant studies were evaluated for eligibility.After excluding any out-of-scope manuscripts, 24 articles were included in the review.MA and LV authors independently screened the full texts to mitigate selection bias.A narrative stracts without the full text available.
The initial search yielded 184 articles.Following the exclusion of duplicates and p pers lacking the full text, 72 potentially relevant studies were evaluated for eligibility.A ter excluding any out-of-scope manuscripts, 24 articles were included in the review.M and LV authors independently screened the full texts to mitigate selection bias.A narrativ synthesis was employed to analyze pertinent papers categorized under themes.The stud selection process is visually represented in Figure 1, as depicted in the PRISMA flow cha

Data Extraction
The characteristics of included studies are shown in Tables 1 and 2. The tables have six entries for each study as follows: title, authors, sample, resear design, objective, and results.Table 1 presents studies examining the obstetric risks ass ciated with pregnancy in advanced age, with a secondary emphasis on psychologic

Data Extraction
The characteristics of included studies are shown in Tables 1 and 2.    The tables have six entries for each study as follows: title, authors, sample, research design, objective, and results.Table 1 presents studies examining the obstetric risks associated with pregnancy in advanced age, with a secondary emphasis on psychological variables.By contrast, Table 2 compiles studies where psychological outcomes of late pregnancy are the primary focus, examining their impact on women and/or their offspring.

Participants
All studies involved in this review considered women who were at least 18 years old during the perinatal period.As regards advanced maternal age, the included studies considered women from 35 years of age or older.

Instruments
Concerning the administered methods, all studies adopted self-reports, and four of these [23,[31][32][33] used semi-structured, face-to-face interviews.Most studies applied multiple measures.Depression was assessed using the Edinburgh Postnatal Depression Scale [38] and the Beck Depression Inventory Short Form (BDI/SF) [39].Parenting stress was assessed with the Parenting Stress Index Short Form (PSI/SF) [40].Regarding anxiety, the tools used were the State-Trait Anxiety Inventory (STAI) [41], the five-item 'Anxiety concerning Health and Defects in the Child' scale from the Baby Schema Questionnaire [42] and the Pregnancy-Related Anxiety Questionnaire [43].
Other quantitative measures included the following: the Maternal-Fetal Attachment Scale (MFAS) [44] to measure the construct of maternal-fetal attachment during pregnancy; the Personal Views Survey (PVS-III-R) [45] to assess psychological hardiness; the 24-Item Intimate Bonds Measure (IBM) [46] assesses the perceived quality of the partner relationship; the Family Adaptability Cohesion Evaluation Scale (FACES) [47] to evaluate the adaptability and cohesion dimensions in family interactions, the Mother-Child Relationship Evaluation (MCRE) [48] to assess maternal attitudes; the Multidimensional Scale of Perceived Social Support (MSPSS) [49], a self-report measure of subjectively assessed social support; the Perception of Pregnancy Risk Questionnaire (PPRQ) [50]; the SF-12 Health Status Survey to measure functional health and well-being [51]; the Multidimensional Health Locus of Control Questionnaire (MHLC) [52] to measure perceived internal control; the Prenatal Scoring Form; and the Cambridge Worry Scare (CWS) to measure women's concerns or worries during pregnancy [53].

Overall Psychological Experience in Women in Advanced Maternal Age
As regards the first objective, which is the mothers' psychological experience, it has been shown that pregnant women aged 35 or older perceive their age as a risk factor for their pregnancy.However, these concerns seem to emerge only in the presence of other risk factors like unfavorable screening test results, previous poor reproductive history, or anxiety [23,33].Older women within a healthy context and without other risks tend to perceive their pregnancy as low-risk [23].Another survey comparing the risk perception in pregnant women aged 35 years or older to that of younger women showed that women of advanced maternal age had a higher perception of pregnancy risk compared to younger women, both for themselves and for the fetus [22].However, the survey shows no significant difference compared to younger women with respect to perinatal-specific anxiety, health status, perceived control, and knowledge of pregnancy risks [22].
Maternal awareness of risk is a key element that can also have a positive influence on their decisions about when to seek medical attention and when to take appropriate measures and actions that can significantly improve maternal and fetal health and development.
Some longitudinal studies showed that older maternal age is associated with decreased risks of child hospital admissions and accidental injuries in the first three years of life [25,34], with better levels of language development and fewer emotional difficulties compared to younger women's children [34].Moreover, children of older mothers show higher educational levels and higher cognitive abilities [30,54].The improved social resources of advanced-aged mothers might, in part, explain such findings.
From the above results, it can be stated that older women show high coping abilities, which may mitigate the obstetrical risks [21, 55,56].
Indeed, several studies seem to confirm that postponing motherhood may represent a psychological advantage to both mothers and their children.Older mothers feel more capable of taking care of their children and more competent [31,36,57]; they also feel fulfilled in their role and consider pregnancy as an experience permeated by perceptions and feelings of satisfaction and achievement [31][32][33]36].These women consider themselves as more prepared, more patient, tolerant, resilient, balanced, and emotionally ready, as well as more secure and competent with their infant [23,26,31,32,36,37].They also describe their partners as less controlling [26].

Psychological Distress
By contrast, results are mixed in relation to the presence of psychological distress.Some studies report lower symptoms of depression and anxiety during pregnancy, a decrease in postpartum depressive symptoms with advancing age, and no significant differences between older and younger women in pregnancy-related anxiety, knowledge of risk, perceived control, and health status [22,26,28,58]; others showed higher concerns during pregnancy [28,35], including more depressive symptoms during the prenatal period [35,59], higher levels of postpartum depression [20,27,[59][60][61] and stress [27,60,61] and slightly higher scores of psychological distress [59].As regards the perception of pregnancy risk, it emerged that older women have a more positive perception than younger women and women's concern about their child's health is connected to the mother's age.Older mothers Behav.Sci.2024, 14, 147 9 of 13 are more worried and consider the risk of dying during pregnancy, preterm birth, a cesarean birth, having a newborn with a birth defect, or having one needing admission to a neonatal intensive care unit more compared to younger women [23,28,32,35,41].
To clarify inconsistencies, it is important to assume a more complex perspective on the issue.For instance, in another study [24], the authors verified that prenatal depressive symptoms were higher in the group of older women during the prenatal period, whereas depressive symptoms and parenting stress in the postpartum period increased at all ages.Moreover, cortisol levels increased starting from 30 years of age but only at 3 months after birth.In contrast, family functioning, social support, and maternal attitudes improved starting from 30 years of age, underlining that some benefits may compensate for other disadvantages.Consistently, other studies reported that despite the higher depressive symptoms during the prenatal period in pregnant women aged over 35, social support (especially objective support and subjective support), family functioning, and maternal attitudes improved with age and had stronger protective effects against depression for women of advanced maternal age compared to women aged under 35 [20,60].
In the case of contradictory results, the different methods used in the studies about the selection of the participants, the analyses, the instruments administered, and specific objects should also be considered.

Parenting Behaviors of Advanced Age Mothers
Regarding the parenting behaviors of advanced-age mothers, some studies suggest that increasing maternal age is linked to a more effective parenting style.Specifically, older mothers seem to be more responsive, supportive, closer, and less strict with their children [21,34].In turn, as maternal age grows, children seem to show fewer behavioral, social, and emotional problems.These data have been confirmed longitudinally from 3 to 15 years of age [20][21][22].

Discussion
An increasing number of women in developed nations are choosing to postpone childbirth until their late thirties and beyond.These women express varying degrees of support from healthcare professionals.
However, there is a paucity of work in the literature on the psychological implications of maternity at an advanced age for both mothers and their children.
The present scoping review has pointed out that there are some positive effects of becoming mothers at older ages.Indeed, older mothers tend to have higher socio-economic levels and feel more secure about their working position.Usually, they are also in a stable relationship.These conditions allow woman to dedicate more resources to their children [29], playing a fundamental role in favoring their well-being.
Moreover, several studies have highlighted how older mothers are likely to pay more attention to the quality of their relationship with their offspring.Certainly, this is possible because these mothers feel more content as parents and are better prepared to take care of their infants.Consequently, their parenting style is characterized by supportiveness and closeness to their child.These dimensions promote a child's positive physical and mental well-being [25,34].In fact, children born to older women have fewer behavioral, social, and emotional difficulties, as well as better language ability [29,34,62], supporting health throughout development up to adulthood.However, this outcome is strongly linked to several concurrent compensating variables, including, above all, the low psychosocial risk background of the studied AMAs.In addition, numerous women indicate their dependence on friends for support, particularly through the exchange of experiences.A significant number of women highlight the advantage of being of advanced maternal age, as others within their circle of friends have already experienced childbirth and could offer valuable insights and information [63].
To summarize, in contrast to the proven physical health risks for older age mothers and their offspring, it seems that advanced maternal age may play a protective influence on behavioral, social, and emotional difficulties for children.
A change in dialogue and ongoing scientific findings regarding certain risks associated with advanced paternal age entering clinical application could transfer the responsibility from predominantly resting on women to being shared by both men and women [64].
In conclusion, this review indicates the need to consider advanced maternal age in a more complex and multifactorial perspective.
Healthcare practitioners can play a crucial role in cultivating trusting relationships and empowering interactions with women.They can offer a range of resources for childbirth preparation and provide sensitive assistance in birth planning, aiming to support the agency of women while effectively managing potential risks.Implementing guidelines and protocols in the antenatal care of older pregnant women based on empirical evidence could promote consistency, especially in terms of risk management and the childbirth process.

Studies Limits
This review presents different limitations.First, the different methodological approaches, as well as different sample sizes, used in studies included in this review make it challenging to identify the specific impact of advanced maternal age on the considered outcomes.In line with this, not all studies consider the several protective factors that older mothers may benefit from.
Also, different studies did not focus on the same outcome variables of advanced maternal age; some focused on women's mental health, others on child development outcomes, and the mother-infant relationship.
Furthermore, most studies were carried out without considering the impact of the maternal educational level and economic status; however, when this was performed, these variables represented a protective factor for the outcomes, regardless of the mother's age.
In addition, most studies were conducted with samples of women from Western countries in which the mean maternal age at childbirth is higher compared to low-resourced countries.
Finally, as is typically conducted in scoping reviews, no systematic quality assessment of the included publications was performed.
For all the above reasons, interpreting this review's conclusions must be undertaken with caution.

Future Directions
More research is still needed; future studies should differentiate between desired and unwanted pregnancies; finally, outcomes must take into consideration the impact of medically assisted pregnancies and acknowledge the significant role of fathers.
Therefore, it is necessary to follow women during the perinatal period, identifying and supporting protective factors.The maturity and financial stability reached with age surely allow these mothers to dedicate more attention to their children.The physical presence and empathic and caring relationship that mothers have with their infants have long-term consequences for their child's well-being.
Finally, as technological progress enables women to delay motherhood well into their forties, fifties, and even sixties, the term 'very advanced maternal age' is becoming increasingly prevalent.Subsequent research could explore the distinctive or shared experiences and needs of this older cohort of women.
In conclusion, the experience of becoming a mother in old age may be felt as desirable if women are informed of all the risks and the benefits related to age and receive, if needed, adequate support both from their social network and healthcare providers.
Behav.Sci.2024, 14, 147 3 of 13 synthesis was employed to analyze pertinent papers categorized under themes.The study selection process is visually represented in Figure1, as depicted in the PRISMA flow chart.

Table 1 .
Table of included studies related to obstetric risk associated with pregnancy in old age.

Table 2 .
Table of included studies related to psychological outcomes of a late pregnancy.