First childbirth at advanced maternal age (AMA), defined as maternal age of 35 years or over at the time of delivery , is an increasing trend in industrialized countries . In the United States, the percentage of live births at AMA has increased from 4.9 to 14.2 percent between 1980 and 2009 [3, 4]. Canada has followed this trend with 18.3 percent of live births at AMA in 2009 . Similar changes have been observed in Europe with a growing expression in southern countries . In Portugal, the proportion of live births at AMA was 20.6 percent in 2009 . Despite changing demographic trends, AMA continues to be associated with higher rates of cesarean birth, fetal and neonatal mortality, and morbidity [8-13], engendering increased financial costs for welfare systems .
Based on sociodemographic data from Northern Europe, the United States, Canada, and Australia, first childbirth at AMA has been frequently understood as a deliberate choice that characterizes well-educated women of higher socioeconomic status who perceive work as important and are less oriented toward motherhood than their younger counterparts [15-21]. This reproductive trend has been related to stereotypes of ambition, selfishness, and violation of the natural order  that interfere with women's well-being and with their relationships with health care practitioners [23, 24]. Recent studies have reported that primiparous women of AMA constitute a more heterogeneous group than previously believed , emphasizing the need to revise these stereotypes  and adopt a broader perspective to understand later motherhood [26, 27].
Beyond the influence of sociodemographic factors, first childbirth at AMA also depends on a complex interplay of marital and reproductive circumstances that are sometimes outside women's control . Contrary to the established view in the few studies that have explored couples’ characteristics in past decades [28, 29], primiparous women of AMA do not always report stable first-time marriages, characterized by gender equity, dual-earner patterns, and high socioeconomic statuses. These women often display second unions with men who already have children or short-time relationships that may be related to women's socioeconomic independence or vulnerability [18, 19, 25]. Despite the diversity of marital realities underlying first childbirth at AMA , women's partners and within-couple characteristics have remained quite unexplored in the present-day context. More knowledge on these topics may enable a broader understanding of this reproductive trend and contribute to the development of appropriate social policies.
With respect to reproductive history, studies have shown that primiparous women of AMA who conceive spontaneously do not always intensively plan and prepare for pregnancy . These women exhibit similar or higher proportions of unplanned pregnancies than their younger counterparts [16, 25]. In addition, childbearing at AMA is frequently preceded by reproductive health problems . Primiparous women of AMA are more likely to have experienced adverse pregnancy outcomes, primary or secondary infertility, and medically assisted reproduction treatments than their younger counterparts [15, 16, 19]. However, previous studies have rarely allowed a clear identification of the different reproductive trajectories that precede first childbirth at AMA, depending on the frequency and course of these reproductive health problems over time. A study of this topic may lead to the development of health care interventions that may promote conscious reproductive decisions .
Despite the apparent heterogeneity of the group , previous studies have rarely explored the possibility of distinguishing different subgroups of couples who experience first childbirth at AMA, depending on distinct patterns of sociodemographic, marital, and reproductive characteristics. Nilsen et al  hypothesized that having an unplanned pregnancy in AMA may reflect either vulnerable socioeconomic and marital situations or an independent feminine lifestyle. Hammarberg and Clarke  suggested that primiparous women who face infertility at AMA display not only a focus on career but also marital realities that do not facilitate earlier childbearing, such as short-time relationships or second unions with men who already have children. Fertile couples who planned pregnancy  and infertile couples who underwent assisted reproduction treatments  usually have stable socioeconomic and marital situations. However, infertile couples often express a stronger childbearing desire than fertile ones . According to Van Balen, infertile women also tend to report a stronger childbearing desire than their partners, whereas fertile couples tend to evidence equally strong childbearing desires. Further studies should distinguish among the different subgroups of couples who experience first childbirth at AMA, so that adequate perinatal care can be tailored to meet their specific psychosocial needs .
To overcome previous limitations, this study aimed to: 1) describe the sociodemographic and marital characteristics of Portuguese couples who experience first childbirth at AMA (the AMA group) compared with their younger counterparts (the comparison group); 2) compare the reproductive characteristics of both groups and identify distinct reproductive trajectories within the AMA group; and 3) distinguish among different subgroups of couples within the AMA group, depending on distinct patterns of sociodemographic, marital, and reproductive characteristics.
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This study showed that couples in the AMA group were more educated, were employed longer, and had higher socioeconomic status than couples in the comparison group. Despite having similar professional statuses, the AMA group displayed more complex marital realities and reproductive trajectories than the comparison group. Within the AMA group, couples who experienced prior infertility were different from those who did not.
The findings corroborate previous studies that found that couples who experience first childbirth at AMA usually have advantaged educational levels, higher socioeconomic status, more stable professional situations, and attribute less importance to parenthood compared to younger couples [20, 28, 29]. Contrary to previous studies, the couples in our study who experienced first childbirth at AMA were not more likely to have a dual-earner pattern, or more likely to perceive work as more important than younger couples [17, 20, 28, 29]. These similarities between the couples who experienced first childbirth at AMA and at younger ages may be related to the increase in women's participation in the labor market and shifts in gender roles that constitute a generalized trend in the present-day context . Couples’ characteristics that were observed either at AMA or at younger ages may also explain this pattern. These findings were consistent with the higher educational level of Portuguese women compared with men , which may contribute to the high female representation in the labor market  and gender equity with respect to the importance attributed to work.
The findings also support that couples who experienced first childbirth at AMA display more diverse marital realities compared with younger couples . The variability in relationship length suggests that first childbirth at AMA may occur in stable first-time marriages [20, 28, 29] but may also result from a delay in union formation or difficulty in finding a suitable partner . The findings also show that first childbirth at AMA seems to sometimes reflect the partnership shifts that have prevailed in the present-day context, namely the increase in divorce rates and second unions .
With respect to reproductive characteristics and trajectories over time, the findings seem to corroborate the higher reproductive vulnerability of the couples who experience first childbirth at AMA than younger couples . However, first childbirth at AMA did not seem to result from more intensive pregnancy planning and preparation than at younger ages. The marital realities underlying first childbirth at AMA may explain these findings, influencing the perception of time pressure  or a last chance to have a baby . The diversity of reproductive trajectories that precede first childbirth at AMA also seems to support that first childbirth at AMA is not always a deliberate or a conscious choice . In addition to including couples who did not plan pregnancy, a substantial proportion of couples seemed to face infertility and adverse pregnancy outcomes as a result of later attempts to become pregnant and, possibly, an inaccurate awareness about maternal age-related risks . First childbirth at AMA also appears to sometimes result from prolonged infertility and/or consecutive adverse pregnancy outcomes, as previously suggested .
Because of the heterogeneity of the AMA group , two distinct subgroups were identified. The first subgroup consisted of fertile couples who are more likely to report unplanned pregnancies and sometimes experience adverse pregnancy outcomes. As shown in prior studies, these reproductive characteristics coexist with shorter marital relationships and an independent lifestyle [18, 25] that characterizes women who attribute less importance to parenthood . In this subgroup, partners embrace similar views about work and parenthood, supporting that fertile couples usually report equally strong childbearing desires . The second subgroup consisted of infertile couples who sometimes faced adverse pregnancy outcomes before undergoing medically assisted reproduction treatments. As shown in prior studies, these complex reproductive histories  coexist with stable marriages and gender equity in sociodemographic characteristics . In this subgroup, partners seem to embrace more traditional views concerning work and parenthood, supporting that infertile women tend to report stronger childbearing desires than men .
Some limitations should be acknowledged. Participants were recruited at only one public health center, focusing on married/cohabitating women whose partners agreed to participate. Nevertheless, single women who are part of the diverse context of pregnancy at AMA  were excluded and the sample sizes for the different reproductive trajectories and subgroups were small. As a result of these sampling limitations, the statistical power of the study only allowed us to detect medium to large effects. Despite the sensitivity of visual analogical scales, the subjective importance of work and parenthood were assessed using only one question. Future studies should overcome sampling limitations to allow a more detailed analysis of the distinct subgroups within the AMA group and could further assess work and parenthood motivations within the recent context of financial crisis.
In spite of these limitations, this study makes several contributions to this area of research. In addition to exploring the sociocultural specifics of southern European countries, it examined couples’ characteristics underlying first childbirth at AMA in the present-day context. The study also distinguished among different reproductive trajectories that precede first childbirth at AMA and identified different subgroups of couples, based on distinct patterns of characteristics.
This study also has several implications for social policies and clinical practice. Policies that further support families with children (such as improved childcare facilities, parental leave, or job flexibility) should be improved to help in reconciling the demands of family and work. Health care practitioners should be aware that stereotyped views may not actually be representative of couples who experience first childbirth at AMA. Practitioners should assume nonjudgmental attitudes to prevent feelings of stigmatization that may interfere with perinatal care.
Health care practitioners should also be aware that couples may be often unaware of maternal age-related risks. Preventive approaches should be developed, so that information about risks is discussed with couples of reproductive age during family planning and preconception to promote conscious reproductive decisions. During perinatal care, health care practitioners should be cautious in providing risk information to couples who experience first childbirth at AMA. This information should be balanced with the normalization of the process of childbearing at AMA, using a holistic approach that integrates risks with health-promoting behaviors, to enhance couples’ sense of control.
Antenatal preparation programs should be tailored to the specific psychosocial needs of the distinct subgroups of couples who experience first childbirth at AMA. Unrealistic or divergent expectations about parenthood and anticipated responsibilities should be discussed to improve shared negotiation strategies, particularly among couples who experienced prolonged reproductive health problems and/or a long-time couple lifestyle without children. Problem-solving strategies that may facilitate the conciliation between work and family should also be enhanced, especially among couples who display complex familial realities and/or are characterized by independent parental lifestyles.