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Above: Mangayamma with her husband. She is the oldest woman to give birth/Photo: ANI

The recent birth of twins to 74-year-old Mangayamma has once again ignited a debate about the moral and ethical dilemmas doctors face in cases of elderly women wanting to have children

By Dr KK Aggarwal

 

The age for motherhood is pushing the frontiers of science. Recently, a 74-year-old woman, Mangayamma, became the oldest ever woman to give birth after she delivered twins at a hospital in Guntur in Andhra Pradesh through in-vitro fertilisation (IVF). In 2016, 70-year-old Daljinder Kaur of Haryana delivered a baby boy following the same procedure. So is there any universal cut-off for advanced reproduction in women? No.

Fertility clearly declines with advancing age, especially after the mid-30s, and women who conceive later are at greater risk of pregnancy complications. However, studies have generally observed that most women over 45 years have good pregnancy outcomes and are able to cope with the physical and emotional stresses of pregnancy and parenting.

Although there is no law for pregnancy age limit, self-regulating ethics of medical professionals don’t permit fertility treatment for women over the age of 50. In India, for adoption of a child, the combined age limit of the couple wanting to adopt should be less than 90 years (single parent age limit is 45 years). Also, as per the Indian Council of Medical Research (ICMR) guidelines, the combined age limit of the parents for IVF should be less than 110 years. In fact, Singapore currently imposes an age limit of 45 years for women undergoing assisted reproduction technology procedures, which include IVF treatments. This age limit will be removed from January 1, 2020.

The oldest mother to ever conceive was 74 years, and the youngest, five years old. According to statistics from the Human Fertilisation and Embryology Authority, in the UK, more than 20 babies are born to women over the age of 50 every year through IVF with the use of donor eggs. Pregnancies among older women have often been the subject of controversy and debate. This is due to various reasons:

There are high health risks.

  • Concern that an older mother might not be able to give proper care to her child as she ages.
  • In the 1990s, France approved a bill which prohibited postmenopausal pregnancy, which the French minister of health then, Philippe Douste-Blazy, said was “… immoral as well as dangerous to the health of mother and child”.
  • In Italy, the Association of Medical Practitioners and Dentists prevented its members from providing fertility treatment to women who were 50 years and above.
  • Britain’s former Secretary of State for Health, Virginia Bottomley, once stated: “Women do not have the right to have a child; the child has a right to a suitable home.” However, in 2005, age restrictions on IVF in the UK were officially withdrawn. Also, many fertility clinics and hospitals set age limits of their own.

Having a child is a fundamental right. Commitment to a child’s well-being is what matters, not the parents’ ages. An Australian survey found that 54.6 per cent believed it was acceptable for a postmenopausal woman to have her own eggs transferred and 37.9 per cent believed it was acceptable for such a woman to receive donated embryos. One must, therefore, weigh each situation based on the four fundamental principles—respect for autonomy, beneficence, non-maleficence and justice as defined by UNESCO in the Universal Declaration on Bioethics and Human Rights.

Article 4 of the Declaration dealing with Benefit and Harm says: “In applying and advancing scientific knowledge, medical practice and associated technologies, direct and indirect benefits to patients, research participants and other affected individuals should be maximised and any possible harm to such individuals should be minimised.

“Article 5: Autonomy and individual responsibility: The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests.

“Article 8: Respect for human vulnerability and personal integrity: In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be considered. Individuals and groups of special vulnerability should be protected, and the personal integrity of such individuals respected.

“Article 10: Equality, justice and equity: The fundamental equality of all human beings in dignity and rights is to be respected so that they are treated justly and equitably.

“Article 11: Non-discrimination and non-stigmatisation: No individual or group should be discriminated against or stigmatised on any grounds, in violation of human dignity, human rights and fundamental freedoms.”

In a situation where there is a geriatric pregnancy, there is a conflict between Articles 4 and 5. The patient has a right to choose pregnancy at any age, but the physician is also committed to first do no harm. The answer, therefore, lies in the next ethical principle of informed consent.

The three judges’ Constitution Bench of the Supreme Court in the landmark Samira Kohli versus Prabha Manchanda held that: “A doctor must seek and secure the consent of the patient before commencing a ‘treat­ment’; (the term ‘treatment’ includes surgery also). The consent so obtained should be real and valid, which means that: the patient should have the capacity and competence to consent; his consent should be voluntary; and his consent should be on the basis of adequate information concerning the nature of the treatment procedure, so that he knows what he is consenting to.

“The ‘adequate information’ to be furnished by the doctor (or a member of his team) who treats the patient, should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment or not. This means that the Doctor should disclose (a) nature and procedure of the treatment and its purpose, benefits and effect; (b) alternatives if any available; (c) an outline of the substantial risks; and (d) adverse consequences of refusing treatment. But there is no need to explain remote or theoretical risks involved, which may frighten or confuse a patient and result in refusal of consent for the necessary treatment. Similarly, there is no need to explain the remote or theoretical risks of refusal to take treatment which may persuade a patient to undergo a fanciful or unnecessary treatment. A balance should be achieved between the need for disclosing necessary and adequate information and at the same time avoid the possibility of the patient being deterred from agreeing to a necessary treatment or offering to undergo an unnecessary treatment.”

All women should be informed that delaying childbearing until the mid-30s significantly increases the risk of infertility and of developing a chronic medical disease which might complicate pregnancy. Information should be given that pregnancy complications occur with increased frequency in older gravidae (a woman’s status regarding pregnancy) and includes ectopic pregnancy, spontaneous abortion, foetal chromosomal abnormalities, congenital anomalies, gestational diabetes and caesarean delivery. Such complications may, in turn, result in pre-term birth. There is also an increased risk of perinatal mortality.

So despite the desire to have a child, a geriatric mother should carefully weigh the pros and cons before going in for a pregnancy.

—The writer is President, Confederation of Medical Associations of Asia and Oceania, and Heart Care Foundation of India

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