The natural reduction in reproductive capacity can be considered an unavoidable part of being human. But in weighing the potential liabilities of delayed childbearing, the slings and arrows of personal fortune must also be considered. Every woman is an individual, and as all college students learn, statistics apply to populations, not people. Whether any particular woman will have difficulty conceiving if she delays childbearing depends in part upon her history and family heritage. For example, the more sexual partners a woman has had, the greater her risk of having been exposed to a disease like chlamydia, which can spread into the pelvic region and cause inflammation and scarring, rendering the passage of ovulated eggs down the fallopian tubes difficult or impossible. Pelvic inflammatory disease, which is often asymptomatic, has been on the rise since the 1970s, and is thought to have affected some 11 percent of women in the United States. Smoking, exposure to chemicals in the workplace and home, and the use of alcohol and other drugs have also been shown to undermine fertility. Women in their forties have higher incidences of cervical, uterine, and ovarian cancer, the ravages of which may leave them incapable of bearing children.
Dorothy Mitchell-Leef and other infertility specialists have expressed concern as well about the number of women they are seeing with premature ovarian failure, or early menopause. Normally, women in the industrialized world go through menopause between the ages of forty-nine and fifty-one. Outwardly marked by a cessation of menstruation, menopause is caused by the depletion of eggs in the ovaries. The store of eggs—some 6 to 8 million in female fetuses—begins to dwindle even during gestation, and eggs continue to be lost throughout girlhood and adulthood by attrition and with each menstrual cycle, until, finally, too few eggs remain to maintain the monthly reproductive cycle. In the past year or so Mitchell-Leef has seen what she considers an unusually large number of women in their mid-thirties to early forties whose hormone levels indicate that they are entering menopause. Last fall she saw ten such patients in two weeks alone.
Because no population-based studies of premature ovarian failure have been performed, and even the anecdotal evidence is not being widely reported, probably the best interpretation for the time being (from a scientific, not a humane, point of view) is that the patients walking into Mitchell-Leef's clinic represent a statistical blip rather than an early warning signal of a major public-health problem. But even without an epidemic of premature ovarian failure, the overall reproductive health of American women is a matter of some concern.
In 1990 William Mosher and William Pratt, at the National Center for Health Statistics, performed an analysis of information gathered in the 1988 National Survey of Family Growth, in which 8,450 women, selected as representative of the population at large, were asked about their reproductive histories and health. Extrapolating from their answers, Mosher and Pratt projected that 8.4 percent of women in the United States, or about 4.9 million of the 57.9 million women aged fifteen to forty-four, could be categorized as having impaired fecundity. When Mosher and Pratt broke out the figures by age, the percentage of those expected to suffer from impaired fecundity increased in stepwise fashion. Falling into that category were 4.1 percent of all American women aged fifteen to twenty-four (some 614,000 women), 13.4 percent of those aged twenty-five to thirty-four (972,000 women), and 21.4 percent of those aged thirty-five to forty-four (620,000).
In part because the survey relied on women's own awareness of their reproductive health, which could be incomplete, the incidence of impaired fecundity appeared greater among married than among unmarried women. The phenomenon was particularly pronounced among childless married women. The survey suggested that approximately 1,037,000 of these women aged twenty-five to forty-four had tried to get pregnant and couldn't, or had had intercourse with a spouse for three years without using contraceptives and had failed during that time to become pregnant, or had been told by a physician not to become pregnant because it might endanger their health, or knew that they could not become pregnant, owing to a previous accident, an illness, or an "unexplained inability to conceive," a condition referred to in medical jargon as idiopathic infertility.
Statisticians have no idea how many women who want children reach the end of their childbearing years without fulfilling that desire, or how many would have liked to have more children than they had but were unable to because of impaired fecundity. The 1992 Current Population Survey, carried out by the Bureau of the Census, estimated that of the 44 million childless U.S. women aged eighteen to thirty-nine, some 15 million expected to have one child or more during her lifetime. About a third of these women were aged thirty to thirty-nine. Even the most conservative National Center for Health Statistics estimate—that one in twelve women suffers from impaired fecundity—suggests that some 350,000 to 700,000 women could encounter impediments to their plans.
Gynecologists and obstetricians argue that the majority of women who want to have children will conceive, and indeed this is true. But as David Meldrum says, "The cup they are looking at is half full, and the one we're looking at is half empty." The one-in-five rate of impaired fecundity among all childless women aged thirty-five to forty-four, and the one-in-eight rate for those aged twenty-five to thirty-four, don't strike this observer as amounting to terribly good odds. They're not cause for panic, but they are worth mulling over. John Collins, of McMaster University, says, "Clinicians should tell women, 'These are the facts, and you see how that fits in with the remainder of your life.'" He believes that his approach—to empower women with information rather than advise them to get pregnant at a certain age—comports with that of the majority of his colleagues. Jean Benward, the California social worker, says, "People's life trajectories are very complicated, and circumstances are not always within our control. Knowing the facts may not have an impact on a woman's behavior, but I think it's valuable for women to have the information so that they can make informed choices."
Of course, those who, having delayed parenthood, find themselves unable to conceive naturally can choose to enter the high-tech world of assisted reproduction. But this path is generally costly (patients must pay tens of thousands of dollars out of their own pockets, because only a few states mandate insurance coverage for infertility treatments), as well as unpleasant (women undergo painful daily injections of fertility drugs, frequent blood tests, general anesthesia, and invasive surgery). Medically mediated conception is also time-consuming and encourages a kind of obsessiveness. Some women, among them the journalist Anne Taylor Fleming, who has written a disquieting account of her own unsuccessful attempts to have a child in Motherhood Deferred, spend the better part of ten years in and out of infertility clinics. If artificial insemination and the various in vitro fertilization options fail, women who want children but don't want to adopt now face the ethical and other quandaries built into two exotic new alternatives: trying to become pregnant using another woman's egg, and enlisting a surrogate mother.
The unfortunate bottom line is that infertility specialists cannot help all couples who seek their services. Even leading clinics using the latest procedures offer no guarantees. True, a certain number of couples who don't succeed by high-tech means go on to achieve pregnancies by the old-fashioned method. But many others are left childless, in debt, and anguished over their failed dreams.
Some reproductive endocrinologists point out that when researchers learn how to freeze eggs (so far, sperm can safely be frozen and thawed, as can embryos, but eggs have proved refractory), women will be able to consign a clutch of young eggs to the cryopreservation tanks when they are twenty and reclaim them at a later date. Clever as that sounds, it seems a highly impractical solution to the problem. As already noted, egg retrieval is expensive and invasive. Without a radical restructuring of health care, few women would be able to take advantage of an option like egg cryopreservation.
Perhaps there's another way. Suppose America put its money where its mouth is on family values. Politicians endlessly invoke that shibboleth, yet the United States—notwithstanding the Family and Medical Leave Act signed with much fanfare by President Clinton in February of 1993—still offers far less social support for childbearing than do most other industrialized countries. Luxembourg, whose state-mandated maternity and parental leaves are among the least generous in the European Union, provides women with up to ten weeks of paid maternity leave and gives parents the option of unpaid absences for certain periods until their children are fifteen years old, with the guarantee of a job upon their return. Italy, whose policies are among the most generous in this regard, gives women up to five months' fully paid maternity leave, and has a proviso allowing either parent to take two or three days at a time off to care for a sick child under three years old. Paid maternity and parental leaves and safe, affordable day care, which are taken for granted by citizens of other nations, remain out of reach in the richest economy in the world.
Women's-rights advocates have been fighting for a century for equity in the American workplace, and still have to deal with corporate bias. Sixty years ago few companies thought twice about firing a female employee who became pregnant; now the discrimination against women who have children is more subtle but nevertheless tangible, as they are shunted off into corporate backwaters or kept out of consideration for partnerships or passed over for pay raises. Women delay childbearing for a variety of reasons, but surely important among these is the need to establish themselves professionally, and the awareness that opportunity and credibility are elusive, particularly if they become mothers.
Felice Schwartz, in her incendiary 1989 Harvard Business Review article "Management Women and the New Facts of Life," which caused the "mommy track" brouhaha, contended that women are more prone to "career interruptions, plateauing, and turnover" than men, and that these all cost companies money, in lost training dollars and in lost expertise, when middle- and upper-level women retire to the nursery. Aside from the fact that "career interruptions, plateauing, and turnover" reads like the resumes of a substantial number of middle-management Baby Boomers in this age of downsizing and globally free-floating corporate dollars, one must seriously question, as Schwartz herself did, whether these are the inevitable consequences of motherhood or an artifact of national social policies.
Notwithstanding subsequent misinterpretations and misuses of her thesis by corporations and feminists alike, Schwartz concluded that the majority of women "want to pursue serious careers while participating actively in the rearing of children," and suggested that employers should help women to "plan for and manage maternity" and should act to "make family supports and high-quality, affordable child care available to all women." That such an approach can yield good results can be seen in Sweden, where government and corporations have made a concerted effort since the 1970s to encourage women to enter the workplace. There, generous parental leave, excellent public day care, and job flexibility have allowed women to balance work and motherhood with aplomb.
Women today make up almost half of the work force in the United States, and the proportion continues to rise. Two thirds of women with children are employed. In light of the biological realities they face, women would do well to continue to press for a reconfiguration of society, so that they might, if they chose to, have babies in their twenties and develop their careers in their thirties—as suggested by Alan DeCherney and Gertrud Berkowitz in the wake of the CECOS study. In order for that to be possible, society will need to amend itself in ways that are likely to redound to the benefit of not just women but everyone.