Key Message. Introduction AOGS MAIN RESEARCH ARTICLE MARIA SALOMON 1, RANDI SYLVEST 1, HELENA HANSSON 2, ANDERS NYBOE ANDERSEN 1 & LONE SCHMIDT 3

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1 A C TA Obstetricia et Gynecologica AOGS MAIN RESEARCH ARTICLE Sociodemographic characteristics and attitudes towards motherhood among single women compared with cohabiting women treated with donor semen a Danish multicenter study MARIA SALOMON 1, RANDI SYLVEST 1, HELENA HANSSON 2, ANDERS NYBOE ANDERSEN 1 & LONE SCHMIDT 3 1 Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, 2 Research Unit, Women s and Children s Health, Rigshospitalet, Copenhagen University Hospital, Copenhagen, and 3 Department of Public Health, University of Copenhagen, Copenhagen, Denmark Key words Medically assisted reproduction, donor semen, motherhood, single women, single mothers Correspondence Maria Salomon, Fertility Clinic, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, section 4071, 2100 Copenhagen, Denmark. maria.salomon@regionh.dk Conflict of interest MS was co-funded by research grants from Ferring Pharmaceuticals, MSD Denmark ApS, and Nordic Cryobank ApS. All other authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Salomon M, Sylvest R, Hansson H, Nyboe Andersen A, Schmidt L. Sociodemographic characteristics and attitudes towards motherhood among single women compared with cohabiting women treated with donor semen a Danish multicenter study. Acta Obstet Gynecol Scand 2015; 94: Abstract Objective. To examine sociodemographic characteristics, family backgrounds, reproductive histories, and attitudes towards motherhood in single vs. cohabiting women seeking treatment with donor semen. Design. Baseline data collection in a multicenter cohort study. Setting. All nine public fertility clinics in Denmark. Sample. In total n = 311 childless women initiating assisted reproduction using donor semen. Methods. Self-reported questionnaire responses from n = 184 single women seeking treatment by using donor semen were compared with responses from n = 127 cohabiting women. Main outcome measures. Sociodemographic characteristics, family backgrounds, reproductive histories, attitudes towards motherhood. Results. Single women were 3.5 years older on average when initiating treatment compared with cohabiting women. No significant differences were found regarding sociodemographic characteristics, previous long-term relationships, previous pregnancies, or attitudes towards motherhood between single women and cohabiting women. The vast majority of single women wanted to achieve parenthood with a partner, 85.8% wished to have a partner in the future, and approximately half of them preferred for a partner to take parental responsibilities. Conclusions. In this study single women seeking treatment with donor semen in the public health system did not differ from cohabiting women, except that they were older. To be a single mother by choice is not their preferred way of parenthood, but a solution they needed to accept. Received: 15 August 2014 Accepted: 16 February 2015 DOI: /aogs Introduction In recent years, national birth data from Denmark have shown an increase in children born to unknown fathers. Key Message Approximately 1% of the national birth cohort in Denmark are children born to single women who choose to use donor semen. For the majority seeking treatment, this is their plan B for motherhood. Single women are older, but they did not otherwise in this study differ from cohabiting women treated with donor semen regarding sociodemographic characteristics or attitudes towards motherhood. ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

2 Single women and semen donation M. Salomon et al. In an ongoing research project based on annual register data from Statistics Denmark, it has been shown that the proportion has increased from 1 to 1.5% from 1980 to 2005 to approximately 3% in 2010 (Prof. Niels Keiding, University of Copenhagen, personal communication). The category of children born without a man registered as the father includes children born to single mothers by choice (solo mothers) and children born to lesbian couples. Since 2007, medical doctors in Denmark have been permitted to offer treatment by donor semen to single women and women in lesbian couples, in addition to its traditional use for infertile heterosexual couples (1). In 2013, almost 1% of the national birth cohort were children born to single mothers treated with donor semen. Further, one in 10 of the children born after medically assisted reproduction in Denmark was born to a single woman (2). Research on single women seeking motherhood by means of a sperm donor has been limited primarily to smaller studies (3), but a recent large study of 281 single mothers by choice (4) showed that the majority had previously been in long-term relationships. They chose not to have children in those relationships because the timing was inappropriate, the relationship was not conducive to having children, or the partner did not want a child. Single women s motives for parenthood centered around the feeling that time was running out (4 6), that they had yet to meet a man who would be a suitable partner and father, and that they had the social support needed to become a solo mother (5). Previous samples showed the majority of single mothers by choice to be well-educated and financially secure (3 5). Single women using assisted reproduction with donor semen frequently report that this choice was not their first choice, but their plan B for motherhood (3,4,7). Concerning the well-being of children born to single women by choice, studies have found no negative effects on parenting style or children s psychological development (8,9). However, there are no large studies comparing single women with cohabiting women in donor insemination treatment to see if they differ regarding sociodemographic characteristics and attitudes towards motherhood. Due to the aforementioned legislative change in Denmark in 2007 and the resulting increased rate of children born after insemination with donor semen in Denmark, we found it of interest to investigate the sociodemographic characteristics, family backgrounds, reproductive histories, and attitudes towards motherhood in single and cohabiting women seeking treatment with donor semen. As Denmark has nine public fertility clinics with free access to treatment, this was an optimal setting for such a study. Material and methods This study includes baseline data collection via a questionnaire in a prospective cohort multicenter study including all nine public fertility clinics in Denmark. The public healthcare system provides women with equal and free of charge access to medically assisted reproduction until the age of 41 years. Only childless single women and women not having a child in common with their partner are permitted public treatment (1). During the period of February 2012 to July 2013, all childless single women and all childless cohabiting women (heterosexual or lesbian) initiating assisted reproduction using donor semen at the nine public clinics were invited by the study nurse or the patients contact nurse to participate in this study (n = 360). Only women able to speak and read Danish were invited. The women did not receive any gift or benefit for participating. Before the initiation of the study the nine study nurses were invited to a seminar discussing the study design and content, and how best to organize the data collection to be in accordance with the daily clinical practice at each fertility clinic. Further, the study nurses were given lectures on clinical and scientific knowledge about single mothers by choice. The study nurses did not receive any gift for their engagement in the study. In total, n = 339 women accepted the invitation and signed the consent form; seven were excluded due to screening failure (they had a child), and n = 311 (94%) returned the questionnaire. The women received a questionnaire and a stamped and self-addressed envelope at the initiation of the first treatment cycle, and the majority responded within 14 days. One reminder was sent out. Overall, 21 women did not wish to participate. Of these, n = 13 were single women. The staff at the fertility clinics did not include all potential participants during the inclusion period due to being occupied with other assignments, but there was no conscious systematic selection regarding the invitation of participants. The questionnaires for single and cohabiting women were developed by fertility clinic staff and researchers within family formation and psychosocial aspects of assisted reproduction and were based on clinical knowledge regarding these patients, experiences with establishment of patient networks for solo mothers, and on previous research. Further, to develop question and response categories of high relevance for single women seeking treatment with donor semen, focus group discussion and semi-structured qualitative interviews among single women were conducted at one of the public clinics included in this study (7). The pilot questionnaire for single women was tested on eight single women, two of whom were also 474 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

3 M. Salomon et al. Single women and semen donation interviewed. Their comments were used to revise the questionnaire. The variables used for this study are described below. Sociodemographic characteristics included age, a standardized measurement of education and occupational social class (10,11), family background, number of sexual partners, number of long-term relationships, and previous reproductive history. Attitudes towards motherhood were assessed during three time periods: (i) retrospectively, when the participants were approximately 20 years of age, (ii) currently, at study inclusion, and (iii) in a future perspective. The items regarding the retrospective measurement were adapted from Lampic et al. (12) and included six items measuring whether the participant wanted to have children, the desired number of children, the desired age when having a first and last child, the importance of having children (a five-point scale from very important to not important), and whether they had desired to meet a partner with whom they wanted to share their life (yes/ no/maybe/do not remember). The participants current attitudes towards motherhood were measured by one item for all participating women: an item adapted from Abbey et al. (13) regarding the importance of motherhood (a five-point Likert scale from totally agree to totally disagree). A further three items were included for single women: whether (i) the decision to become a solo mother was reached because it was their preferred choice of motherhood (yes/no/do not know); (ii) whether they would prefer to live a life without a partner vs. without a child (yes/maybe/no/do not know); and (iii) whether they believed that they soon would be too old to get pregnant and hence run out of time to find a partner with whom to have children (a five-point Likert scale from totally agree to totally disagree). Attitudes towards motherhood in a future perspective were assessed by two items, also only for single participants: whether they intended to stay single with a child (yes/maybe/no/do not know), and if they intended to have a partner later and whether this partner should have parental responsibility for the child (yes/maybe/no/do not know). The attitudes towards motherhood, i.e. the importance of different circumstances surrounding the decision to become a mother, was measured by nine items adapted from Lampic et al. (12) and Frederiksen et al. (7). We measured the importance of having an adequate social network, adequate energy, wanting a child before growing too old, the possibility of combining work and family, the feeling of maturity, living in a good economy, having completed one s education, to have sufficiently good living conditions, and having a permanent job position. Responses were on a five-point scale from very important to not important. Participants were further asked whether they had perceived pressure from their own parents to become mothers (a five-point Likert scale from totally agree to totally disagree). All women invited to participate were provided with written information about the study and written consent was obtained from all participants. The study was approved by the Danish Data Protection Agency (Approval no ) and declared to the Regional Committees for Medical and Health Research Ethics. Statistical analysis Data were registered in an SPSS database and were analyzed in SPSS version 19 (IBM Corp., Armonk, NY, USA) with descriptive statistics and chi-squared tests. Statistical significance was set at p < Results from single women were compared with results from cohabiting women. Initially, data were compared separately for cohabiting women with a male vs. a female partner to control for any significant differences among cohabiting women. However, as the two groups of cohabiting participants showed no significant differences in terms of the investigated variables, single women were finally compared with all cohabiting women (n = 127) in the applied analysis in this study. Results Study participants were 184 single women (one lesbian) and 127 cohabiting women (n = 73 heterosexuals and n = 54 lesbians). Overall, 14 participants stated they were bisexual. Table 1 presents sociodemographic and reproductive characteristics of single women vs. cohabiting women. The single women were significantly older than the cohabiting women at the initiation of treatment (mean age 36.1 years vs years, p = 0.000). In total, 96.6% of the single women and 88.8% of the cohabiting women were born in Denmark. We found no differences in educational level, occupational social class, family background, previous pregnancies, or previous total number of long-term relationships between single women and cohabiting women. Study participants were from occupational social class I (professionals, executives) to social class V (unskilled and semi-skilled workers), with the majority being from social class II (medium-level white collar employees; 44.6% among single women vs. 34.9% among cohabiting women, p = 0.348). Table 2 shows the women s retrospective attitudes towards motherhood when they were 20 years old. We found no significant differences between single women and cohabiting women. At age 20, the majority desired to meet a partner to share their lives with, to have two or three children, and to have their first child around the age of 27 years. ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

4 Single women and semen donation M. Salomon et al. Table 1. Demographic and social characteristics in relation to the cohabiting status of 311 women undergoing assisted reproduction with donor semen. Cohabiting women Single women (n = 184) All couples (n = 127) Heterosexual couples (n = 73) Lesbian couples (n = 54) Single women vs. cohabiting women p-value Age in years; mean SD Age groups, years <30 11 (6.0) 42 (33.1) 26 (35.6) 16 (29.6) (19.6) 34 (26.8) 18 (24.7) 16 (29.6) (35.3) 25 (19.7) 12 (16.4) 13 (24.1) (39.1) 26 (20.5) 17 (23.3) 9 (16.7) Educational level None 11 (6.0) 11 (8.7) 3 (4.1) 8 (14.8) Short 45 (24.6) 37 (29.1) 27 (36.9) 10 (18.5) Medium 72 (39.3) 44 (34.6) 25 (34.2) 19 (35.2) Long 48 (26.2) 27 (21.3) 14 (19.2) 13 (24.1) Other 7 (3.8) 8 (6.3) 4 (5.5) 4 (7.4) Grew up with both parents Yes 157 (85.8) 109 (85.8) 63 (86.3) 46 (85.2) Parents divorced while lived at home Yes 58 (31.7) 35 (27.6) 17 (23.3) 18 (33.3) Grew up in a major city Yes 72 (39.1) 56 (44.4) 33 (45.8) 23 (42.6) Currently living in a major city Yes 135 (73.4) 82 (64.6) 42 (57.5) 40 (74.1) Tried previously to achieve a pregnancy Yes 52 (28.3) 24 (19.2) 20 (27.8) 4 (7.5) Ever been pregnant? Yes 55 (30.1) 32 (25.2) 21 (28.8) 11 (20.4) Total number of sexual partners since age 20 <2 12 (6.6) 27 (21.3) 23 (31.5) 4 (7.4) (43.2) 74 (58.3) 38 (52.1) 36 (66.6) (23.0) 18 (14.2) 8 (11.0) 10 (18.5) 20 or more 50 (27.3) 8 (6.3) 4 (5.5) 4 (7.4) Responders 183 (99.5) 127 (100) 73 (100) 54 (100) Total number of long-term relationships since age 20 (>6 month) <2 57 (31.8) 44 (34.6) 32 (43.8) 12 (22.2) (59.8) 76 (59.8) 38 (52.1) 38 (70.4) 5 or more 15 (8.4) 7 (5.5) 3 (4.1) 4 (7.4) Responders 179 (97.3) 127 (100) 73 (100) 54 (100) Total number of years being single since aged 20 years; mean SD Table 3 shows the attitudes towards motherhood as the importance of different considerations associated with the decision to become mothers. No significant differences between single women and cohabiting women were found. The majority of single women (>70%) found it very important/important to have sufficient energy and a sufficient social network, to have a child before growing too old, to feel mature, and to have a job that could be combined with raising children. Less than 55% found it very important/important to have completed their studies before having children and to have a sufficiently large home. No significant differences were found regarding whether the participants had felt pressure from their parents to become mothers (single women 19.6%, women in heterosexual couples 30.6%, women in lesbian couples 18.5%, p = 0.684). Table 4 presents results specifically for single women s decisions to become single mothers by choice. The vast majority initially desired to establish a family with a partner and 66.1% had had a partner with whom they wished to have children. In 38.4% of these relationships, the man already had children, and 39.8% of the men did not desire more children. If the participants in their current situations had to choose between having a child or find- 476 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

5 M. Salomon et al. Single women and semen donation Table 2. Retrospective attitudes towards motherhood at the age of 20 in relation to the cohabiting status of 311 women undergoing assisted reproduction with donor semen. Cohabiting women Single women (n = 184) All couples (n = 127) Heterosexual couples (n = 73) Lesbian couples (n = 54) Single women vs. cohabiting women p-value Did you desire to meet a partner with whom you wanted to share your life? Yes 166 (90.2) 114 (89.8) 68 (93.2) 46 (85.2) Responders 184 (100.0) 127 (100.0) 73 (100.0) 54 (100.0) Did you want to have children? Yes 159 (86.9) 97 (77.0) 57 (79.2) 40 (74.1) Responders 183 (100.0) 126 (99.2) 72 (98.6) 54 (100.0) If yes, how many children did you want? Number; mean SD Responders 149 (81.0) 106 (83.5) 61 (83.6) 45 (83.3) If yes, at what age did you want the first child? Years; mean SD Responders 136 (73.9) 106 (83.5) 61 (83.6) 45 (83.3) If yes, at what age did you want the last child? Years; mean SD Responders 106 (57.6) 105 (82.7) 60 (82.2) 45 (83.3) If yes, how important was it for you to have children? Very important 95 (56.9) 56 (52.8) 39 (63.9) 17 (37.8) Important 48 (28.7) 31 (29.2) 16 (26.2) 15 (33.3) Responders 167 (90.8) 106 (83.5) 61 (83.6) 45 (83.3) ing a partner, the majority preferred to have a child. The vast majority (85.8%), however, wished to have a partner in the future and approximately half of them desired a future partner to take parental responsibility for the child. Discussion Overall, single women and cohabiting women initiating treatment with donor semen were similar in terms of their sociodemographic characteristics, family backgrounds, reproductive histories, and attitudes towards motherhood. Only two significant differences between the two groups were identified: more single women had had 20 or more sexual partners, and single women were on average 3.5 years older than cohabitating women at the initiation of treatment. A possible explanation could be that single women spent more time searching for a suitable partner and father for their future child. This is supported by the finding that the single women had been single for an average of more than 4 years at the beginning of the study. We found no differences in educational level or occupational social class among single women compared with cohabiting women, and participants were from all different social class categories from high (I) to low (V). In comparison with the online questionnaire study by Jadva et al. linked from the choice mum website of 291 single mothers by choice (4), it seems that our study included a small proportion of women with long further education (26.2%) and a larger proportion with mid-further education (39.3%) compared with 59% and 29%, respectively. In the study by Jadva et al. (4), 73% of the participants were currently living in the USA, 10% in Canada, 8% in the UK, 4% in Australia, and the remaining 5% in different European countries and Israel. The difference in proportion of women with long further education in the studies could be explained by differences in access to medically assisted reproduction, as our study was confined to participants from public fertility clinics where the patient does not pay out of pocket, whereas the majority of participants in the Jadva et al. study (4) were living in the USA, where medically assisted reproduction is mainly offered in the private healthcare sector and hence requires a financial commitment. When comparing the single women s educational levels with the female background population aged years, we found that a larger proportion of the single women had ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

6 Single women and semen donation M. Salomon et al. Table 3. Importance of different considerations for the participants decisions to have children in relation to cohabiting status of 311 women undergoing fertility treatment with donor semen. Cohabiting women Single women (n = 184) All couples (n = 127) Heterosexual couples (n = 73) Lesbian couples (n = 54) Single women vs. cohabiting women p-value That I have sufficient energy Very important 102 (55.4) 63 (49.6) 32 (43.8) 31 (57.4) Important 74 (40.2) 52 (40.9) 35 (47.9) 17 (31.5) Total 176 (95.6) 115 (90.5) 67 (91.7) 48 (88.9) That I have a child, before I am too old Very important 134 (72.8) 72 (56.7) 38 (52.1) 34 (63.0) Important 37 (20.1) 37 (29.1) 26 (35.6) 11 (20.4) Total 171 (92.9) 109 (85.8) 64 (87.7) 45 (83.4) That I have a sufficient social network Very important 96 (52.2) 29 (22.8) 15 (20.5) 14 (25.9) Important 67 (36.4) 59 (46.5) 36 (49.3) 23 (42.6) Total 163 (88.6) 88 (69.3) 51 (69.8) 37 (68.5) That I feel sufficiently mature Very important 80 (43.5) 81 (63.8) 45 (61.6) 36 (66.7) Important 76 (41.3) 35 (27.6) 20 (27.4) 15 (27.8) Total 156 (84.8) 116 (91.4) 65 (89.0) 51 (94.5) That my work can be combined with having children Very important 65 (35.3) 31 (24.4) 13 (17.8) 18 (33.3) Important 72 (39.1) 55 (43.3) 32 (43.8) 23 (42.6) Total 137 (74.5) 86 (67.7) 45 (61.6) 41 (75.9) That I have a permanent position Very important 43 (23.4) 30 (23.6) 17 (23.3) 13 (24.1) Important 85 (46.2) 47 (37.0) 28 (38.4) 19 (35.2) Total 128 (69.6) 77 (60.6) 45 (61.7) 32 (59.3) That I have a good economy Very important 27 (14.7) 28 (22.0) 16 (21.9) 12 (22.2) Important 100 (54.3) 62 (48.8) 34 (46.6) 28 (51.9) Total 127 (69.0) 90 (70.8) 50 (68.5) 40 (74.1) That I have a home that is sufficiently large Very important 23 (12.5) 31 (24.4) 24 (32.9) 7 (13.0) Important 76 (41.3) 46 (36.2) 26 (35.6) 20 (37.0) Total 99 (53.8) 77 (60.6) 50 (68.5) 27 (50.0) That I have completed my studies Very important 28 (15.2) 24 (18.9) 17 (23.3) 7 (13.0) Important 58 (31.5) 39 (30.7) 25 (34.2) 14 (25.9) Total 86 (46.7) 63 (49.6) 42 (57.5) 21 (38.9) completed a long further education (26.2% vs. 13.0%) (14). Similar results were found when comparing the educational level of the cohabiting women with the background population. However, a previous Danish cohort study of couples initiating assisted reproduction at public fertility clinics and including all different types of treatment showed no differences in the distribution of occupational social class compared with the background population in similar age groups (15). As there are no occupational social class differences in infertility in Denmark (16), this study population s higher educational level compared with the background population may also reflect that the decision to use donor semen is more widespread among better-educated women. Women today have better opportunities to influence and control their lives, including the ability to regulate their reproduction by use of the contraceptive pill (since 1966) and access to legally induced abortions in the public healthcare sector, as in Denmark from Since 2005, an increasing number of children in Denmark have 478 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

7 M. Salomon et al. Single women and semen donation Table 4. Circumstances regarding the decision to become a single mother by choice. Single women (n = 184) n % Was it your original wish to become a parent in the traditional way that is, to have a child with a life partner? Yes Have you had a partner with whom you wanted to have children? Yes I will soon become too old to get pregnant and I therefore no longer have time to find a partner with whom I want to have children Agree If you had to choose, would you rather live your life without a partner than without a child? Yes Do you want to have a partner in the future? Yes been born without a registered father, indicating that an increasing number of women are single mothers by choice or are establishing families within lesbian couples. The permission given in 2007 for medical doctors to offer the use of donor semen both in the public and private healthcare systems to both single women and lesbian couples provides even more possibilities for these women to become mothers. In Denmark, the employment frequencies of women and men are equal and a greater proportion of women complete advanced degrees than men, which suggests increased societal and financial independence for Danish women. In our study, no educational or occupational social class differences between single women and cohabiting women were found, which could indicate that choosing to be a single mother by the use of donor semen has become a more common and socially accepted decision. Further, it has become more common to live single with or without children, and in Denmark, one-third of all men and women in the age group years live without a married/cohabiting partner (17). As in previous studies among single mothers by choice, having a child with donor semen was not their preferred choice of parenthood, but a plan B, a necessity (3 5,7). Single mothers by choice do not deny the traditional family, and a vast majority of the single study participants desired to have a partner in the future. The strengths of the study include the national, multicenter design with the inclusion of a large number of participants from all public fertility clinics in Denmark, the high response rate, and the detailed comparison of single women to cohabiting women seeking treatment using donor semen. The multicenter design enhances the external validity of the study for countries with similar access to fertility treatment offered free of charge, similar education opportunities, and similar access to benefits and maternal leave such as the Nordic welfare states. It is a strength to collect data about attitudes to motherhood and decision-making regarding single motherhood in a study sample including women initiating fertility treatment compared with collecting retrospective data among women who have already achieved motherhood. In general there are high participation rates in Denmark in studies involving fertility patients. In this study the high participation rate could reflect that the nurses inviting the women to the study were very engaged in the aims of this study and that the data collection was designed as best as possible to be an integrated part of their daily clinical routines at each specific clinic. Moreover, both the items and the response categories in the questionnaires were developed by experienced clinical staff and researchers within family formation, infertility and assisted reproduction, and further based on focus group discussion and individual semi-structured interviews with single women seeking treatment by the use of donor semen at one of the public Danish fertility clinic (7). This potentially enhanced invited women assessing the study as important and the questionnaire items and response categories as relevant, and hence increased the participation rate. One of the limitations is that this study included participants from the public healthcare sector only. Private fertility clinics in Denmark are permitted to offer treatment to women up to the age of 45 and to women who already have children. It is reasonable to believe that sociodemographic characteristics and probably importance ratings according to different circumstances for the motherhood decision would have been different if participants seeking treatment in the private healthcare sector had been included. The sample size was not large enough to indicate whether the absence of differences was not due to a type-2 error. A post hoc power calculation showed that to achieve statistically significant differences with a power of 80% in the probability of cohabitation between women with long compared with shorter education, more than ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

8 Single women and semen donation M. Salomon et al participants in each group would have been required. We have identified only one previous study that investigated single women and cohabiting women during donor semen treatment and this study included 54 women (5) compared with our study, which included 311 participants. In conclusion, this is the first national study in Denmark investigating women initiating assisted reproduction with use of donor semen at any of the country s nine public fertility clinics. The study confirms that single women seeking treatment with donor semen do not differ from cohabiting women seeking treatment with regard to sociodemographic characteristics or attitudes towards motherhood. For the majority of single women, the decision to seek treatment was a necessary solution to become mothers not their preferred choice of parenthood. The new knowledge from this study may benefit health professionals and social workers in their efforts to improve the well-being and understanding of these new types of families and may also contribute to the new generation s considerations of family planning. A clinical follow-up study investigating the women s reproductive outcome of treatment and a self-reported questionnaire study exploring motherhood, family structure, and future reproductive intentions is currently under development. Acknowledgments First we would like to thank nurse Birgitte Holten Hansen and nurse Helle Bach Sørensen who participated in the initial phase of this project. We also want to thank the group of study-nurses at each public clinic who were part of the project and responsible for gathering the relevant data: Line Buur Dessing (Holbæk Hospital), Hanne Udengaard (Herlev Hospital), Dorte Okholm Svendsen (Skejby University Hospital), Janne Roskær (Dronninglund Hospital), Janne Simonsen (Odense University Hospital), Pernilla Andersson (Hvidovre Hospital), Alice Toft Mikkelsen (Skive Hospital), Anne Dorte Øhlers (Horsens Hospital). Finally, we want to acknowledge Hanne Kjaergaard PhD, who passed away on 15 December 2013, for her valuable contributions to this project and for her support as supervisor. Funding The project was co-funded by research grants from Ferring Pharmaceuticals, MSD Denmark ApS., Nordic Cryobank ApS. and Juliane Marie Center, Copenhagen University Hospital. The funds had no influence on study design, data analysis, or content of the manuscript. References 1. Ministry of Health. Bekendtgørelse om lov om kunstig befrugtning i forbindelse med lægelig behandling, diagnostik og forskning m.v. [Act on artificial fertilization in relation to medical treatment, diagnostics, and research etc. and subsequent changes] (in Danish). Copenhagen: Ministry of Health, Danish Fertility Society. Annual report Available online at: (accessed May 15, 2014). 3. Brewaeys A. Men not included: a review of single and lesbian mother DI families: mother child relationships en child development. Facts Views Vis ObGyn. 2010; Monograph: Jadva J, Badger S, Morrisette M, Golombok S. Mom by choice, single by life s circumstances... Findings from a large scale survey of the experience of single mothers by choice. Hum Fertil. 2009;12: Leiblum SR, Palmer MG, Spector IP. Non-traditional mothers: single heterosexual/lesbian women and lesbian couples electing motherhood via donor insemination. J Psychosom Obstet Gynecol. 1995;16: Murray C, Golombok S. Solo mothers and their donor insemination infants: follow-up at age 2 years. Hum Reprod. 2005;20: Frederiksen ME, Christensen U, Tjørnhøj-Thomsen T, Schmidt L. Solo mother by donor the plan B of motherhood. A perspective on person-centered reproductive medicine. Int J Pers Cent Med. 2011;1: Murray C, Golombok S. Going it alone: solo mothers and their infants conceived by donor insemination. Am J Orthopsychiatry. 2005;75: Golombok S, Badger S. Children raised in mother-headed families from infancy: a follow-up of children of lesbian and single heterosexual mothers, at early adulthood. Hum Reprod. 2010;25: Hansen EJ. Socialgrupper i Danmark. [Social classes in Denmark] (in Danish). Copenhagen: The Danish National Institute of Social Research, Krølner R, Holstein BE. Coding of occupational social class. Copenhagen: University of Copenhagen, Department of Public Health, Lampic C, Skoog Svanberg A, Karlstr om P, Tyden T. Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics. Hum Reprod. 2006;21: Abbey A, Andrews FM, Halman LJ. Gender s role in responses to infertility. Psychol Women Q. 1991;15: Statistics Denmark. Available online at: (accessed June 1, 2014). 480 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

9 M. Salomon et al. Single women and semen donation 15. Schmidt L. Infertility and assisted reproduction in Denmark. Epidemiology and psychosocial consequences. [Dissertation] Dan Med Bull. 2006;53: Schmidt L, M unster K, Helm P. Infertility and the seeking of infertility treatment in a representative population. Br J Obstet Gynaecol. 1995;102: Statistics Denmark. Husstande og familier. [Households and families] (in Danish). News, no. 89, 20 February Available online at: /nr089.pdf (accessed June 1, 2014). ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)