Association between number of children and mortality of mothers: results of a 37-year follow-up study

Reproductive and child health transition among selected empowered action groups states of India: A district-level analysis

BACKGROUND

Health is an inseparable part of life and central to all life supporting systems. The reproductive and child health shares a major portion of public health cases that is crucial for socio-economic development. Studies on reproductive and child health have traditionally been focused on demographic aspects using socio-economic parameters. Given the emphasis of Sustainable Development Goal (SDG)-3 on health and well-being, it is imperative to understand the geo-spatial dimension with the visible transition of key health indicators of fertility, maternal and infant/child health in the high burdened districts within these high focus Empowered Action Group (EAG) states of Rajasthan, Madhya Pradesh, Uttar Pradesh and Bihar that make up nearly 40% of India's population with relatively laggard health status.

METHODOLOGY

This paper aims to understand the status and trend of key reproductive and child health indicators and vital statistics based on the recent representative demographic surveys. We intend to undertake a district level spatio-temporal analysis by developing District Composite Health Profile (DCHP) using Composite Index Method on selected 13 equally weighted key reproductive and child health indicators. The study has been carried out using data from National Family Health Survey-4 (2015-16) and National Family Health Survey-5 (2019-21) survey rounds. We employed geo-spatial techniques i.e. Moran's-I, and univariate LISA to comprehend the geographical clustering of high and low health burden districts and their heterogeneities at the district level.

RESULTS/CONCLUSIONS

The study highlights emerging inter-districts, and inter-state disparities over survey periods. With consistent improvement in the selected EAG states over time, the overall reproductive and child health status through DCHP along with each indicator was relatively better in the states of Rajasthan and worse in Bihar. Districts along the Terai belt in Uttar Pradesh and Bihar consistently performed sluggish during survey rounds. The geo-spatial clustering follows the political boundary of states, albeit with intra-state variations. Monitoring of key health indicators using composite index method provides a useful leverage for identifying priority districts/regions for universal health access that should also consider geographical space as an important policy dimension.

Comparing labour induction outcomes using misoprostol and dinoprostone in term pregnancies: A retrospective study at Kiambu Level 5 Hospital between 2018 and 2020

BACKGROUND

The Maternal and Perinatal Death Surveillance and Response (MPDSR) was introduced in Kenya in 2016 and implemented at Kiambu Level 5 Hospital (KL5H) three years later in 2019. During a routine MPDSR meeting at KL5H, committee members identified a possible link between the off-label use of 200mcg misoprostol tablets divided eight times to achieve the necessary dose for labour induction (25mcg) and maternal deaths. Following this, an administrative decision was made to switch from misoprostol to dinoprostone for the induction of labour in June of 2019. This study aimed to assess the overall impact of MPDSR as well as the effect of replacing misoprostol with dinoprostone on uterine rupture, maternal and neonatal deaths at KL5H.

METHODS

We conducted a retrospective cohort study of women who gave birth at KL5H between January 2018 and December 2020. We defined the pre-intervention period as January 2018-June 2019, and the intervention period as July 2019-December 2020. We randomly selected the records of 411 mothers, 167 from the pre-intervention period and 208 from the intervention period, all of whom were induced. We used Bayes-Poisson Generalised Linear Models to fit the risk of uterine rupture, maternal and perinatal death. 12 semi-structured key person questionnaires was used to describe staff perspectives regarding the switch from misoprostol to dinoprostone. Inductive and deductive data analysis was done to capture the salient emerging themes.

RESULTS

We reviewed 411 patient records and carried out 12 key informant interviews. Mothers induced with misoprostol (IRR = 3.89; CI = 0.21-71.6) had an increased risk of death while mothers were less likely to die if they were induced with dinoprostone (IRR = 0.23; CI = 0.01-7.12) or had uterine rupture (IRR = 0.56; CI = 0.02-18.2). The risk of dying during childbearing increased during Jul 2019-Dec 2020 (IRR = 5.43, CI = 0.68-43.2) when the MPDSR activities were strengthened. Induction of labour (IRR = 1.01; CI = 0.06-17.1) had no effect on the risk of dying from childbirth in our setting. The qualitative results exposed that maternity unit staff preferred dinoprostone to misoprostol as it was thought to be more effective (fewer failed inductions) and safer, regardless of being more expensive compared to misoprostol.

CONCLUSION

While the period immediately following the implementation of MPDSR at KL5H was associated with an increased risk of death, the switch to dinoprostone for labour induction was associated with a lower risk of maternal and perinatal death. The use of dinoprostone, however, was linked to an increased risk of uterine rupture, possibly attributed to reduced labour monitoring given that staff held the belief that it is inherently safer than misoprostol. Consequently, even though the changeover was warranted, further investigation is needed to determine the reasons behind the rise in maternal mortalities, even though the MPDSR framework appeared to have been put in place to quell such an increase.

Reproductive factors and cardiometabolic disease among middle-aged and older women: a nationwide study from CHARLS

Background

Cardiometabolic disease is skyrocketing to epidemic proportions due to the high prevalence of its components and the aging of the worldwide population. More efforts are needed to improve cardiometabolic health. The aim of this nationally representative study based on the China Health and Retirement Longitudinal Study (CHARLS, 2014-2018) was to examine the association between reproductive factors and cardiometabolic disease among Chinese women aged ≥45 years.

Methods

The CHARLS is an ongoing longitudinal study initiated in 2011, and the latest follow-up was completed in 2018. In total, 6,407 participants were analyzed. Effect-sizes are expressed as odds ratios (OR) and 95% confidence intervals (CI). Confounding was considered from statistical adjustment, subsidiary exploration, and unmeasured confounding assessment aspects.

Results

Of 6,407 accessible participants, 60.9% were recorded as having one or more of five predefined cardiovascular or metabolic disorders. Compared to those with two children, participants who had 0-1 child were found to have a lower risk of cardiometabolic disease (OR = 0.844, 95% CI: 0.714-0.998), and those who had ≥3 children had a greater risk (OR = 1.181, 95% CI: 1.027-1.357). Age at menarche of 16-18 years was a protective factor compared with ≤16 years of age (OR = 0.858, 95% CI: 0.749-0.982). In contrast, participants with a history of abortion were 1.212 times more likely to have cardiometabolic disorders (OR = 1.212, 95% CI: 1.006-1.465). The likelihood for the presence of unmeasured confounding was low, as reflected by E-values.

Conclusions

Our findings demonstrate that number of children, age at menarche, and history of abortion were associated with a significant risk of cardiometabolic disease among Chinese women aged ≥45 years.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 2024.

DNA methylation as a window into female reproductive aging

People with ovaries experience reproductive aging as their reproductive function and system declines. This has significant implications for both fertility and long-term health, with people experiencing an increased risk of cardiometabolic disorders after menopause. Reproductive aging can be assessed through markers of ovarian reserve, response to fertility treatment or molecular biomarkers, including DNA methylation. Changes in DNA methylation with age associate with poorer reproductive outcomes, and epigenome-wide studies can provide insight into genes and pathways involved. DNA methylation-based epigenetic clocks can quantify biological age in reproductive tissues and systemically. This review provides an overview of hallmarks and theories of aging in the context of the reproductive system, and then focuses on studies of DNA methylation in reproductive tissues.

Are pregnancy and parity associated with telomere length? A systematic review

BACKGROUND

Women's reproduction requires increased energy demands, which consequently may lead to cellular damage and aging. Hence, Telomere Length (TL), a biomarker of biological aging and health status may possibly serve as a biomarker of reproductive effort. The aim of this systematic review is to evaluate telomere dynamics throughout pregnancy and the association between parity and TL.

METHODS

A systematic search was conducted across seven databases including CINAHL, Cochrane, PsycINFO, Proquest, PubMed; Scopus; and Web of Science, using keywords and MeSH descriptors of parity and TL. Predefined inclusion and exclusion criteria were used to screen abstracts and titles. After the removal of duplicates, 3431 articles were included in the primary screening, narrowed to 194 articles included in the full-text screening. Consensus was reached for the 14 studies that were included in the final review, and the Newcastle-Ottawa scale (NOS) was utilized to assess the quality of the selected studies. A mini meta-analysis utilized JASP 0.17.3 software and included 4 applicable studies, comprising a total of 2564 participants to quantitatively assess the estimated effect size of parity on TL.

RESULTS

Of the 11 studies reviewed on parity and TL, four demonstrated a negative correlation; one - a positive correlation and six -found no correlation. Studies demonstrating a negative correlation encompassed rigorous methodological practices possibly suggesting having more children is associated with enhanced telomere attrition. Of the four longitudinal studies assessing telomere dynamics throughout pregnancy, most found no change in TL from early pregnancy to postpartum suggesting pregnancy does not affect TL from early pregnancy to early postpartum. The meta-analysis revealed a negative, yet, non-significant effect, of the estimated effect size of parity on TL(ES = -0.009, p = 0.126, CI -0.021, 0.03).

CONCLUSIONS

Studies assessing pregnancy, parity and TL yielded mixed results, most likely due to the different research methods utilized in each study. Improvements in study design to better understand the short-term effects of pregnancy on TL and the effect of parity on TL over time, include precise definitions of parity, comparisons of different age groups, inclusion of reproductive lifespan and statistically adjusting for potential confounders in the parity and TL relationship.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE)

BACKGROUND

Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women.

METHODS

Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD.

RESULTS

Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m²) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each).

CONCLUSIONS

In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Social Support, social ties, and cognitive function of women with breast cancer: findings from the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) Study

PURPOSE

This study examined associations between self-reported cognitive functioning and social support as well as social ties among women with breast cancer.

METHODS

The study included 3351 women from the Women's Health Initiative Life and Longevity After Cancer cohort who were diagnosed with breast cancer stages I-III. Social support was assessed using a modified Medical Outcomes Study (MOS) Social Support Survey, and marital status was obtained from the baseline questionnaire. We also assessed social ties (e.g., number of friends, relatives, living children) and cognitive function (Functional Assessment of Cancer Therapy-Cognitive Function [FACT-COG]) on the year-1-follow up questionnaire. Multivariable quantile regression was used to estimate the changes in median cognitive scores. Kruskal-Wallis tests were used to assess the association of cognitive function with social ties.

RESULTS

The majority of participants were non-Hispanic White (93.3%), presently married (49%), with at least a 4-year college degree (53.2%), and had been diagnosed with localized breast cancer (79%). A 10-point higher social support score correlated to a 0.32 higher (better) median cognitive score (p < 0.001). Women who were presently married tended to have better cognition than women who were divorced/separated or widowed (p = 0.01). Significant associations were also present for having close relatives (p < 0.001) or friends (p < 0.001), with cognitive scores being higher in those with at least one close relative or friend compared to none.

CONCLUSION

Women reporting higher social support and greater numbers of friends or relatives have higher cognitive functioning. Compared to divorced or separated women, married women were likely to have higher cognitive functioning. These findings suggest that social support assessments have the potential to help identify women at higher risk of cognitive decline.

Cardiovascular disease risk factors and health behaviors of ultra-Orthodox Jewish women in Israel: a comparison study

Objectives: Women from low socio-economic, culturally insular populations are at increased risk for cardiovascular disease (CVD). The ultra-Orthodox Jewish (UOJ) community in Israel is a rapidly growing low socio-economic, insular, cultural-ethnic minority with numerous obstacles to health. The current cross-sectional study investigates CVD-related health behaviors and risk factors in a sample of UOJ females, comparing sample characteristics with the general population. Design: Self-administered questionnaires completed by a cluster randomized sample of 239 UOJ women included demographics, CVD-related health behaviors (consumption of fruit, vegetables, and sweetened beverages; hours of sleep; secondhand smoke exposure; and physical activity engagement) and risk factors (BMI, reported diagnoses of diabetes, high blood pressure, and heart disease). Results: Compared with the general population, UOJ women were less likely to consume 5 fruits and vegetables a day (12.7% vs. 24.3%, p < .001); more likely to consume ≥ 5 cups of sweetened beverages a week (18.6% vs. 12.6%, p = .019), and more likely to sleep <7 hours a night (62.0% vs. 50.6%, p = .002). UOJ women also reported less secondhand smoke exposure (7.2% vs. 51.4%, p < .001) and higher rates of physical activity recommendation adherence (60.1% vs. 25.6%, p < .0001) than the general population. Obesity was higher in UOJ women (24.3% vs. 16.1%, p < .0001). Increased parity and reduced moderate physical activity were associated with increased BMI. Increased parity was also associated with reduced sleep. Grand multiparous women (a 68% prevalence rate), in particular, were more likely to be overweight or obese than women with less than 5 children. Conclusions: This study suggests that health promotion interventions in this population target healthy weight maintenance, nutrition, and physical activity.

Epigenetic Clock Deceleration and Maternal Reproductive Efforts: Associations With Increasing Gray Matter Volume of the Precuneus

Reproductive efforts, such as pregnancy, delivery, and interaction with children, make maternal brains optimized for child-rearing. However, extensive studies in non-human species revealed a tradeoff between reproductive effort and life expectancy. In humans, large demographic studies have shown that this is the case for the most part; however, molecular marker studies regarding aging remain controversial. There are no studies simultaneously evaluating the relationship between reproductive effort, aging, and brain structures. We therefore examined the associations between reproductive efforts (parity status, number of deliveries, motherhood period, and cumulative motherhood period), DNA methylation age (mAge) acceleration (based on Horvath’s multi-tissue clock and the skin & blood clock), and the regional gray matter volumes (obtained through brain magnetic resonance imaging (MRI) using voxel-based morphometry) in 51 mothers aged 27–46 years of children in early childhood. We found that increasing reproductive efforts were significantly associated with decelerated aging in mothers with one to four children, even after adjusting for the confounding effects in the multiple linear regression models. We also found that the left precuneus gray matter volume was larger as deceleration of aging occurred; increasing left precuneus gray matter volume, on the other hand, mediates the relationship between parity status and mAge deceleration. Our findings suggest that mothers of children in early childhood, who have had less than four children, may benefit from deceleration of aging mediated via structural changes in the precuneus.

The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease

Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman's predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.

Number of parity/live birth(s) and cardiovascular disease among Iranian women and men: results of over 15 years of follow-up

Background

Most previous studies conducted in non-Middle Eastern populations have suggested that an increase in the number of parity/live birth(s) leads to cardiovascular disease (CVD) development, although their findings were inconclusive on this issue for both sexes. Biologic and socioeconomic pathways were suggested to explain this association. We studied this issue among urban Iranian men and women.

Methods

In this population-based cohort study, which included 3929 women and 2571 men aged ≥30 years, data for the number of parity/live birth(s) were obtained by a standard questionnaire. Participants were then annually followed for CVD events. Multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the number of parity/live birth(s) and other traditional CVD risk factors.

Results

During more than 15 years of follow-up, 456 and 524 CVD events have occurred among women and men, respectively. Among women, a J-shaped association was found between the number of live births and incident CVD with the lowest risk for women with two live births. Among women in multivariable analyses, each unit increase in parity had a HR of 1.05 (CI: 1.01–1.10), and having ≥4 parity was associated with a HR of 1.86 (0.97–3.56, p-value = 0.061). Among men, in comparison with participants who had 1 child, multivariable HRs of having 2, 3, and ≥ 4 children were 1.97 (1.24–3.12), 2.08 (1.31–3.31), and 2.08 (1.30–3.34), respectively.

Conclusion

To the best of our knowledge, the current study is the first report on this issue in the Middle East and North Africa region, a region with a high burden of CVD. It can now be suggested that the number of parity/live birth(s) is linked to CVD among the Iranian population, with this issue being more prominent among men. Further research is needed to support our results and clarify the pathways between the number of parity/live birth(s) and CVD development among Iranian populations by considering potential risk factors, especially psycho-socio-economic risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03499-2.

Parity predicts biological age acceleration in post-menopausal, but not pre-menopausal, women

Understanding factors contributing to variation in ‘biological age’ is essential to understanding variation in susceptibility to disease and functional decline. One factor that could accelerate biological aging in women is reproduction. Pregnancy is characterized by extensive, energetically-costly changes across numerous physiological systems. These ‘costs of reproduction’ may accumulate with each pregnancy, accelerating biological aging. Despite evidence for costs of reproduction using molecular and demographic measures, it is unknown whether parity is linked to commonly-used clinical measures of biological aging. We use data collected between 1999 and 2010 from the National Health and Nutrition Examination Survey (n = 4418) to test whether parity (number of live births) predicted four previously-validated composite measures of biological age and system integrity: Levine Method, homeostatic dysregulation, Klemera–Doubal method biological age, and allostatic load. Parity exhibited a U-shaped relationship with accelerated biological aging when controlling for chronological age, lifestyle, health-related, and demographic factors in post-menopausal, but not pre-menopausal, women, with biological age acceleration being lowest among post-menopausal women reporting between three and four live births. Our findings suggest a link between reproductive function and physiological dysregulation, and allude to possible compensatory mechanisms that buffer the effects of reproductive function on physiological dysregulation during a woman’s reproductive lifespan. Future work should continue to investigate links between parity, menopausal status, and biological age using targeted physiological measures and longitudinal studies.

'They are my future': childbearing desires and motivations among women with disabilities in Ghana - implications for reproductive healthcare

BACKGROUND

Previous research has highlighted widespread public mis/perceptions that portray women with disabilities (WWDs) as asexual, less likely to marry, and often not interested in childbearing. However, evidence from high-income settings shows that many WWDs are sexually active and do have or want to have children. Notwithstanding this, very few studies have focused on understanding childbearing desires and motivations among WWDs in low-income settings. This qualitative research explored childbearing desires and motivations among WWDs in Ghana.

METHODS

A cross-sectional qualitative study was conducted with WWDs aged 18-49 years in Northern Ghana. The distribution of participants by disability types were as follows: physical disability/impairment (n = 37); visual impairment (n = 11); speech and hearing impairment (n = 14); epilepsy (n = ten); and albinism (n = five). A pre-tested open-ended thematic topic guide was designed and used to conduct in-depth interviews. Interviews were tape-recorded and later transcribed for analysis. Transcripts were coded using QSR NVivo 11 software. Thematic content analysis techniques were used to analyse and present the data.

RESULTS

Nearly all the WWDs interviewed were sexually active, desiring to have children, and intended to have as many children as they could support. Strong desire to experience the joy of motherhood; fear of social insecurity; fear of old age economic insecurity; desire to challenge stigma and negative stereotypes about disability, sexuality and motherhood; and desire for self-actualisation, were key motivations for childbearing.

CONCLUSION

Our findings challenge existing negative public perceptions about the status of WWDs in relation to sexuality, childbearing and motherhood. More importantly, our findings suggest that if the Sustainable Development Goals related to universal access to sexual and reproductive healthcare are to be attained, WWDs must be targeted with quality sexual and reproductive healthcare information and services.

Frailty: A cost incurred by reproduction?

Evolutionary theories of senescence, such as the ‘disposable soma’ theory, propose that natural selection trades late survival for early fecundity. ‘Frailty’, a multidimensional measure of health status, may help to better define the long-term consequences of reproduction. We examined the relationship between parity and later life frailty (as measured by the Frailty Index) in a sample of 3,534 adults aged 65 years and older who participated in the English Longitudinal Study of Ageing. We found that the most parous adults were the most frail and that the parity-frailty relationship was similar for both sexes. Whilst this study provided some evidence for a ‘parity-frailty trade-off’, there was little support for our hypothesis that the physiological costs of childbearing influence later life frailty. Rather, behavioural and social factors associated with rearing many children may have contributed to the development of frailty in both sexes.

Adverse obstetric outcomes in public hospitals of southern Ethiopia: the role of parity

Purpose: Direct obstetric causes have a significant contribution for severe maternal morbidities and mortalities, although the effect of grand multiparity on adverse obstetric outcomes remains controversial across studies. This study aimed to compare obstetric outcomes in grand multiparous and low multiparous women in two hospitals of southern Ethiopia.Materials and methods: A comparative cross-sectional study was conducted in one general and one comprehensive specialized hospitals in 2018. Four hundred and sixty-one mothers were included in the study. Data were collected by structured questionnaire and extraction sheets from clinical documents, and were analyzed using STATA version 14 (StataCorp, College Station, TX, USA).Results: About 39% of the included mothers had at least one adverse obstetric outcome. Hypertensive disorders of pregnancy, antepartum hemorrhage, and premature rupture of membrane and were higher in the grand multiparous mothers. However, obstructed labor and risk of cesarean delivery were higher in low multiparous women. History of medical illnesses, previous cesarean delivery, and high birth weight were independent predictors of adverse maternal outcomes regardless of parity. However, parity did not show statistically significant difference in obstetric outcomes.Conclusion: Parity did not show statistically significant difference in experiencing adverse obstetric outcomes in women. Early identification and treatment of high-risk mothers is recommended regardless of parity.

Hidden Figures: Are Ultra-Orthodox Jewish Women Really so Different When it Comes to Health Care?

Incorporating the needs of at-risk populations into national health care initiatives is essential. Israel has identified ultra-Orthodox Jewish, or Haredi, women, as at risk of increased morbidity and mortality, yet actual data on this insular community are lacking. We reviewed published research on Israeli Haredi women's health status, behaviors and health care access and examined methodologies. Of 273 articles identified, 14 publications and four government reports were included. More research is needed on this community, essential not only to Israeli health care policy, but to that of the USA and the UK, who share the largest percentages of Haredi Jews.

Fertility History and Biomarkers Using Prospective Data: Evidence From the 1958 National Child Development Study

Research on the later-life health implications of fertility history has predominantly considered associations with mortality or self-reported indicators of health. Most of this previous research has either not been able to account for selection factors related to both early-life and later-life health or has had to rely on retrospectively reported accounts of childhood circumstances. Using the 1958 National Child Development Study, and in particular the biomedical survey conducted in 2002-2003, we investigate associations between fertility histories (number of children and age at first and at last birth) and biomarkers for cardiometabolic risk and respiratory function in midlife among both men and women. Results from models that adjusted for a very wide range of childhood factors, including early-life socioeconomic position, cognitive ability, and mental health, showed weak associations between parity and biomarkers. However, we found an inverse association between age at first birth and biomarkers indicative of worse cardiometabolic health, with poorer outcomes for those with very young ages at entry to parenthood and increasingly better outcomes for those becoming parents at older ages. A very young age at last birth was also associated with less favorable biomarker levels, especially among women. Results highlight the value of prospectively collected data and the availability of biomarkers in studies of life course determinants of health in midlife and later.

Integration of Mixed Methods in Community-Based Participatory Research: Development of a Disease Prevention Intervention for Ultra-Orthodox Jewish Women

Purpose:

To describe the development of the first disease prevention intervention with ultra-Orthodox Jewish (UOJ) women in Israel using mixed methods and community-based participatory research (CBPR).

Design:

This collaborative, 7-staged development process used an exploratory sequential mixed methods design integrated into a community-based participatory approach.

Setting:

The UOJ community in Israel, a high-risk, low socioeconomic, culturally insular minority that practices strict adherence to religious standards, maintains determined seclusion from mainstream culture and preserves traditional practices including extreme modesty and separation between the sexes.

Participants:

Women from a targeted UOJ community in Israel with distinct geographic, religious, and cultural parameters. These included 5 key informant interviewees, 5 focus groups with 6 to 8 participants in each, a cluster randomized sample of 239 questionnaire respondents (an 87% response rate), and 11 steering committee participants.

Method:

Qualitative data were analyzed through Interpretative Phenomenological Analysis by 2 researchers. Quantitative data were collected via questionnaire (designed based on qualitative findings) and analyzed utilizing descriptive statistics.

Results:

Barriers to health behavior engagement and intervention preferences were identified. The final intervention included walking programs, health newsletters, community leader trainings, teacher and student trainings, and health integration into schools.

Conclusion:

Utilizing mixed methods in CBPR improved cultural tailoring, potentially serving as a model for intervention design in other difficult to access, low socioeconomic, and culturally insular populations.

Relationships Between Reproductive History and Mortality From Cardiovascular Diseases Among Japanese Women: The Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC) Study

Background

Reproductive history has been addressed as a risk factor for cardiovascular disease (CVD). We examined the relationship between reproductive history and CVD mortality in Japanese women.

Methods

We followed 53,836 women without previous CVD or cancer history from 1988–1990 to 2009 in a prospective cohort study. Hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD mortality were estimated according to the number of deliveries and maternal age at first delivery.

Results

During the follow-up, 2,982 CVD-related deaths were identified. There was U-shaped association between the number of deliveries and risk of CVD mortality with reference to three deliveries, although the excess risk of CVD mortality associated with ≥5 deliveries was of borderline statistical significance. The corresponding multivariable HRs were 1.33 (95% CI, 1.12–1.58) and 1.11 (95% CI, 0.99–1.24). In addition, higher CVD mortality was associated with maternal age ≥28 years at first delivery than maternal age of 24–27 years at first delivery. The multivariable HRs were 1.22 (95% CI, 1.10–1.36) for 28–31 years at first delivery and 1.26 (95% CI, 1.04–1.52) for ≥32 years at first delivery. Moreover, among women with ≥3 deliveries, maternal age ≥28 years at first delivery was associated with 1.2- to 1.5-fold increased CVD mortality.

Conclusion

The number of deliveries showed a U-shaped association with risk of CVD mortality. Higher maternal age at first delivery was associated with an increased risk of CVD mortality, and excessive risk in women aged ≥28 years at first delivery was noted in those with ≥3 deliveries.

Fertility histories and chronic conditions later in life in Europe

Understanding the association between fertility histories and health later in life is necessary in the context of ageing societies. Past literature has generally found a U-shaped relationship between parity, age at first birth, and several health-related outcomes. However, these findings differed to some extent depending on the country under analysis and on the measures of health considered. As such, using wave 3 (2008-2009) and 5 (2013) of the Survey of Health, Ageing and Retirement in Europe (SHARE), this work aimed to answer the question: "Are fertility histories associated with the presence of chronic conditions later in life in Europe?" The analysis included 11 European countries and compared results using two different measures of chronic conditions: self-reported chronic or long-term illness and chronic diseases diagnosed by a doctor. Results showed that age at first birth is more relevant than parity for health outcomes at older ages. Moreover, in socio-democratic and continental countries, the association between fertility and chronic conditions-in particular between age at first birth and long-term illnesses-is statistically significant among women, but not among men. Finally, the association between fertility history and health was similar when using self-reported measures and chronic diseases diagnosed by a doctor.

The parental co-immunization hypothesis: An observational competing risks analysis

The main interest of this study is the hypothesis that contact with small children may be beneficial for the parents’ later health and mortality (because of changes in their immune system). For this purpose, we document the relationship of a set of individual characteristics—including parenthood and marital state—and socioeconomic status with an individual’s cause of death. Using a novel and rich data set made available by the Office for National Statistics Longitudinal Study (ONS-LS), which follows 1% of the population of England and Wales along five census waves 1971, 1981, 1991, 2001, and 2011, our competing risks analysis yields several striking results: (1) Females with children have a 72.5% reduced risk of dying of cancer compared to childless females (for childless females of age 70, this corresponds to a risk of dying of cancer of 1.3% compared to a risk of about 1.3 × 0.275 = 0.4% for females with children). (2) Males have a 171% increased chance of dying of cancer when they are married (e.g., a baseline probability of 1.2% when 75 year old) compared to unmarried males. (3) Females with children have only a 34% risk of dying of heart disease (corresponding to a conditional probability of 0.3% when aged 65) relative to females without children and (4) a 53% chance of dying of infections (i.e., 0.1% at 65 years of age) compared to the risk for females without children. (5) At the same age, married men have an increased expectation of 123% of dying of heart disease (corresponding to an expected death probability of 0.7%) compared to unmarried men. (6) High income and house ownership is always associated with higher survival but less so than having children. While these results document a relationship between the presence of children and mortality, the specific transmission mechanisms remain unclear and we cannot make causality assertions.

Parity and Mortality: An Examination of Different Explanatory Mechanisms Using Data on Biological and Adoptive Parents

A growing literature has demonstrated a relationship between parity and mortality, but the explanation for that relationship remains unclear. This study aims to pick apart physiological and social explanations for the parity-mortality relationship by examining the mortality of parents who adopt children, but who have no biological children, in comparison with the mortality of parents with biological children. Using Swedish register data, we study post-reproductive mortality amongst women and men from cohorts born between 1915 and 1960, over ages 45-97. Our results show the relative risks of mortality for adoptive parents are always lower than those of parents with biological children. Mortality amongst adoptive parents is lower for those who adopt more than one child, while for parents with biological children we observe a U-shaped relationship, where parity-two parents have the lowest mortality. Our discussion considers the relative importance of physiological and social depletion effects, and selection processes.

Mechanisms of Sex Disparities in Cardiovascular Function and Remodeling

Epidemiological studies demonstrate disparities between men and women in cardiovascular disease prevalence, clinical symptoms, treatments, and outcomes. Enrollment of women in clinical trials is lower than men, and experimental studies investigating molecular mechanisms and efficacy of certain therapeutics in cardiovascular disease have been primarily conducted in male animals. These practices bias data interpretation and limit the implication of research findings in female clinical populations. This review will focus on the biological origins of sex differences in cardiovascular physiology, health, and disease, with an emphasis on the sex hormones, estrogen and testosterone. First, we will briefly discuss epidemiological evidence of sex disparities in cardiovascular disease prevalence and clinical manifestation. Second, we will describe studies suggesting sexual dimorphism in normal cardiovascular function from fetal life to older age. Third, we will summarize and critically discuss the current literature regarding the molecular mechanisms underlying the effects of estrogens and androgens on cardiac and vascular physiology and the contribution of these hormones to sex differences in cardiovascular disease. Fourth, we will present cardiovascular disease risk factors that are positively associated with the female sex, and thus, contributing to increased cardiovascular risk in women. We conclude that inclusion of both men and women in the investigation of the role of estrogens and androgens in cardiovascular physiology will advance our understanding of the mechanisms underlying sex differences in cardiovascular disease. In addition, investigating the role of sex-specific factors in the development of cardiovascular disease will reduce sex and gender disparities in the treatment and diagnosis of cardiovascular disease. © 2019 American Physiological Society. Compr Physiol 9:375-411, 2019.

Early-life environment and differences in costs of reproduction in a preindustrial human population

Reproduction is predicted to trade-off with long-term maternal survival, but the survival costs often vary between individuals, cohorts and populations, limiting our understanding of this trade-off, which is central to life-history theory. One potential factor generating variation in reproductive costs is variation in developmental conditions, but the role of early-life environment in modifying the reproduction-survival trade-off has rarely been investigated. We quantified the effect of early-life environment on the trade-off between female reproduction and survival in pre-industrial humans by analysing individual-based life-history data for >80 birth cohorts collected from Finnish church records, and between-year variation in local crop yields, annual spring temperature, and infant mortality as proxies of early-life environment. We predicted that women born during poor environmental conditions would show higher costs of reproduction in terms of survival compared to women born in better conditions. We found profound variation between the studied cohorts in the correlation between reproduction and longevity and in the early-life environment these cohorts were exposed to, but no evidence that differences in early-life environment or access to wealth affected the trade-off between reproduction and survival. Our results therefore do not support the hypothesis that differences in developmental conditions underlie the observed heterogeneity in reproduction-survival trade-off between individuals.

A systematic review of micro correlates of maternal mortality

In the year 2000, the World Health Organization launched the Millennium Development Goals (MDGs) which were to be achieved in 2015. Though most of the goals were not achieved, a follow-up post 2015 development agenda, the Sustainable Development Goals (SDGs) was launched in 2015, which are to be achieved by 2030. Maternal mortality reduction is a focal goal in both the MDGs and SDGs. Achieving the maternal mortality target in the SDGs requires multiple approaches, particularly in developing countries with high maternal mortality. Low-income developing countries rely to a great extent on macro determinants such as public health expenditure, which are spent mostly on curative health and health facilities, to improve population health. To complement the macro determinants, this study employs the systematic review technique to reveal significant micro correlates of maternal mortality. The study searched MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, and Global Index Medicus of the World Health Organization. Our search was time framed from the 1st January, 2000 to the 30th September, 2016. In the overall search result, 6758 articles were identified, out of which 33 were found to be eligible for the review. The outcome of the systematic search for relevant literature revealed a concentration of literature on the micro factors and maternal mortality in developing countries. This shows that maternal mortality and micro factors are a major issue in developing countries. The studies reviewed support the significant relationship between the micro factors and maternal mortality. This study therefore suggests that more effort should be channelled to improving the micro factors in developing countries to pave the way for the timely achievement of the SDGs' maternal mortality ratio (MMR) target.

Number of Offspring and Cardiovascular Disease Risk in Men and Women: The Role of Shared Lifestyle Characteristics

Supplemental Digital Content is available in the text.

Background:

Previous studies of the number of offspring and cardiovascular disease (CVD) report conflicting findings. We re-examined this association in both sexes to clarify the role of the cardiometabolic changes that women experience during pregnancy versus shared lifestyle characteristics.

Methods:

We studied 180,626 women and 133,259 men participating in the UK Biobank cohort who were free of CVD at baseline. CVD events were obtained from hospital and death registers. Analyses were conducted using Cox proportional hazards regression.

Results:

The incidence rates of overall CVD were six per 1000 person-years for women and nine per 1000 person-years for men. Number of children showed an association with risk of CVD among women; the adjusted HR (95% CI) was 1.2 (1.1, 1.3) for one, 1.1 (1.0, 1.2) for two, 1.2 (1.1, 1.3) for three, and 1.2 (1.1, 1.4) for four or more as compared to none. Number of children was also associated with CVD among men; the adjusted HR (95% CI) was 1.1 (1.0, 1.2) for one, 1.0 (0.96, 1.1) for two, 1.1 (1.0, 1.2) for three, and 1.1 (1.0, 1.3) for four or more as compared to none. There was no evidence of heterogeneity in the associations between sexes (P_interaction = 0.80). Number of offspring also showed similar associations with ischemic heart disease and hypertensive disorders in both sexes.

Conclusions:

We observed similar associations between number of offspring and CVD in both sexes. The association among women might therefore be largely explained by unobserved behavioral and lifestyle characteristics.

The significant influence of having children on the postoperative prognosis of patients with nonsmall cell lung cancer: A propensity score-matched analysis

The aim of this study was to elucidate the relationship between family‐associated factors and the postoperative prognosis in patients with nonsmall cell lung cancer (NSCLC). Additionally, we investigated whether having children was associated with the postoperative maintenance of the nutritional status. We selected 438 NSCLC patients who had undergone curative lung resection between 2004 and 2011 at Kyushu University (Fukuoka, Japan), whose family‐associated factors were available. Nutritional indices, including the prognostic nutritional index (PNI), were used to estimate the change in the nutritional status for 1 year after surgery. A propensity score analysis was conducted after adjusting the following variables: sex, age, smoking history, performance status, pathological stage, and histological type. Three hundred patients (68.5%) had both children and partners. Forty‐nine patients (11.2%) only had children, and 56 (12.8%) patients only had a partner. Thirty‐three patients (7.5%) did not have a partner or children. The overall survival (OS) and disease‐free survival (DFS) of the partner‐present and partner‐absent patients did not differ to a statistically significant extent (P = .862 and P = .712, respectively). However, childless patients showed significantly shorter OS and DFS in comparison with patients with children (P = .005 and P = .002, respectively). The postoperative exacerbation of PNI was significantly greater in childless patients than in patients with children (P = .003). These results remained after propensity score matching. Childless patients had a significantly poorer postoperative prognosis than those with children. Surgeons caring for childless NSCLC patients should be aware of the poorer postoperative outcomes in this population.

Fertility History and Physical and Mental Health Changes in European Older Adults

Previous studies have shown that aspects of reproductive history, such as earlier parenthood and high parity, are associated with poorer health in mid and later life. However, it is unclear which dimensions of health are most affected by reproductive history, and whether the pattern of associations varies for measures of physical, psychological and cognitive health. Such variation might provide more insight into possible underlying mechanisms. We use longitudinal data for men and women aged 50–79 years in ten European countries from the Survey of Health, Ageing and Retirement in Europe to analyse associations between completed fertility history and self-reported and observed health indicators measured 2–3 years apart (functional limitations, chronic diseases, grip strength, depression and cognition), adjusting for socio-demographic, and health factors at baseline. Using multiple imputation and pattern mixture modelling, we tested the robustness of estimates to missing data mechanisms. The results are partly consistent with previous studies and show that women who became mothers before age 20 had worse functional health at baseline and were more likely to suffer functional health declines. Parents of 4 or more children had worse physical, psychological and cognitive health at baseline and were more likely to develop circulatory disease over the follow-up period. Men who delayed fatherhood until age 35 or later had better health at baseline but did not experience significantly different health declines. This study improves our understanding of linkages between fertility histories and later life health and possible implications of changes in fertility patterns for population health. However, research ideally using prospective life course data is needed to further elucidate possible mechanisms, considering interactions with partnership histories, health behaviour patterns and socio-economic trajectories.

U-shaped association between fertility and mortality in a community-based sample of Japanese women

BACKGROUND

Prospective cohort studies of contemporary populations in both Western and Asian settings have reported a U-shaped association between fertility and mortality. We examined whether an association exists between fertility and all-cause and cause-specific mortality in a sample of Japanese women.

METHODS

A prospective cohort study was conducted in one rural and one urban community in Gunma Prefecture, Japan, in 1993. A follow-up survey was conducted in the year 2000 in 4858 women aged 47-77 years, and information on demographic and lifestyle characteristics was collected. Mortality and migration data through December 2008 were obtained. A Cox proportional hazard model was used to examine the relationship between parity and mortality.

RESULTS

Compared with women with 2-4 children (reference group), higher total mortality was observed among women with 0-1 or 5+ children. Low (HR 1.7, 95% CI 1.2 to 2.3) and high (HR 2.1, 95% CI 1.0 to 4.7) parities were both associated with higher all-cause mortality even after adjusting for potential confounders. Mortality due to ischaemic heart disease exhibited a significant association with parity; the HRs were 3.2 (95% CI 1.1 to 9.2) for women with 0-1 child and 8.7 (95% CI 1.7 to 45.5) for women with 5 or more children. No significant association was observed for mortality from malignancies, cancer of the digestive system, cardiovascular disease or cerebrovascular disease.

CONCLUSIONS

There exists a U-shaped association between parity and all-cause mortality and cause-specific mortality due to ischaemic heart disease among Japanese women.

Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis

OBJECTIVES

Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.

METHODS

MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.

RESULTS

Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.

CONCLUSIONS

Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

Current versus future reproduction and longevity: a re-evaluation of predictions and mechanisms

Oxidative damage is predicted to be a mediator of trade-offs between current reproduction and future reproduction or survival, but most studies fail to support such predictions. We suggest that two factors underlie the equivocal nature of these findings: (1) investigators typically assume a negative linear relationship between current reproduction and future reproduction or survival, even though this is not consistently shown by empirical studies; and (2) studies often fail to target mechanisms that could link interactions between sequential life-history events. Here, we review common patterns of reproduction, focusing on the relationships between reproductive performance, survival and parity in females. Observations in a range of species show that performance between sequential reproductive events can decline, remain consistent or increase. We describe likely bioenergetic consequences of reproduction that could underlie these changes in fitness, including mechanisms that could be responsible for negative effects being ephemeral, persistent or delayed. Finally, we make recommendations for designing future studies. We encourage investigators to carefully consider additional or alternative measures of bioenergetic function in studies of life-history trade-offs. Such measures include reactive oxygen species production, oxidative repair, mitochondrial biogenesis, cell proliferation, mitochondrial DNA mutation and replication error and, importantly, a measure of the respiratory function to determine whether measured differences in bioenergetic state are associated with a change in the energetic capacity of tissues that could feasibly affect future reproduction or lifespan. More careful consideration of the life-history context and bioenergetic variables will improve our understanding of the mechanisms that underlie the life-history patterns of animals.

Family size and old-age wellbeing: effects of the fertility transition in Mexico

The present study aims to determine how family size affects psycho-social, economic and health wellbeing in old age differently across two cohorts with declining fertility. The data are from the 2012 Mexican Health and Ageing Study (MHAS) including respondents aged 50+ (N = 13,102). Poisson (standard and zero-inflated) and logistic regressions are used to model determinants of wellbeing in old age: psycho-social (depressive symptoms), economic (consumer durables and insurance) and health (chronic conditions). In the younger cohort, having fewer children is associated with fewer depressive symptoms and chronic conditions, and better economic well-being. For the older cohort, having fewer children is associated with lower economic wellbeing and higher odds of being uninsured. Lower fertility benefited the younger cohort (born after 1937), whereas the older cohort (born in 1937 or earlier) benefited from lower fertility only in chronic conditions. Further research is needed to continue exploring the old-age effects of the fertility transition.

Maternal Age at Childbirth and Parity as Predictors of Longevity Among Women in the United States: The Women's Health Initiative

OBJECTIVES

To examine associations of maternal age at childbirth and parity with survival to age 90 years (longevity).

METHODS

We performed a prospective study among a multiethnic cohort of postmenopausal US women in the Women's Health Initiative recruited from 1993 to 1998 and followed through August 29, 2014. We adjusted associations with longevity for demographic, lifestyle, reproductive, and health-related characteristics.

RESULTS

Among 20 248 women (mean age at baseline, 74.6 years), 10 909 (54%) survived to age 90 years. The odds of longevity were significantly higher in women with later age at first childbirth (adjusted odds ratio = 1.11; 95% confidence interval = 1.02, 1.21 for age 25 years or older vs younger than 25 years; P for trend = .04). Among parous women, the relationship between parity and longevity was significant among White but not Black women. White women with 2 to 4 term pregnancies compared with 1 term pregnancy had higher odds of longevity.

CONCLUSIONS

Reproductive events were associated with longevity among women. Future studies are needed to determine whether factors such as socioeconomic status explain associations between reproductive events and longevity.

Radiation and circulatory disease

Exposure to therapeutic doses of ionizing radiation is associated with damage to the heart and coronary arteries. However, only recently have studies with high-quality individual dosimetry data allowed this risk to be quantified while also adjusting for concomitant chemotherapy, and medical and lifestyle risk factors. At lower levels of exposure the evidence is less clear. In this article I review radiation-associated risks of circulatory disease in groups treated with radiotherapy for malignant and non-malignant disease, and in occupationally- or environmentally-exposed groups receiving rather lower levels of radiation dose, also for medical diagnostic purposes. Results of a meta-analysis suggest that excess relative risks per unit dose for various types of heart disease do not exhibit statistically significant (p>0.2) heterogeneity between studies. Although there are no marked discrepancies between risks derived from the high-dose therapeutic and medical diagnostic studies and from the moderate/low dose occupational and environmental studies, at least for ischemic heart disease and stroke there are indications of larger risks per unit dose for lower dose rate and fractionated exposures. Risks for stroke and other types of circulatory disease are significantly more variable (p<0.0001), possibly resulting from confounding and effect-modification by well known (but unobserved) risk factors. Adjustment for any of mean dose, dose fractionation or age at exposure results in the residual heterogeneity for cerebrovascular disease becoming non-significant. The review provides strong evidence in support of a causal association between both low and high dose radiation exposure and most types of circulatory disease.

Parity and serum lipid levels: a cross-sectional study in chinese female adults

Reproductive factors have been shown to correlate with lipid metabolism. The aim of this study was to investigate the relationship between parity and serum lipid levels in community-based Chinese female adults. A total of 4,217 female participants were enrolled. Parity was recorded according to questionnaire and serum lipid profile, including triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), and high density lipoprotein cholesterol (HDL-C), was measured. Logistic regression models were used to analyze the association of parity to serum lipid levels, while adjusting for demographics and metabolic risk factors. Parity in this population ranged from 0 to 7. After adjusting for potential confounders, it indicated that females with more than 2 parities appeared to be less likely to suffer from abnormal serum TC level compared with nulliparae (parity = 2, odds ratio (OR) = 0.457, 95% confidence interval (CI) = 0.284–0.736; parity ≥ 3, OR = 0.363, 95% CI = 0.202–0.653). These findings suggested that parity could correlate with lipid metabolism in Chinese women. Individuals with higher parity appeared to have a lower total cholesterol in blood.

Parity, coronary heart disease and mortality in the old order Amish

BACKGROUND AND AIMS

Prior data on the association between parity and mortality are limited by the presence of sociodemographic confounders including cultural norms of parity. Our objective was to determine the association between parity and mortality in the Amish, a socioeconomically homogenous group with large numbers of children per family.

METHODS

We conducted a population-based cohort study among 518 Old Order Amish women enrolled in a cardiovascular awareness program. The mean length of follow-up for mortality was 13.52 years. We determined the adjusted associations between parity and obesity, prevalent coronary heart disease and mortality.

RESULTS

The mean number of total births per woman was 6.7 ± 3.6 with a mode of 8. No significant association was observed between parity and all-cause mortality when adjusted for age (HR 1.00 per additional birth; 95% CI 0.96-1.05; p = 0.85) or in multivariate analysis (HR 1.00, 95% CI 0.95-1.05; p = 0.95). There was also no association of parity in age- or multivariable adjusted models with prevalent diabetes, hypertension or coronary heart disease. Despite the lack of effect of parity on mortality, a significant association of ten or more births was observed with higher body mass index (BMI) compared to the referent group of 8-9 total births.

CONCLUSIONS

In a highly homogeneous population with high rates of parity, no association between overall mortality and parity was observed. Ten or more births were significantly associated with a higher BMI but not with overall mortality.

Association of Women's Reproductive History With Long-term Mortality and Effect of Socioeconomic Factors

OBJECTIVE

To assess the effects of socioeconomic factors on the association between parity and long-term maternal mortality.

METHODS

This was a population-based cohort study of mothers with births registered in the Medical Birth Registry of Norway during the period 1967-2009. We estimated age-specific (40-69 years) cardiovascular and noncardiovascular mortality ratios by number of births using Cox proportional hazard models. To assess effect modification by mothers' attained education, we stratified on low (less than 11 years) and high (11 years or greater) educational level. We further evaluated fathers' mortality by number of births using the same analytical approach.

RESULTS

Mothers with low education had higher mortality (cardiovascular: hazard ratio 2.62, 95% confidence interval [CI] 2.34-2.93, noncardiovascular: hazard ratio 1.67, 95% CI 1.62-1.73). Among mothers with low education, cardiovascular mortality increased linearly with each additional birth above one (P trend=.02). In contrast, among mothers with high education, cardiovascular mortality declined with added births (P trend=.045). For noncardiovascular mortality there was no association among mothers with low education, whereas mortality declined with increasing number of births among mothers with high education (P trend<.01). Father's mortality showed similar associations with number of births when stratified on maternal education.

CONCLUSION

Women's long-term mortality rose with number of births only for cardiovascular causes of death and only among mothers with low education. Partners of women with low education had similar increasing risk with increasing number of births. Maternal educational level is a strong modifier of the association between parity and long-term mortality.

LEVEL OF EVIDENCE

II.

Parity and All-cause Mortality in Women and Men: A Dose-Response Meta-Analysis of Cohort Studies

To quantitatively assess the association between parity and all-cause mortality, we conducted a meta-analysis of cohort studies. Relevant reports were identified from PubMed and Embase databases. Cohort studies with relative risks (RRs) and 95% confidence intervals (CIs) of all-cause mortality in three or more categories of parity were eligible. Eighteen articles with 2,813,418 participants were included. Results showed that participants with no live birth had higher risk of all-cause mortality (RR= 1.19, 95% CI = 1.03–1.38; I² = 96.7%, P < 0.001) compared with participants with one or more live births. Nonlinear dose-response association was found between parity and all-cause mortality (P for non-linearity < 0.0001). Our findings suggest that moderate-level parity is inversely associated with all-cause mortality.

Mortality, cancer incidence, and survival in parents after bereavement

PURPOSE

The study objective was to investigate whether child loss is related to mortality, cancer incidence, and cancer survival in parents.

METHODS

We used a population-based birth cohort (1964-1976) in Jerusalem and ascertained mortality (average follow-up of 39.1 years) and any cancer (average follow-up of 35.6 years) among parents who lost a child (2838 mothers and 2532 fathers) and among nonbereaved parents (38,212 mothers and 36,433 fathers). We also assessed mortality among parents with cancer. Time-dependent Cox models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Overall mortality rates among bereaved parents were modestly increased when compared with nonbereaved parents (HR = 1.18, 95% CI: 1.05-1.32 in mothers; HR = 1.10, 95% CI: 1.01-1.20 in fathers). Hazard models indicated a significant relationship between bereavement and deaths from coronary heart disease in mothers (HR = 1.90, 95% CI: 1.23-2.95) and circulatory causes in both parents (HR = 1.69; 95% CI: 1.22-2.34 in mothers and HR = 1.25; 95% CI: 1.02-1.54 in fathers). Bereavement was not associated with parental risk of cancer disease and with survival from cancer. The association between bereavement and parental overall mortality was similar in the different parental sociodemographic characteristics. We observed a decrease in HRs for parental mortality associated with bereavement, with increasing time since the death of the child (HRs = 9-10, 0-3 years; HRs = 0.9-1.0, 9+ years; P(heterogeneity) ≤ 3 × 10(-32)). A similar decrease in HRs was observed for parental survival from cancer (HRs = 6.7-8.7, 0-3 years; HRs = 0.9-1.0, 9+ years).

CONCLUSIONS

Our study suggests that child loss was associated with slightly increased risk of all-cause and circulatory mortality in parents but not with incidence of cancer and cancer survival. The considerable increased parental mortality during a short period after child loss support the involvement of pathways related to psychological stress.