Skip Navigation


American Journal of Epidemiology Advance Access originally published online on December 21, 2005
American Journal of Epidemiology 2006 163(4):367-373; doi:10.1093/aje/kwj048
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
163/4/367    most recent
kwj048v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (5)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Hinkula, M.
Right arrow Articles by Pukkala, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hinkula, M.
Right arrow Articles by Pukkala, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

American Journal of Epidemiology Copyright © 2005 by the Johns Hopkins Bloomberg School of Public Health All rights reserved; printed in U.S.A.

Original Contribution

Cause-specific Mortality of Grand Multiparous Women in Finland

Marianne Hinkula1, Antti Kauppila1, Simo Näyhä2,3 and Eero Pukkala4

1 Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
2 Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland
3 Regional Institute of Occupational Health in Oulu, University of Oulu, Oulu, Finland
4 Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland

Correspondence to Dr. Marianne Hinkula, Department of Obstetrics and Gynecology, University of Oulu, PL 24, FIN-90029 OYS, Oulu, Finland (e-mail: marianne.hinkula{at}oulu.fi).

Received for publication March 15, 2005. Accepted for publication October 4, 2005.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Knowledge is limited on mortality of grand multiparous women (≥5 deliveries), whose hormonal, metabolic, and social conditions differ from the average. The authors studied overall and cause-specific mortality in 1974–2001 among 87,922 grand multiparous women including 3,678 grand grand multiparous women (≥10 deliveries) in Finland. Standardized mortality ratios were defined as ratios of observed to expected numbers of deaths, both derived from national cause-of-death files. During follow-up, 18,870 grand multiparous women and 625 grand grand multiparous women died (standardized mortality ratios (SMRs) = 0.95 and 1.01, respectively). Decreased mortality among grand multiparous women was found for cancers of the breast (SMR = 0.64, 95% confidence interval (CI): 0.59, 0.69), corpus uteri (SMR = 0.68, 95% CI: 0.56, 0.80), ovary (SMR = 0.68, 95% CI: 0.60, 0.75), bladder (SMR = 0.59, 95% CI: 0.41, 0.82), and respiratory tract (SMR = 0.80, 95% CI: 0.72, 0.88). The only malignant tumor associated with elevated mortality was kidney cancer (SMR = 1.38, 95% CI: 1.21, 1.56). The standardized mortality ratio was also low for dementia (SMR = 0.78, 95% CI: 0.72, 0.84), respiratory diseases (SMR = 0.80, 95% CI: 0.75, 0.85), and accidents and violent causes (SMR = 0.79, 95% CI: 0.73, 0.84). Mortality from diabetes mellitus (SMR = 1.42, 95% CI: 1.29, 1.55) and ischemic heart disease (SMR = 1.10, 95% CI: 1.08, 1.13) was increased. According to this study, overall mortality among grand multiparous women is not elevated. Low mortality from cancers is offset by higher mortality from cardiovascular conditions and diabetes mellitus.

mortality; obesity; parity

Abbreviations: CI, confidence interval; GM, grand multiparous; GGM, grand grand multiparous; SMR, standardized mortality ratio


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
We previously reported a low incidence of cancers of the breast and corpus uteri and a slightly increased incidence of cervical cancer among grand multiparous (GM) women, compared with all women, in Finland (1Go–3Go). Pregnancies and sex-related hormones may induce significant changes in factors controlling malignant transformation of reproductive organs (4Go–7Go). They also predispose to diabetes, preeclampsia, hypertension, and obesity, which are well-known risk factors for mortality (8Go–16Go). Little is known about the cumulative effects of numerous childbearings on long-term mortality (15Go, 17Go–22Go). We therefore examined the overall and cause-specific mortality among all GM women in Finland during the period 1974–2001.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
A study cohort of all women in Finland with at least five deliveries (N = 87,922; the whole GM cohort) and of those 3,678 women with at least 10 deliveries (grand grand multiparous (GGM) women) from January 1, 1974, to December 31, 1997, was drawn from the national population register (stillborn babies were not taken into account). Records were linked with the national cause-of-death files of Statistics Finland by using a unique personal identification code up to the year 2001. Deaths had been classified according to the International Classification of Diseases (the Eighth Revision in 1969–1986, the Ninth Revision in 1987–1995, and the Tenth Revision in 1996–2001). Person-years were calculated from the fifth or 10th birth or January 1, 1974, whichever was later, until death or December 31, 2001, by 5-year age groups. Standardized mortality ratios were defined as ratios of observed to expected numbers of deaths by using cause-specific mortality among all Finnish women as a reference. The confidence intervals for the standardized mortality ratios were based on the Poisson distribution.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Among the 87,922 GM women, 18,870 deaths occurred, slightly fewer than expected (n = 19,819) from the whole female population (standardized mortality ratio (SMR) = 0.95, 95 percent confidence interval (CI): 0.94, 0.95). For the GGM women, the standardized mortality ratio did not deviate from the national average (625 deaths; expected deaths, 621; SMR = 1.01, 95 percent CI: 0.93, 1.08).

Among the GM women, overall cancer mortality was 11 percent lower than expected (table 1). It was significantly low for cancers of the breast (36 percent deficit), corpus uteri (32 percent), ovary (32 percent), bladder (41 percent), and respiratory organs (20 percent). Significantly high mortality was found for cancer of the kidney (38 percent excess). The standardized mortality ratio for cervical cancer did not differ from the average.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Standardized mortality ratios for cancer, by site, in grand multiparous women* in Finland, 1974–2001

 
The standardized mortality ratios for cardiovascular diseases, notably ischemic heart disease and cerebrovascular diseases, slightly exceeded the national average (table 2). The standardized mortality ratio for diabetes mellitus was increased by 42 percent.


View this table:
[in this window]
[in a new window]
  		TABLE 2. Standardized mortality ratios for diseases other than cancer in grand multiparous women* in Finland, 1974–2001

 
Mortality from diseases of the respiratory organs was 20 percent lower than expected (table 2). Mortality from tuberculosis was decreased by 40 percent and from diseases of the bladder and from genitourinary diseases by 15 percent.

The standardized mortality ratios for dementia and Alzheimer's disease, as well as for other diseases of the nervous system and sense organs, were significantly low (22–23 percent deficit) (table 2).

Among GM women, mortality from accidents was lower than average (21 percent deficit). The standardized mortality ratio was especially low for accidental poisoning (43 percent) and suicides (43 percent) (table 3). Only traffic accidents were associated with high mortality (17 percent excess).


View this table:
[in this window]
[in a new window]
  		TABLE 3. Standardized mortality ratios for violent causes for grand multiparous women* in Finland, 1974–2001

 
Among the GGM women, the standardized mortality ratios were 0.70 (95 percent CI: 0.45, 1.03; 24 deaths) for breast cancer, 0.43 (95 percent CI: 0.16, 0.94; six deaths) for ovarian cancer, and 0.34 (95 percent CI: 0.04, 1.22; two deaths) for corpus uterine cancer. The standardized mortality ratios were 1.28 (95 percent CI: 1.11, 1.47; 192 deaths) for ischemic heart disease and 1.18 (95 percent CI: 0.94, 1.45; 86 deaths) for cerebrovascular diseases. The standardized mortality ratio for diabetes mellitus was 1.81 (95 percent CI: 1.06, 2.90; 17 deaths). Decreased mortality was seen for suicides (SMR = 0.26, 95 percent CI: 0.05, 0.76; three deaths) and dementia and Alzheimer's disease (SMR = 0.78, 95 percent CI: 0.45, 1.24; 17 deaths).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
This study reports the overall and cause-specific standardized mortality ratios for GM women in a national cohort from a country with well-organized health care systems and with registers that include reliable data on births and deaths. According to our study, overall mortality among GM women was slightly lower than average. This finding is in line with a Norwegian study (20Go) but disagrees with studies from England and Wales (17Go, 18Go, 22Go). For the GGM women, the overall standardized mortality ratio was average. The low mortality among GM women in our study was mainly due to low rates of cancers of the breast, ovary, corpus uteri, and lung and, to a lesser extent, to low mortality for dementia and Alzheimer's disease, respiratory diseases, and most kinds of violent causes. Increased mortality was found for cancer of the kidney; all metabolic diseases, mainly diabetes mellitus; and diseases of the circulatory organs. The figures for the latter two were especially high in GGM women.

The Finnish population of GM women represents 2.6 percent of all parturients during the study period in the north and 0.5 percent in the south (23Go). Longevity of women is poorer in the north of Finland than elsewhere (24Go) mainly because of 20–30 percent higher mortality from ischemic heart disease (25Go). This conforms to our finding of increased cardiovascular deaths in GM women, the majority of whom are from northern Finland.

Most GM women belong to the Laestadian movement within the Lutheran church. All kinds of contraception are forbidden; otherwise, however, the living habits of Laestadians do not differ markedly from those of other Finns. Smoking is permitted, but alcohol consumption is rare. The percentage of smokers (7 percent) among Finnish GM women during pregnancy is half that among all pregnant women (14 percent). Of GM women, about 50 percent were economically active in the 1990s and about 80 percent of them were entrepreneurs (mainly independent farmers) or white-collar workers. The respective proportions in the general female population were 75 percent and 65 percent. The GM women are nearly always married; during the mid-1990s, about 95 percent of the GM women were married, but, for all other parturients, the percentage was 67. The income of Finnish GM families may be satisfactory because of the allowance paid by the state for each child (23Go). Roos et al. (26Go) from Finland and Sweden demonstrated that married mothers who are employed had the best perceived health in both countries, whereas income status had only a small effect on that patterning. The net effects of those factors on mortality are difficult to determine. In addition, the primary health status of GM women is probably better than that of average Finnish women.

Perinatal mortality among Finnish GGM women was low in each birth category (1.1 percent for first-born and 1.6 percent for 10th- to 20th-born children). The frequency of large-for-gestational-age children increased respectively from 7.4 percent to 22.4 percent. The frequency of gestational diabetes and hypertensive disease increased with advancing number of deliveries (11Go). Such changes increase the risk of contracting diabetes (27Go, 28Go) or hypertensive and cardiovascular diseases (15Go, 29Go, 30Go) in older age.

Reliability regarding the causes of death listed in the national cause-of-death files was deemed adequate for our purposes. The agreement of diagnoses of myocardial infarction and stroke in the national death files with those in a large prospective study was reasonable (31Go), and a review of cardiovascular diagnoses on the death certificates confirmed 85 percent of them in autopsy (32Go). A recent comparison of death-certificate diagnoses of stroke with diagnoses made in an independent study found agreement in more than 90 percent of the instances (33Go). For cancer deaths, comparability of the official mortality statistics with cancer registry information, known to be very accurate, was already high in the 1970s (34Go). Although no validity studies pertaining to other diagnostic classifications are known to be available in this country, potential misclassification would be unlikely to introduce a bias regarding comparisons between multiparous and other women.

Of the decreased overall cancer mortality in our study (11 percent deficit; about 600 cases in absolute terms), 90 percent was attributable to breast, corpus uteri, and ovarian cancers. The specific hormonal milieu during pregnancy, repeated several times in GM women, may counteract malignant transformation in most gynecologic organs, with cervical cancer as the only exception (1Go, 4Go–6Go, 35Go). The standardized mortality ratio for all cancer mortality (SMR = 0.89) in our study was actually lower than that observed in Norwegian (SMR = 0.97) (20Go) and English (SMR = 0.97) (18Go) studies. There might be differences in lifestyle and social support of life between those countries. For example, smoking in general and especially by pregnant women is more common in Norway than in Finland (20Go, 36Go).

The standardized mortality ratios for breast cancer (SMR = 0.64) and corpus uteri cancer (SMR = 0.68) were somewhat higher than the respective standardized incidence ratios of 0.55 (95 percent CI: 0.52, 0.57) and 0.57 (95 percent CI: 0.52, 0.63) in our previous studies (1Go, 2Go). An explanation for this discrepancy regarding breast cancer may be a delayed diagnosis in GM women. The standardized mortality ratio for breast cancer in the present study (SMR = 0.64) was about the same as the standardized incidence ratios for advanced breast cancer in the earlier study; the standardized incidence ratio for breast cancer with regional metastases was 0.63 and for distant metastases was 0.66 (1Go). For corpus uteri cancer, the standardized incidence ratios did not vary by stage. The standardized mortality ratio (SMR = 1.10) for cervical cancer did not essentially differ from the respective standardized incidence ratio of 1.13 (95 percent CI: 0.98, 1.29) (3Go). It should be borne in mind that, in terms of cancer, incidence is more a reliable measure of disease occurrence and often gives different risk patterns than mortality does (37Go). The main reason is varying survival in population subgroups (38Go) and, sometimes, factors related to the choice of underlying cause of death when several causes are mentioned on the death certificate.

In our sample, mortality from cancer of the bladder was low, as was also found in previous studies (39Go, 40Go). Our investigation favors the hypothesis that oncogens in transitional cell tissue of the human bladder are influenced by sex hormones, and that the hormonal changes related to pregnancy thereby reduce the risk (39Go). The standardized mortality ratio (SMR = 0.59) appears to be too low to be explained by infrequent smoking alone, which is the most powerful, single factor in the etiology of bladder cancer (40Go).

Lung cancer was associated with a standardized mortality ratio of 0.80. The standardized mortality ratio for all other respiratory diseases was also 0.80. As explained above, pregnant women in Finland smoke less than nonpregnant women, and GGM women with a short interpregnancy interval (8.9 (standard deviation, 5.6) months) smoke less than women with fewer children (10Go). Our results differ from those observed by Kvale et al. (20Go), who noted increased mortality from all respiratory conditions—including asthma, pneumonia, bronchitis, and emphysema—and from lung cancer (standardized incidence ratio = 1.4) among GM women, which they attributed to the higher prevalence of smoking among Norwegian women than Finnish women (36Go). Our results support the hypothesis that estrogen and other steroid hormones in lung tissue may reduce the risk of lung cancer, as observed among the users of oral contraceptives or hormone replacement therapy (41Go–43Go).

The standardized mortality ratio for cancer of the colon was also slightly lowered. This finding was expected because the colonic epithelium is dependent on ovarian hormones (44Go–46Go).

Mortality from cancer of the kidney was 38 percent higher than the national average, which is in line with the 40 percent higher mortality from this cancer seen among Swedish GM women compared with nulliparous women (47Go). Some other studies did not show any association between risk of kidney cancer and number of pregnancies (18Go, 48Go). Chow et al. (49Go, 50Go) and Lindblad et al. (51Go) speculated that hormonal factors per se are important in the pathogenesis of this malignancy, and that obesity associated with childbearing may lead to a permanent hyperestrogenic environment and increased levels of insulin and insulin-like growth factors. These hormonal factors with hypertension during and after pregnancies might influence factors involved in renal carcinogenesis. Obesity (body mass index >30 kg/m2) has been found to increase the risk of kidney cancer (52Go).

As expected from previous works (17Go, 18Go, 20Go, 53Go), our study found a slightly increased risk of death from ischemic heart disease, cerebrovascular diseases, and diabetes mellitus. Pregnancy often induces diabetogenic and hypertensive changes, the likelihood of which increases with the number of pregnancies (9Go, 11Go, 15Go, 54Go, 55Go). Indeed, mortality from these diseases was markedly higher in GGM than in GM women. Repeated pregnancies increase the risk of hypertensive disorders and gestational diabetes, as shown by a Finnish study on GGM women, and they also cause a gradual and persistent increase in body weight (11Go). In all Finnish women, the prevalence of overweight increased gradually with the number of children (56Go). An average increase of 3.3 kg/m2 in body mass index between the first and sixth pregnancies was reported in Sweden (47Go). Parity has been found to explain the presence of obesity and greater central accumulation of body fat, a low concentration of high density lipoprotein cholesterol, and insulin resistance in women older than age 55 years (9Go, 56Go–59Go). The biologic effects of pregnancy may thus increase morbidity and mortality associated with several diseases years after the reproductive age ends (29Go).

Few studies have focused on number of children and the risk of dementia and Alzheimer's disease (61Go, 62Go). To our knowledge, the present finding of a markedly lowered risk of death from these conditions is new. In previous results, parous women, compared with nulliparous women, have had a higher risk of Alzheimer's disease (61Go–63Go). The role of ovarian hormones in neuroprotection has remained unclear despite intensive research (64Go, 65Go). Mothers who have many children live an active life, which might protect the brain and the nervous system from early degeneration. Having a large number of children is said to prevent suicides due to maternity (66Go, 67Go), not marriage per se (68Go). The 40 percent and 74 percent lower-than-expected risk of suicide for GM and GGM women, respectively, is in line with this hypothesis.

Heavy alcohol consumption during pregnancy is uncommon in Finland. It is likely to be most rare in the Finnish GM population, many of whom have a special religious persuasion. This finding could explain the low standardized mortality ratio (SMR = 0.69) for alcohol-related diseases and accidents.

Deaths from traffic accidents were common among the GM women. Many GM families live in the sparsely populated area of northern Finland, where distances are long and the families are therefore predisposed to traffic accidents.

In conclusion, Finnish GM women had slightly lower-than-average mortality (949 deaths fewer than expected), mainly from cancers (gynecologic and others), although this lower rate was partly outweighed by relatively high mortality from cardiovascular diseases and diabetes mellitus. Among women with at least 10 deliveries, overall mortality was totally offset by high mortality from the latter two causes. Suggested factors underlying the findings would be preventive effects of hormones on the development of cancers, and harmful effects of overweight on the pancreas and cardiovascular system. However, in the absence of individual data on possible confounders, the independent effect of parity remains open.


   ACKNOWLEDGMENTS
 
This study was supported by the Cancer Society of Finland and the Finnish Cultural Foundation.

Conflict of interest: none declared.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Hinkula M, Pukkala E, Kyyrönen P, et al. Grand multiparity and the risk of breast cancer; population-based study in Finland. Cancer Causes Control 2001;12:491–500.[CrossRef][Web of Science][Medline]
  2. Hinkula M, Pukkala E, Kyyrönen P, et al. Grand multiparity and incidence of endometrial cancer: a population-based study in Finland. Int J Cancer 2002;98:912–15.[CrossRef][Web of Science][Medline]
  3. Hinkula M, Pukkala E, Kyyrönen P, et al. A population-based study on the risk of cervical cancer and cervical intraepithelial neoplasia among grand multiparous women in Finland. Br J Cancer 2004;90:1025–9.[CrossRef][Web of Science][Medline]
  4. Pike MC. Reducing cancer risk in women through lifestyle-mediated changes in hormone levels. Cancer Detect Prev 1990;14:595–607.[Web of Science][Medline]
  5. Key TJ. Hormones and cancer in humans. Mutat Res 1995;333:59–67.[Web of Science][Medline]
  6. Russo IH, Russo J. Hormonal approach to breast cancer prevention. J Cell Biochem 2000;77:1–6.[Web of Science][Medline]
  7. Barrett JC, Barbara JD, Bennett LM. Pregnancy and protection from hormonally associated tumor development. Epidemiology 2003;14:139–40.[CrossRef][Web of Science][Medline]
  8. Fuchs K, Peretz BA, Marcovici R, et al. The "grand multipara"—is it a problem? A review of 5785 cases. Int J Gynaecol Obstet 1985;23:321–6.[CrossRef][Medline]
  9. Ness RB, Schotland HM, Flegal KM, et al. Reproductive history and coronary heart disease risk in women. Epidemiol Rev 1994;16:298–314.[Free Full Text]
  10. Juntunen K, Kirkinen P, Kauppila A. Natural interpregnancy intervals of fertile couples: a longitudinal survey of grand grand multiparous women. Fertil Steril 1994;62:722–5.[Web of Science][Medline]
  11. Juntunen K, Kirkinen P, Kauppila A. The clinical outcome in pregnancies of grand grand multiparous women. Acta Obstet Gynecol Scand 1997;76:755–9.[Web of Science][Medline]
  12. Abu-Heija AT, Chalabi HE. Great grand multiparity: is it a risk? Int J Gynaecol Obstet 1997;59:213–16.[CrossRef][Medline]
  13. Jousilahti P, Vartiainen E, Tuomilehto J, et al. Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14 786 middle-aged men and women in Finland. Circulation 1999;99:1165–72.[Abstract/Free Full Text]
  14. Babinszki A, Kerenyi T, Torok O, et al. Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors. Am J Obstet Gynecol 1999;181:669–74.[CrossRef][Web of Science][Medline]
  15. Lawlor DA, Emberson JR, Ebrahim S, et al. Is the association between parity and coronary heart disease due to biological effects of pregnancy or adverse lifestyle risk factors associated with child-rearing? Findings from the British Women's Heart and Health Study and the British Regional Heart Study. Circulation 2003;107:1260–4.[Abstract/Free Full Text]
  16. Roman H, Robillard PY, Verspyck E, et al. Obstetric and neonatal outcomes in grand multiparity. Obstet Gynecol 2004;103:1294–9.[CrossRef][Web of Science][Medline]
  17. Beral V. Long term effects of childbearing on health. J Epidemiol Community Health 1985;39:343–6.[Abstract/Free Full Text]
  18. Green A, Beral V, Moser K. Mortality in women in relation to their childbearing history. BMJ 1988;297:391–5.[Abstract/Free Full Text]
  19. Ness RB, Harris T, Cobb J, et al. Number of pregnancies and the subsequent risk of cardiovascular disease. N Engl J Med 1993;328:1528–33.[Abstract/Free Full Text]
  20. Kvale G, Heuch I, Nilssen S. Parity in relation to mortality and cancer incidence: a prospective study of Norwegian women. Int J Epidemiol 1994;23:691–9.[Abstract/Free Full Text]
  21. Klein BE, Klein R, Moss SE. Mortality and hormone-related exposures in women with diabetes. Diabetes Care 1999;22:248–52.[Abstract/Free Full Text]
  22. Grundy E, Tomassini E. Fertility history and health in later life: a record linkage study in England and Wales. Soc Sci Med 2005;61:217–28.[CrossRef][Web of Science][Medline]
  23. Stakes. Facts about Finnish social welfare and health care. (http://www.stakes.info/files/pdf/Raportit/Facts_2005.pdf).
  24. Valkonen T. Trends in regional and socio-economic mortality differentials in Finland. Int J Health Sci 1992;3:157–66.[Medline]
  25. Kaipio J, Näyhä S, Valtonen V. Fluoride in the drinking water and the geographical variation of coronary heart disease in Finland. Eur J Cardiovasc Risk Rehabil 2004;11:56–62.
  26. Roos E, Burström BO, Saastamoinen P, et al. A comparative study of the patterning of women's health by family status and employment status in Finland and Sweden. Soc Sci Med 2005;60:2443–51.[CrossRef][Web of Science][Medline]
  27. Dornhorst A, Rossi M. Risk and prevention of type 2 diabetes in women with gestational diabetes. Diabetes Care 1998;21(suppl 2):B43–9.
  28. Metzger BE, Cho NH, Roston SM, et al. Prepregnancy weight and antepartum insulin secretion predict glucose tolerance five years after gestational diabetes mellitus. Diabetes Care 1993;16:1598–605.[Abstract]
  29. Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? BMJ 2002;325:157–60.[Free Full Text]
  30. Ramsay JE, Ferrell WR, Crawford L, et al. Maternal obesity is associated with dysregulation of metabolic, vascular, and inflammatory pathways. J Clin Endocrinol Metab 2002;87:4231–7.[Abstract/Free Full Text]
  31. Heliövaara M, Reunanen A, Aromaa A, et al. Validity of hospital discharge data in a prospective epidemiological study on stroke and myocardial infarction. Acta Med Scand 1984;216:309–15.[Web of Science][Medline]
  32. Stenbäck F. Accuracy of antemortem diagnosis in the north. An autopsy study. Arctic Med Res 1986;41:9–15.[Medline]
  33. Leppälä JM, Virtamo J, Heinonen OP. Validation of stroke diagnosis in the National Hospital Discharge Register and the Register of Causes of Death in Finland. Eur J Epidemiol 1999;15:155–60.[CrossRef][Web of Science][Medline]
  34. Saxen EA. The cancer registry in cancer control. Arch Geschwulstforsch 1984;54:403–8.[Web of Science][Medline]
  35. Nair BS, Pillai R. Oncogenesis of squamous carcinoma of the uterine cervix. Int J Gynaecol Pathol 1992;11:47–57.[Web of Science][Medline]
  36. Pukkala E, Söderman B, Okeanov A, et al. Cancer atlas of northern Europe. Helsinki, Finland: Cancer Society of Finland, 2001. (Publication no. 62).
  37. Hakama M, Hakulinen T, Teppo L, et al. Incidence, mortality or prevalence as indicators of the cancer problem. Cancer 1975;36:2227–31.[Web of Science][Medline]
  38. Auvinen A, Karjalainen S. Possible explanations for social class differences in cancer patient survival. IARC Sci Publ 1997;138:377–97.
  39. Cantor KP, Lynch CF, Johnson D. Bladder cancer, parity, and age at first birth. Cancer Causes Control 1992;3:57–62.[CrossRef][Web of Science][Medline]
  40. Pelucchi C, La Vecchia C, Negri E, et al. Smoking and other risk factors for bladder cancer in women. Prev Med 2002;35:114–20.[CrossRef][Web of Science][Medline]
  41. Brenner AV, Wang Z, Kleinerman RA, et al. Menstrual and reproductive factors and risk of lung cancer among Chinese women, Eastern Gansu Province, 1994–1998. J Epidemiol 2003;13:22–8.[Web of Science][Medline]
  42. Caracta CF. Gender differences in pulmonary disease. Mt Sinai J Med 2003;70:215–24.[Medline]
  43. Kreuzer M, Gerken M, Heinrich J, et al. Hormonal factors and risk of lung cancer among women? Int J Epidemiol 2003;32:263–71.[Abstract/Free Full Text]
  44. Talamini R, Franceschi S, Dal Maso L, et al. The influence of reproductive and hormonal factors on the risk of colon and rectal cancer in women. Eur J Cancer 1998;34:1070–6.[CrossRef][Web of Science][Medline]
  45. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321–33.[Abstract/Free Full Text]
  46. Cantor KP, Lynch CF, Johnson D. Reproductive factors and risk of brain, colon, and other malignancies in Iowa (United States). Cancer Causes Control 1993;4:505–11.[CrossRef][Web of Science][Medline]
  47. Lambe M, Lindblad P, Wuu J, et al. Pregnancy and risk of renal cell cancer: a population-based study in Sweden. Br J Cancer 2002;86:1425–9.[CrossRef][Web of Science][Medline]
  48. Mellemgaard A, Engholm G, McLaughlin JK, et al. Risk factors for renal-cell carcinoma in Denmark. III. Role of weight, physical activity and reproductive factors. Int J Cancer 1994;56:66–71.[Web of Science][Medline]
  49. Chow WH, McLaughlin JK, Mandel JS, et al. Reproductive factors and the risk of renal cell cancer among women. Int J Cancer 1995;60:321–4.[Web of Science][Medline]
  50. Chow WH, McLaughlin JK, Mandel JS, et al. Risk of renal cell cancer in relation to diuretics, antihypertensive drugs, and hypertension. Cancer Epidemiol Biomarkers Prev 1995;4:327–31.[Abstract]
  51. Lindblad P, Mellemgaard A, Schlehofer B, et al. International renal-cell cancer study. V. Reproductive factors, gynecologic operations and exogenous hormones. Int J Cancer 1995;61:192–8.[Web of Science][Medline]
  52. Bianchini F, Kaaks R, Vainio H. Overweight, obesity, and cancer risk. Lancet Oncol 2002;3:565–74.[CrossRef][Web of Science][Medline]
  53. Qureshi AI, Giles WH, Croft JB, et al. Number of pregnancies and risk for stroke and stroke subtypes. Arch Neurol 1997;54:203–6.[Abstract/Free Full Text]
  54. Juntunen KST, Laara EMJ, Kauppila AJI. Grand grand multiparity and birth weight. Obstet Gynecol 1997;90:495–9.[CrossRef][Web of Science][Medline]
  55. Wolfe WS, Sobal J, Olson CM, et al. Parity-associated weight gain and its modification by sociodemographic and behavioral factors: a prospective analysis in US women. Int J Obes Relat Metab Disord 1997;21:802–10.[CrossRef][Web of Science][Medline]
  56. Rissanen AM, Heliövaara M, Knekt P, et al. Determinants of weight gain and overweight in adult Finns. Eur J Clin Nutr 1991;45:419–30.[Web of Science][Medline]
  57. Rissanen A, Knekt P, Heliovaara M, et al. Weight and mortality in Finnish women. J Clin Epidemiol 1991;44:787–95.[CrossRef][Web of Science][Medline]
  58. Laara E, Rantakallio P. Body size and mortality in women: a 29 year follow up of 12,000 pregnant women in northern Finland. J Epidemiol Community Health 1996;50:408–14.[Abstract/Free Full Text]
  59. Humphries KH, Westendorp IC, Bots ML, et al. Parity and carotid artery atherosclerosis in elderly women: The Rotterdam Study. Stroke 2001;32:2259–64.[Abstract/Free Full Text]
  60. Laitinen J, Power C, Jarvelin MR. Family social class, maternal body mass index, childhood body mass index, and age at menarche as predictors of adult obesity. Am J Clin Nutr 2001;74:287–94.[Abstract/Free Full Text]
  61. Ptok U, Barkow K, Heun R. Fertility and number of children in patients with Alzheimer's disease. Arch Women Ment Health 2002;5:83–6.[CrossRef][Medline]
  62. McLay RN, Maki PM, Lyketsos CG. Nulliparity and late menopause are associated with decreased cognitive decline. J Neuropsychiatry Clin Neurosci 2003;15:161–7.[Abstract/Free Full Text]
  63. Hankinson SE, Colditz GA, Hunter DJ, et al. Reproductive factors and family history of breast cancer in relation to plasma estrogen and prolactin levels in postmenopausal women in the Nurses' Health Study (United States). Cancer Causes Control 1995;6:217–24.[CrossRef][Web of Science][Medline]
  64. Hogervorst E, Williams J, Budge M, et al. The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: a meta-analysis. Neuroscience 2000;101:485–512.[CrossRef][Web of Science][Medline]
  65. Garcia-Segura LM, Azcoitia I, DonCarlos LL. Neuroprotection by estradiol. Prog Neurobiol 2001;63:29–60.[CrossRef][Web of Science][Medline]
  66. Hoyer G, Lund E. Suicide among women related to number of children in marriage. Arch Gen Psychiatry 1993;50:134–7.[Abstract/Free Full Text]
  67. Qin P, Mortensen PB. The impact of parental status on the risk of completed suicide. Arch Gen Psychiatry 2003;60:797–802.[Abstract/Free Full Text]
  68. Durkheim E. Le suicide (Paris, 1897). Translated by Spalding JA and Simpson G as Suicide: a study in sociology. New York, NY: Free Press of Glenco, 1951.

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 J. Epidemiol. Community HealthHome page
E Koch, M Bogado, F Araya, T Romero, C Diaz, L Manriquez, M Paredes, C Roman, A Taylor, and A Kirschbaum
Impact of parity on anthropometric measures of obesity controlling by multiple confounders: a cross-sectional study in Chilean women
J Epidemiol Community Health, May 1, 2008; 62(5): 461 - 470.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
163/4/367    most recent
kwj048v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (5)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Hinkula, M.
Right arrow Articles by Pukkala, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Hinkula, M.
Right arrow Articles by Pukkala, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?