We aimed to examine the long-term effects of parity, age at first childbirth, and age at last childbirth on later-life health-related quality of life (HRQoL) in postmenopausal women.
Materials and Methods:
The Women’s Health Initiative data included 15,416 postmenopausal women with repeated measures in HRQoL. We used propensity score matching to create matched samples, where each exposure group was matched with a reference group based on their propensity scores. We employed mixed-effects models to examine the associations of parity and age at childbirth with HRQoL. We performed multiple mediation analyses to assess the effects of potential mediators on the associations.
Results:
The overall HRQoL scores of women with parity of 4 and 5+ compared to parity of 2 significantly increased by 1.4 (95% confidence interval [CI]: 0.56–2.24) and 1.3 (95% CI: 0.36–2.24), respectively. Having the last childbirth after 40 was associated with increased overall HRQoL by 2.2 (95% CI: 0.50–4.4). However, the HRQoL for women with age at first childbirth of <20 was reduced by 2.7 (95% CI: 1.66–3.74) compared to age at first childbirth of 25–29. In multiple mediation analyses, we identified the path: age at first childbirth of <20 → premature menopause → reduced HRQoL.
Conclusions:
The mixed-effects models demonstrated that age at first childbirth of <20 was related to decreased HRQoL over time, while parity of 4 and ≥5 and late age at last childbirth were associated with increased HRQoL. Premature menopause significantly mediated the association between young age at first childbirth and reduced HRQoL.
KarimiM, BrazierJ. Health, health-related quality of life, and quality of life: What is the difference? Pharmacoeconomics, 2016; 34(7):645–649; doi: 10.1007/s40273-016-0389-9
2.
ParkS, ChoiN-K. The relationships between timing of first childbirth, parity, and health-related quality of life. Qual Life Res, 2018; 27(4):937–943; doi: 10.1007/s11136-017-1775-4
3.
McAuliffeFM. Impact of pregnancy on long-term health: Advances in postpregnancy care—An opportunity to improve long-term maternal health. Int J Gynaecol Obstet, 2023; 160(Suppl 1):4–6; doi: 10.1016/j.bpobgyn.2022.11.001
4.
Coussons-ReadME. Effects of prenatal stress on pregnancy and human development: Mechanisms and pathways. Obstet Med, 2013; 6(2):52–57; doi: 10.1177/1753495X13485749
5.
SetseR, GroganR, PhamL, et al.Longitudinal study of depressive symptoms and health-related quality of life during pregnancy and after delivery: The Health Status in Pregnancy (HIP) study. Matern Child Health J, 2009; 13(5):577–587; doi: 10.1007/s10995-008-0392-7
6.
WikH, EndenT, JacobsenA, et al.Long-term quality of life after pregnancy-related deep vein thrombosis and the influence of socioeconomic factors and comorbidity. J Thromb Haemost, 2011; 9(10):1931–1936; doi: 10.1111/j.1538-7836.2011.04466.x
7.
HandaVL, ZyczynskiHM, BurgioKL, et al.; Pelvic Floor Disorders Network. The impact of fecal and urinary incontinence on quality of life 6 months after childbirth. Am J Obstet Gynecol, 2007; 197(6):636.e1–636.e6; doi: 10.1016/j.ajog.2007.08.036
8.
ChoiJI, KimSJ, KimMJ, et al.Relationship between delivery history and health-related quality of life in menopausal South Korean women: The Korea National Health and Nutrition Examination Surveys. Maturitas, 2016; 92:24–29; doi: 10.1016/j.maturitas.2016.07.009
9.
LiW-Y, LiabsuetrakulT, Stray-PedersenB, et al.The effects of mode of delivery and time since birth on chronic pelvic pain and health-related quality of life. Int J Gynaecol Obstet, 2014; 124(2):139–142; doi: 10.1016/j.ijgo.2013.08.020
10.
CarlanderA-KK, AndolfE, EdmanG, et al.Health-related quality of life five years after birth of the first child. Sex Reprod Healthc, 2015; 6(2):101–107; doi: 10.1016/j.srhc.2015.01.002
11.
AbbaspoorZ, RazmjuPS, HekmatK. Relation between quality of life and mental health in pregnant women with prior pregnancy loss. J Obstet Gynaecol Res, 2016; 42(10):1290–1296; doi: 10.1111/jog.13041
12.
NeigerR. Long-term effects of pregnancy complications on maternal health: A review. J Clin Med, 2017; 6(8):76; doi: 10.3390/jcm6080076
13.
NazarpourS, SimbarM, Ramezani TehraniF, et al.Factors associated with quality of life of postmenopausal women living in Iran. BMC Womens Health, 2020; 20(1):104–109; doi: 10.1186/s12905-020-01077-8
14.
Mohammad-Alizadeh-CharandabiS, RezaeiN, HakimiS, et al.Predictors of health-related quality of life in postmenopausal women: A population-based study. J Caring Sci, 2012; 1(4):201–208; doi: 10.5681/jcs.2012.029
15.
ShobeiriF, JenabiE, HazaveheiSMM, et al.Quality of life in postmenopausal women in Iran: A population-based study. J Menopausal Med, 2016; 22(1):31–38; doi: 10.6118/jmm.2016.22.1.31
16.
Study TWsHI. Design of the Women’s Health Initiative clinical trial and observational study. Control Clin Trials, 1998; 19(1):61–109; doi: 10.1016/S0197-2456(97)00078-0
17.
FixJ, DonneyongMM, RappSR, et al.Predictors of influenza and pneumococcal vaccination among participants in the Women’s Health Initiative. Public Health Rep, 2023; 138(2):281–291; doi: 10.1177/00333549231158001
18.
WrightCE, EnquobahrieDA, PragerS, et al.Pregnancy loss and risk of incident CVD within 5 years: Findings from the Women’s Health Initiative. Front Cardiovasc Med, 2023; 10:1108286; doi: 10.3389/fcvm.2023.1108286
19.
ShadyabAH, GassML, StefanickML, et al.Maternal age at childbirth and parity as predictors of longevity among women in the United States: The Women’s Health Initiative. Am J Public Health, 2017; 107(1):113–119; doi: 10.2105/AJPH.2016.303503
20.
ParikhNI, CnattingiusS, DickmanPW, et al.Parity and risk of later-life maternal cardiovascular disease. Am Heart J, 2010; 159(2):215–221.e6; doi: 10.1016/j.ahj.2009.11.018
21.
AndersonGL, MansonJ, WallaceR, et al.Implementation of the Women’s Health Initiative study design. Ann Epidemiol, 2003; 13(9 Suppl):S5–S17; doi: 10.1016/S1047-2797(03)00043-7
22.
QureshiAI, SaeedO, MalikAA, et al.Pregnancy in advanced age and the risk of stroke in postmenopausal women: Analysis of Women’s Health Initiative Study. Am J Obstet Gynecol, 2017; 216(4):409.e1–409.e6; doi: 10.1016/j.ajog.2016.11.1078
23.
Open-AccessmanL, BraconiF. Gentrification and displacement: New York City in the 1990s. J Am Plann Assoc, 2004; 70(1):39–52; doi: 10.1080/01944360408976337
24.
HaysRD, SherbourneCD, MazelRM. The RAND 36‐item health survey 1.0. Health Econ, 1993; 2(3):217–227; doi: 10.1002/hec.4730020305
25.
StewartAL, WareJE. Measuring functioning and well-being: The medical outcomes study approach. Durham, NC: Duke University Press; 1992.
26.
FrameworkIC. The MOS 36-item short-form health survey (SF-36). Med Care, 1992; 30(6):473–483; doi: 10.1097/00005650-199206000-00002
27.
GuyattGH, OsobaD, WuAW, et al.; Clinical Significance Consensus Meeting Group. Methods to explain the clinical significance of health status measures. Mayo Clin Proc, 2002; 77(4):371–383; doi: 10.4065/77.4.371
28.
ZaslavskyO, WoodsNF, LaCroixAZ, et al.Identification of risk factors for mortality and poor-quality-of-life survival in frail older women participating in the Women’s Health Initiative Observational Study. J Am Geriatr Soc, 2016; 64(4):831–837; doi: 10.1111/jgs.14068
29.
HaysRD, ShapiroMF. An overview of generic health-related quality of life measures for HIV research. Qual Life Res, 1992; 1(2):91–97; doi: 10.1007/BF00439717
30.
AppiahD, KimC, FuquayT, et al.Maternal age at birth of last child and cardiovascular disease mortality later in life among a national cohort of postmenopausal women from the United States. Menopause, 2023; 30(4):393–400; doi: 10.1097/GME.0000000000002183
31.
PeilaR, XueX, QiQ, et al.Healthy lifestyle index and risk of cardiovascular disease among postmenopausal women with normal body mass index. J Am Heart Assoc, 2023; 12(12):e029111; doi: 10.1161/JAHA.123.029111
32.
AustinPC, YuAYX, VyasMV, et al.Applying propensity score methods in clinical research in neurology. Neurology, 2021; 97(18):856–863; doi: 10.1212/WNL.0000000000012547
33.
MaoH, LiL. Flexible regression approach to propensity score analysis and its relationship with matching and weighting. Stat Med, 2020; 39(15):2017–2034; doi: 10.1002/sim.8548
34.
NianH, YuC, DingJ, et al.Performance evaluation of propensity score methods for estimating average treatment effects with multi-level treatments. J Appl Stat, 2019; 46(5):853–873; doi: 10.1080/02664763.2018.1511540
35.
LiF, LiF. Propensity score weighting for causal inference with multiple treatments. ArXiv, 2019preprint arXiv:1908.11652,
36.
AhmedA, HusainA, LoveTE, et al.Heart failure, chronic diuretic use, and increase in mortality and hospitalization: An observational study using propensity score methods. Eur Heart J, 2006; 27(12):1431–1439; doi: 10.1093/eurheartj/ehl012
37.
AronowHD, TopolEJ, RoeMT, et al.Effect of lipid-lowering therapy on early mortality after acute coronary syndromes: An observational study. Lancet, 2001; 357(9262):1063–1068; doi: 10.1016/S0140-6736(00)04208-5
38.
GreiferN. Covariate balance tables and plots: A guide to the cobalt package. R J, 2020; 12(1):175–184.
39.
RandolphJJ, FalbeK. A step-by-step guide to propensity score matching in R. Pract Assess Res Eval, 2014; 19(1):18.
40.
WestBT, WelchKB, GaleckiAT. Linear mixed models: A practical guide using statistical software. 2nd ed. Boca Raton, FL: CRC Press; 2022.
41.
KirkegaardH, BliddalM, StøvringH, et al.Breastfeeding and later maternal risk of hypertension and cardiovascular disease: The role of overall and abdominal obesity. Prev Med, 2018; 114:140–148; doi: 10.1016/j.ypmed.2018.06.010
42.
KlingbergS, BrekkeHK, WinkvistA, et al.Parity, weight change, and maternal risk of cardiovascular events. Am J Obstet Gynecol, 2017; 216(2):172.e1–172.e15; doi: 10.1016/j.ajog.2016.09.099
43.
MukaT, Oliver-WilliamsC, KunutsorS, et al.Association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality: A systematic review and meta-analysis. JAMA Cardiol, 2016; 1(7):767–776; doi: 10.1001/jamacardio.2016.2415
44.
BaronRM, KennyDA. The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. J Pers Soc Psychol, 1986; 51(6):1173–1182; doi: 10.1037/0022-3514.51.6.1173
45.
ShroutPE, BolgerN. Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychol Methods, 2002; 7(4):422–445; doi: 10.1037/1082-989X.7.4.422
46.
VanderWeeleTJ. Mediation analysis: A practitioner’s guide. Annu Rev Public Health, 2016; 37:17–32; doi: 10.1146/annurev-publhealth-032315-021402
47.
LiSD. Testing mediation using multiple regression and structural equation modeling analyses in secondary data. Eval Rev, 2011; 35(3):240–268; doi: 10.1177/0193841X11412037
48.
ReinholdS, GegenfurtnerA, LewalterD. Social support and motivation to transfer as predictors of training transfer: Testing full and partial mediation using meta-analytic structural equation modelling. Int J Training Development, 2018; 22(1):1–14; doi: 10.1111/ijtd.12114
49.
TingleyD, YamamotoT, HiroseK, et al.Package ‘mediation.’. Computer software manual. 2019:175–184.
50.
BlazekK, van ZwietenA, SaglimbeneV, et al.A practical guide to multiple imputation of missing data in nephrology. Kidney Int, 2021; 99(1):68–74; doi: 10.1016/j.kint.2020.08.019
51.
HankK. Childbearing history, later-life health, and mortality in Germany. Popul Stud (Camb), 2010; 64(3):275–291; doi: 10.1080/00324728.2010.510202
52.
KingtonR, LillardL, RogowskiJ. Reproductive history, socioeconomic status, and self-reported health status of women aged 50 years or older. Am J Public Health, 1997; 87(1):33–37; doi: 10.2105/AJPH.87.1.33
53.
SpenceNJ. The long-term consequences of childbearing: Physical and psychological well-being of mothers in later life. Res Aging, 2008; 30(6):722–751; doi: 10.1177/0164027508322575
54.
BattulgaB, BenjaminMR, ChenH, et al.The impact of social support and pregnancy on subjective well-being: A systematic review. Front Psychol, 2021; 12:710858; doi: 10.3389/fpsyg.2021.710858
55.
Al-MutawtahM, CampbellE, KubisH-P, et al.Women’s experiences of social support during pregnancy: A qualitative systematic review. BMC Pregnancy Childbirth, 2023; 23(1):782; doi: 10.1186/s12884-023-05975-w
56.
XingZ, KirbyR. Parity, age at childbirth, and premature menopause, hysterectomy, and bilateral oophorectomy before age 40. J Women Health Care, 2023; 40(3):1999–2018; doi: 10.1186/s40748-023-00201-3
XingZ, AlmanAC, KirbyRS. Premature menopause and all-cause mortality and life span among women older than 40 years in the NHANES I Epidemiologic Follow-Up Study: Propensity score matching analysis. J Womens Health (Larchmt), 2023; 32(9):950–959; doi: 10.1089/jwh.2022.0110
59.
SamsaG, EdelmanD, RothmanML, et al.Determining clinically important differences in health status measures: A general approach with illustration to the Health Utilities Index Mark II. Pharmacoeconomics, 1999; 15(2):141–155; doi: 10.2165/00019053-199915020-00003
60.
NormanGR, SloanJA, WyrwichKW. Interpretation of changes in health-related quality of life: The remarkable universality of half a standard deviation. Med Care, 2003; 41(5):582–592; doi: 10.1097/01.MLR.0000062554.74615.4C
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