Parity, Job Strain, and Cardiovascular Risk in the Women’s Health Study

  • Eva M. DurazoEmail author
  • Tomás Cabeza de Baca
  • Natalie Slopen
  • Nisha I. Parikh
  • Julie E. Buring
  • Robert J. Glynn
  • Michelle A. Albert
Women and Heart Disease (E. Jackson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Women and Heart Disease


Purpose of Review

Pregnancy and employment are critical life events that can affect chronic disease risk in women. Hence, we examined the relationship between parity and cardiovascular risk, and whether job stress affected this association.

Recent Findings

Cox proportional hazard models examined the association of parity with cardiovascular disease (CVD) risk [myocardial infarction (MI), coronary artery revascularization, ischemic stroke, and CVD death] in 23,905 participants in the Women’s Health Study. Parity was defined at baseline as pregnancy lasting > 6 months gestation, categorized as none (referent), 1–2, 3–4, and 5+. Job strain assessed at year 5 was operationalized using the Karasek job strain model, and job insecurity was defined based on the item “My job security is good” (yes or no). The mean age of the women at baseline was 57.3 ± 5.2 years with an average follow-up for CVD of 16 years. In models adjusted for age, race/ethnicity, income, education, CVD risk factors, and age of menarche, increasing parity was associated with increased CVD risk compared to no pregnancies [hazard ratio (HR), 95% confidence interval (CI) 1.15, 0.94–1.41 (1–2 pregnancies); 1.29, 1.06–1.58 (3–4 pregnancies); 1.52, 1.20–1.93 (5+ pregnancies)]. Further adjustment for job strain did not attenuate the noted relationship (HR, 95% CI 1.15, 0.94–1.41 (1–2 pregnancies); 1.30, 1.06–1.58 (3–4 pregnancies); 1.52, 1.20–1.93 (5+ pregnancies). There was no significant interaction between job strain (p = 0.68) or job insecurity (p = 0.97) and parity.


Among working women, increased parity was related to heightened CVD risk, a relationship that was not attenuated by job strain or job insecurity.


Pregnancy Cardiovascular disease Job stress Parity 



We would like to thank the participants of the Women’s Health Study.

Funding Information

The Women’s Health Study is supported by grants HL080467, HL099355, HL043851, CA047988, and UM1- CA182913 from the National Heart, Lung, and Blood Institute and the National Cancer Institute. This study is funded by NIH RO1 grant AG038492 (Dr. MA Albert). Dr. Cabeza de Baca was partially supported by a National Institute of Mental Health training grant T32-MH019391.

Compliance with Ethical Standards

Conflict of Interest

Eva M. Durazo, Tomás Cabeza de Baca, Natalie Slopen, Nisha I. Parikh, Julie E. Buring, Robert J. Glynn, and Michelle A. Albert declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Women in the labor force: A databook. US Bur Labor Stat Rep. 2014;1052:1–107.Google Scholar
  2. 2.
    Table 5. Employment status of the population by sex, marital status, and presence and age of own children under 18, 2014–2015 annual averages [Internet]. Bureau of Labor Statistics; 2015 [cited 2016 Sep 2]. Available from:
  3. 3.
    • Slopen N, Glynn RJ, Buring JE, Lewis TT, Williams DR, Albert MA. Job strain, job insecurity, and incident cardiovascular disease in the Women’s Health Study: results from a 10-year prospective study. PLoS One. 2012;7:e40512. In this prospective study, Slopen et al. showcased that psychosocial factors, such as job strain, played a considerable role in the incident risk of cardiovascular disease among women CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Parikh NI, Cnattingius S, Dickman PW, Mittleman MA, Ludvigsson JF, Ingelsson E. Parity and risk of later-life maternal cardiovascular disease. Am Heart J. 2010;159:215–221.e6.CrossRefPubMedGoogle Scholar
  5. 5.
    Sanghavi M, Kulinski J, Ayers CR, Nelson D, Stewart R, Parikh N, et al. Association between number of live births and markers of subclinical atherosclerosis: the Dallas Heart Study. Eur J Prev Cardiol. 2016;23:391–9.CrossRefPubMedGoogle Scholar
  6. 6.
    • Ness RB, Harris T, Cobb J, Flegal KM, Kelsey JL, Balanger A, et al. Number of pregnancies and the subsequent risk of cardiovascular disease. N Engl J Med. 1993;328:1528–33. In their landmark study, Ness et al. were able to support the parity and cardiovascular disease association using a large sample of physician-validated cardiovascular endpoints CrossRefPubMedGoogle Scholar
  7. 7.
    Wong JA, Rexrode KM, Sandhu RK, Conen D, Albert CM. Number of pregnancies and atrial fibrillation risk: the Women’s Health Study. Circulation. 2017;135:622–4.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kivimäki M, Nyberg ST, Batty GD, Fransson EI, Heikkilä K, Alfredsson L, et al. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data. Lancet. 2012;380:1491–7.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kivimäki M, Kawachi I. Work stress as a risk factor for cardiovascular disease. Curr Cardiol Rep. 2015;17(9):74.Google Scholar
  10. 10.
    Nyberg ST, Fransson EI, Heikkilä K, Alfredsson L, Casini A, Clays E, et al. Job strain and cardiovascular disease risk factors: meta-analysis of individual-participant data from 47,000 men and women. PLoS One. 2013;8:e67323.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Jacobs AS, Bailey Z, Albert MA. Job burnout, job stress and cardiovascular disease. In: Nanda NC, Kesser N, editors. Heart disease in women. New Delhi: Jaypee Brothers Medical Publishers; 2015.Google Scholar
  12. 12.
    Mutambudzi M, Meyer JD, Warren N, Reisine S. Effects of psychosocial characteristics of work on pregnancy outcomes: a critical review. Women Health. 2011;51:279–97.CrossRefPubMedGoogle Scholar
  13. 13.
    Loomans EM, van Dijk AE, Vrijkotte TGM, van Eijsden M, Stronks K, Gemke RJBJ, et al. Psychosocial stress during pregnancy is related to adverse birth outcomes: results from a large multi-ethnic community-based birth cohort. Eur J Pub Health. 2013;23:485–91.CrossRefGoogle Scholar
  14. 14.
    Vrijkotte TGM, van der Wal MF, van Eijsden M, Bonsel GJ. First-trimester working conditions and birthweight: a prospective cohort study. Am J Public Health. 2009;99:1409–16.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Larsen AD, Schlünssen V, Christensen BH, Peter BJ, Obel C, Thulstrup AM, et al. Exposure to psychosocial job strain during pregnancy and odds of asthma and atopic dermatitis among 7-year old children—a prospective cohort study. Scand J Work Environ Health. 2014;40:639–48.CrossRefPubMedGoogle Scholar
  16. 16.
    Ridker PM, Cook NR, Lee I-M, Gordon D, Gaziano JM, Manson JE, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293–304.CrossRefPubMedGoogle Scholar
  17. 17.
    Rexrode KM, Lee I-M, Cook NR, Hennekens CH, Buring JE. Baseline characteristics of participants in the Women’s Health Study. J Womens Health Gend Based Med. 2000;9:19–27.CrossRefPubMedGoogle Scholar
  18. 18.
    Karasek RA, Theorell T. Healthy work: stress, productivity, and the reconstruction of working life. New York: Basic books; 1992.Google Scholar
  19. 19.
    Lee S, Colditz G, Berkman LF, Kawachi I. Prospective study of job insecurity and coronary heart disease in US women. Ann Epidemiol. 2004;14:24–30.CrossRefPubMedGoogle Scholar
  20. 20.
    Hanson HA, Smith KR, Zimmer Z. Reproductive history and later-life comorbidity trajectories: a Medicare-linked cohort study from the Utah population database. Demography. 2015;52:2021–49.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Canoy D, Beral V, Balkwill A, Wright FL, Kroll ME, Reeves GK, et al. Age at menarche and risks of coronary heart and other vascular diseases in a large UK cohort. Circulation. 2015;131:237–44.CrossRefPubMedGoogle Scholar
  22. 22.
    Frontini MG, Srinivasan SR, Berenson GS. Longitudinal changes in risk variables underlying metabolic Syndrome X from childhood to young adulthood in female subjects with a history of early menarche: the Bogalusa Heart Study. Int J Obes. 2003;27:1398–404.CrossRefGoogle Scholar
  23. 23.
    Feng Y, Hong X, Wilker E, Li Z, Zhang W, Jin D, et al. Effects of age at menarche, reproductive years, and menopause on metabolic risk factors for cardiovascular diseases. Atherosclerosis. 2008;196:590–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of menarcheal age to obesity in childhood and adulthood: the Bogalusa heart study. BMC Pediatr. 2003;3Google Scholar
  25. 25.
    Lv H, Wu H, Yin J, Qian J, Ge J. Parity and cardiovascular disease mortality: a dose-response meta-analysis of cohort studies. Sci Rep. 2015;5:13411.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Parikh NI, Jeppson RP, Berger JS, Eaton CB, Kroenke CH, LeBlanc ES, et al. Reproductive risk factors and coronary heart disease in the Women’s Health Initiative Observational Study. Circulation. 2016;133:2149–58.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Elajami TK, Giuseffi J, Avila MD, Hovnanians N, Mukamal KJ, Parikh N, et al. Parity, coronary heart disease and mortality in the old order Amish. Atherosclerosis. 2016;254:14–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Vladutiu CJ, Siega-Riz AM, Sotres-Alvarez D, Stuebe AM, Ni A, Tabb KM, et al. Parity and components of the metabolic syndrome among US Hispanic/Latina women: results from the Hispanic Community Health Study/Study of Latinos. Circ Cardiovasc Qual Outcomes. 2016;9:S62–9.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Ziomkiewicz A, Sancilio A, Galbarczyk A, Klimek M, Jasienska G, Bribiescas RG. Evidence for the cost of reproduction in humans: high lifetime reproductive effort is associated with greater oxidative stress in post-menopausal women. PLoS One. 2016;11:e0145753.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000;342:836–43.CrossRefPubMedGoogle Scholar
  31. 31.
    Albert MA. The role of C-reactive protein in cardiovascular disease risk. Curr Cardiol Rep. 2000;2:274–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Blake GJ, Ridker PM. C-reactive protein and other inflammatory risk markers in acute coronary syndromes. J Am Coll Cardiol. 2003;41:S37–42.CrossRefGoogle Scholar
  33. 33.
    Cimmino G, Loffredo F, Morello A, d’ Elia S, De Palma R, Cirillo P, et al. Immune-inflammatory activation in acute coronary syndromes: a look into the heart of unstable coronary plaque. Curr Cardiol Rev. 2016;12:1–1.CrossRefGoogle Scholar
  34. 34.
    Lawlor DA, Emberson JR, Ebrahim S, Whincup PH, Wannamethee SG, Walker M, 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.CrossRefPubMedGoogle Scholar
  35. 35.
    Manczak EM, DeLongis A, Chen E. Does empathy have a cost? Diverging psychological and physiological effects within families. Health Psychol. 2016;35:211–8.CrossRefPubMedGoogle Scholar
  36. 36.
    • Magnus MC, Iliodromiti S, Lawlor DA, Catov JM, Nelson SM, Fraser A. Number of offspring and cardiovascular disease risk in men and women: the role of shared lifestyle characteristics. Epidemiology 2017;1. Using a prospective sample of men and women, Magnus and colleagues tested potential cardiometabolic and lifestyle mechanisms as explanations for the parity-CVD relationship.Google Scholar
  37. 37.
    Eghbali M, Deva R, Alioua A, Minosyan TY, Ruan H, Wang Y, et al. Molecular and functional signature of heart hypertrophy during pregnancy. Circ Res. 2005;96:1208–16.CrossRefPubMedGoogle Scholar
  38. 38.
    Li J, Umar S, Amjedi M, Iorga A, Sharma S, Nadadur RD, et al. New frontiers in heart hypertrophy during pregnancy. Am J Cardiovasc Dis. 2012;2:192–207.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Parikh NI, Lloyd-Jones DM, Ning H, Ouyang P, Polak JF, Lima JA, et al. Association of number of live births with left ventricular structure and function. The Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J. 2012;163:470–6.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Eva M. Durazo
    • 1
    Email author
  • Tomás Cabeza de Baca
    • 1
  • Natalie Slopen
    • 2
  • Nisha I. Parikh
    • 1
  • Julie E. Buring
    • 3
    • 4
  • Robert J. Glynn
    • 3
  • Michelle A. Albert
    • 1
  1. 1.Division of Cardiology, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of Epidemiology and BiostatisticsUniversity of Maryland College Park, School of Public HealthCollege ParkUSA
  3. 3.Division of Preventive Medicine, Department of MedicineBrigham & Women’s Hospital, Harvard Medical SchoolBostonUSA
  4. 4.Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonUSA

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