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Gravidity, Parity, Blood Pressure and Mortality Among Women in Bangladesh from the HEALS Cohort

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Gravidity, Parity, Blood Pressure and Mortality Among Women in Bangladesh from the HEALS Cohort Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-037244 on 26 August 2020. Downloaded from Gravidity, parity, blood pressure and mortality among women in Bangladesh from the HEALS cohort Yu- Hsuan Shih ,1 Molly Scannell Bryan,2 Faruque Parvez,3 Keriann Hunter Uesugi,1 Mohammed Shahriar,4 Alauddin Ahmed,4 Tariqul Islam,4 Habibul Ahsan,5 Maria Argos1 To cite: Shih Y- H, Scannell ABSTRACT Strengths and limitations of this study Bryan M, Parvez F, et al. Objectives Despite a hypothesised connection of Gravidity, parity, blood pressure reproductive history with hypertension and mortality, the ► Large, rigorously conducted prospective study in a and mortality among women nature of this association is poorly characterised. We in Bangladesh from the middle- income country context. evaluated the association of parity and gravidity with blood HEALS cohort. BMJ Open ► Childbearing history was self- reported, and meno- pressure, hypertension and all- cause mortality. 2020;10:e037244. doi:10.1136/ pause status was not ascertained. Design Prospective cohort study. bmjopen-2020-037244 ► Unmeasured confounders may remain unaccounted Setting Health Effects of Arsenic Longitudinal Study for in our analyses. ► Prepublication history and cohort in rural Bangladesh. additional material for this Participants There were 21 634 Bangladeshi women paper are available online. To recruited in 2000–2002, 2006–2008 and 2010–2014 view these files, please visit for approximately 9.4 million deaths world- included in the present analysis. the journal online (http:// dx. doi. wide.3 In Bangladesh, as in other South Asian org/ 10. 1136/ bmjopen- 2020- Methods Reproductive history was ascertained through 037244). an interviewer- administered questionnaire at the baseline countries, hypertension is a significant health visit. Blood pressure was measured by a trained study concern with an overall prevalence of 26.4% Received 24 January 2020 physician following a standard protocol at the baseline among adults, with a higher prevalence Revised 11 June 2020 visit. Vital status was ascertained at the biennial follow- (32.4%) in women.4 Accepted 17 July 2020 up of study participants through June 2017. Linear and A woman’s risk for developing hyper- logistic regression models estimated the relationship tension is influenced by several factors, between parity and gravidity with blood pressure and including age, body mass index (BMI), http://bmjopen.bmj.com/ hypertension, respectively. Cox proportional hazards menopause, dietary behaviour and phys- models estimated the relationship with all- cause mortality ical activity.4 5 Previous research has also only among women aged >45 years. provided suggestive evidence that pregnancy © Author(s) (or their Results Diastolic blood pressure was lowest in women employer(s)) 2020. Re- use with parity one (reference) and elevated in nulliparous and childbirth influence blood pressure and permitted under CC BY- NC. No women (adjusted % change=3.12; 95% CI 1.93 to 4.33) subsequent morbidity and mortality. Preg- commercial re- use. See rights and women with parity >2 (adjusted % change=1.71; nancy and childbirth may affect long- term and permissions. Published by BMJ. 95% CI 1.12 to 2.31). The associations with nulliparity cardiovascular health by several mechanisms, 1 were stronger for women aged >45 years. Similar some of which are thought to be protective Division of Epidemiology and on October 1, 2021 by guest. Protected copyright. Biostatistics, School of Public association patterns were observed with hypertension. (elevated oestrogen levels during the preg- 6 7 Health, University of Illinois at Further, in nulliparous women aged >45 years, 265 nancy ), and others of which are thought Chicago, Chicago, Illinois, USA deaths (6.6%) were ascertained during the follow-up to increase risk (functional vascular property 2 Institute for Minority Health period (median follow- up time=8 years), and we observed changes, decreased lipid and glucose metab- Research, College of Medicine, suggestive elevated risks of all-cause mortality (adjusted olism, oxidative stress8–11 and haemodynamic University of Illinois at Chicago, HR 3.83; 95% CI 0.74 to 19.78). The relationships between 12 Chicago, Illinois, USA reproductive history, blood pressure, hypertension and changes during the pregnancy ). Further 3 Department of Environmental mortality were similar when modelling reproductive history complicating the evaluation of this relation- Health Sciences, Columbia as gravidity rather than parity. ship is the possibility that a subset of nullipa- University Mailman School of Conclusions For women in rural Bangladesh, nulliparity rous and nulligravid women did not conceive Public Health, New York, New York, USA and nulligravidity appear to be associated with higher because of an underlying health issue, which 4UChicago Research blood pressure and subsequent elevated risk of mortality. may be an independent risk factor for CVD, Bangladesh, Dhaka, Bangladesh such as polycystic ovary syndrome and uterine 5Department of Public Health leiomyoma.13 14 Sciences, University of Chicago, INTRODUCTION Studies, largely in populations of Euro- Chicago, Illinois, USA Elevated blood pressure is an established risk pean descent, have investigated the associa- 1 2 Correspondence to factor for cardiovascular diseases (CVDs), tion between reproductive history and blood Dr Maria Argos; argos@ uic. edu and complications of hypertension account pressure.12 15–21 Still, the findings have been Shih Y- H, et al. BMJ Open 2020;10:e037244. doi:10.1136/bmjopen-2020-037244 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-037244 on 26 August 2020. Downloaded from equivocal and have not adequately addressed the effect analyses to the 21 634 women (99%) with no missing data of nulliparity and nulligravidity. Studies investigating on exposures, outcomes and covariates of interest. parity and mortality have also been inconsistent, and these studies have differed in study design, sample size Assessing parity and gravidity or confounders for which a study adjusted.22–27 Two large The primary exposure variables are the number of total meta- analyses of cohort studies,26 27 largely without South births (parity) and the number of pregnancies (gravidity). Asian participants, suggest J-shaped associations, with Gravidity, number of livebirths, number of stillbirths and parities of 1–6 negatively related to all- cause and CVD number of abortions were obtained from the interviewer- mortality, and nulliparous women at increased risk. Only administered baseline questionnaire. Parity was derived one study, using data collected from 1982 to 1998, has by subtracting the number of abortions from the total examined the effect of parity on all-cause mortality among number of pregnancies. Bangladeshi women aged 45–55 years and observed no Assessing blood pressure association.28 Blood pressure was measured by a trained study physician Given the multiple pathways that may connect repro- using an automated sphygmomanometer with a digital ductive history to morbidity and mortality, it remains display at the baseline visit.30 Subjects remained seated unclear whether any associations found in other popu- for 5 min, and blood pressures were taken with the cuff lations are also valid for the Bangladeshi context as well around their upper left arms. After 5 min of rest, a second as other middle- income countries. Therefore, this study reading was taken and averaged with the first. Participants aimed to evaluate the associations of parity and gravidity were asked by trained interviewers to list any medications with blood pressure and mortality in Bangladeshi women. they were currently taking, and 2.4% (n=523) reported taking antihypertensive medication. For those partici- pants, 10 and 5 mm Hg were added to their observed METHODS systolic and diastolic blood pressures, respectively, to Study population account for the magnitude of the potential treatment effect.31 32 In subsequent analyses, blood pressure was The Health Effects of Arsenic Longitudinal Study modelled as a natural log-transformed continuous vari- (HEALS) is an ongoing population- based study in Arai- able to improve normality. Hypertension was also defined hazar, Bangladesh. To establish the cohort, a sampling based on the Joint National Committee (JNC) 8 guideline frame was developed based on demographic, geograph- as systolic blood pressure ≥140 mm Hg or diastolic blood ical and well water arsenic data collected through a pressure ≥90 mm Hg.33 complete enumeration of the geographically defined 2 25 km study area through a house-to- house survey, as Assessing mortality has been detailed elsewhere.29 Between October 2000 The vital status of each participant was ascertained at http://bmjopen.bmj.com/ and May 2002, we recruited 11 746 participants (5042 biennial follow- up visits through June 2017. Follow- up males and 6704 females) who met the following eligibility time was calculated as the number of days between the criteria: (1) married couples/individuals (to reduce lost baseline visit and date of death or, if alive, the date of the to follow- up); (2) aged 18–75 years; (3) users of a tube well last report of being alive. as a primary water supply; and (4) residents of the study A verbal autopsy (VA) procedure, previously validated area for at least 5 years. During 2006–2008 (ACE I) and by the International Centre for Diarrhoeal Disease 2010–2014 (ACE II), the cohort was expanded to include Research,
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