*Diana Pirjol  did an MPhil in Public Health. She is currently a Public Health Advocate Fellow with the European Public Health Alliance. Picture by Alex Proimos from Sydney, Australia (Washing on the Line Uploaded by russavia) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons.
Does having a large family have an impact on women's long-term health? There has been a lot of focus on pregnancy and health, but less on the long-term impact of the impact of multiple births on women's health. Given that the UK has the second highest percentage of families with four or more children in Europe, it is a good time to reflect on that impact.
My research explores one aspect of this: coronary heart disease (CHD). CHD is the number one cause of death among women in the world and often has a significant impact not only on an individual's life, but also on a country's economy due to increased absenteeism from work, use of medication and in-hospital admission.
Previous studies suggest that biological and physiological changes during pregnancy may affect the risk of CHD. I explored these links further as part of my research with the Department of Public Health and Primary Care at the University of Cambridge. My research was based on the European Prospective Investigation into Cancer and Nutrition-Heart study which investigates the impact that genetic, environmental and metabolic factors have on CHD. Using lifestyle information and blood tests from 11, 299 women from 10 European countries followed for 15 years, the study suggests that women with large families are particularly affected by CHD. Indeed women with four or more children had a 47% higher risk compared to women with no children.
Although each new pregnancy is known to have a detrimental effect on women's level of bad cholesterol, triglycerides and lipids, which may translate later in life to increased risk of hypertension, weight variability and body fat distribution, this was not linked to the risk of death in the study.
Instead, lifestyle-related risks seemed to have most impact on women's health. This may suggest the need for new directions of research which look at the role played by stress levels, dietary intake and physical activity. Generally, each new pregnancy may potentially lead to rising stress levels owing to increased responsibilities, financial stress and sleep deprivation and may encourage sedentary behaviour and smoking, poor diet and lower levels of physical activity. The study showed women with large families had a similar chance of experiencing a heart attack regadless of their socio-economic status.
As well as lifestyle issues, it may also be worth looking at other factors such as ethnicity. My interest is in Roma communities. Although data is scarce on differences in health outcomes for Roma men and women, previous studies suggest that Roma communities have a higher risk of cardiovascular disease, such as CHD, and a higher mortality rate as a result compared with non-Roma people in Serbia, Slovakia and Bulgaria as indicated by recent studies. Roma women tend to have children from an early age and consequently they have large families. They also face a number of barriers related to their traditional roles, limited educational and employment opportunities, poor living conditions and physical and social isolation. In addition they are more likely to experience stress, loneliness and depression as a result of their subordinate role in the Roma community as highlighted in a thematic study issued in 2012 in Slovenia by Fundamental Rights Agency.
We need further and stronger evidence on the role that lifestyle factors such as diet and depression might play in risk of CHD. From what we know from this research, though, it is clear that women need to bear in mind the health risks that may result from having large families.