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Association between parity and breastfeeding with maternal high blood pressure
Samantha J. Lupton, BMedRes; Christine L. Chiu, PhD; Sanja Lujic, MBiostat; Annemarie Hennessy, MBBS, PhD; Joanne M. Lind, PhD
OBJECTIVE: The objective of this study was to determine how parity

and breastfeeding were associated with maternal high blood pressure, and how age modies this association.
STUDY DESIGN: Baseline data for 74,785 women were sourced

from the 45 and Up Study, Australia. These women were 45 years of age or older, had an intact uterus, and had not been diagnosed with high blood pressure before pregnancy. Odds ratios (ORs) and 99% condence intervals (CIs) for the association between giving birth, breastfeeding, lifetime breastfeeding duration, and average breastfeeding per child with high blood pressure were estimated using logistic regression.
RESULTS: The combination of parity and breastfeeding was associated

whereas there was no signicant difference between mothers who did not breastfeed and nulliparous women (adjusted OR, 1.06; 99% CI, 0.951.18; P .20). Women who breastfed for longer than 6 months in their lifetime, or greater than 3 months per child, on average, had signicantly lower odds of having high blood pressure when compared with parous women who never breastfed. The odds were lower with longer breastfeeding durations and were no longer signicant in the majority of women over the age of 64 years.
CONCLUSION: Women should be encouraged to breastfeed for as long

as possible and a womans breastfeeding history should be taken into account when assessing her likelihood of high blood pressure in later life. Key words: breastfeeding, cardiovascular disease, high blood pressure, parity, women

with lower odds of having high blood pressure (adjusted OR, 0.89; 99% CI, 0.82 0.97; P .001), compared with nulliparous women,

Cite this article as: Lupton SJ, Chiu CL, Lujic S, et al. Association between parity and breastfeeding with maternal high blood pressure. Am J Obstet Gynecol 2013;208:454.e1-7.

regnancy and breastfeeding are associated with large changes to the female hormonal prole. A correlation between these events and a womans risk of cardiovascular disease has been reported since the 1950s1 with more recent large cohort studies showing breastfeeding is benecial to maternal cardiovascular health.2-5 Cardiovascular diseases are the leading cause of death among women in de-

From the University of Western Sydney, School of Medicine, Campbelltown, NSW, Australia. Received Sept. 12, 2012; revised Dec. 19, 2012; accepted Feb. 5, 2013. The authors report no conict of interest. Presented orally at the 24th Annual Scientic Meeting of the International Society of Hypertension, Sept. 30-Oct. 4, 2012, Sydney, NSW, Australia. Reprints not available from the authors.
0002-9378/free 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.02.014

For Editors Commentary, see Contents

veloped countries. Hypertension is one of the most prevalent cardiovascular diseases and is a strong predictor of other cardiovascular diseases including atherosclerosis, myocardial infarction, and stroke. Age is a powerful predictor of hypertension, with increasing age associated with increasing rates of hypertension in industrialized countries.6 The association between pregnancy and hypertension in later life remains unclear. Early work within the eld found an association between increasing number of pregnancies and lower odds of hypertension,7 whereas other studies have shown no association between parity and blood pressure.8,9 These studies had relatively small sample sizes in comparison to the large cohorts that have since been established. Breastfeeding has been reported to confer many benets upon the newborn, including reduced levels of childhood obesity,10 hypertension,11-13 and hyperlipidemia.14,15 More recent studies have found an association between breastfeeding and a lower risk of ma-

ternal hypertension. This was rst reported in 2005 by the Korean Womens Cohort (KWC) Study2 and has since been reported by the Study of Womens Health Across the Nation (SWAN),3 the Womens Health Initiative (WHI) Study,4 and the US Nurses Health Study II.5 No studies have examined whether the combined effect of parity and breastfeeding is associated with high blood pressure, and how age modies the association between breastfeeding and high blood pressure. The present study aimed to determine: (a) the association between the event of giving birth with high blood pressure in later life, using observational data from the 45 and Up Study, Australia, (b) whether the combination of giving birth and breastfeeding is associated with high blood pressure in later life, and (c) if the duration of breastfeeding was associated with high blood pressure in later life, and how this association is modied as women age.

M ATERIALS AND M ETHODS

This study obtained data from women participating in the 45 and Up Study, a

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FIGURE 1

Participants included in the study

Flow chart of participant inclusion.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

large scale cohort study of 267,153 men and women aged 45 and over in New South Wales, Australia. Participants were randomly selected from the Australian Medicare Database, which provides near complete coverage of the population, and they were enrolled into the study by completing a baseline questionnaire (available at www.45andUp.org. au) and providing a signed consent form. People aged 80 years and over, and residents of rural and remote areas were oversampled. Study recruitment commenced in 2006 and was completed in 2009. The methods for the 45 and Up Study have been

described elsewhere.16 The 45 and Up Study received ethics approval from the University of NSW Human Ethics Committee, and the current study was approved by the University of Western Sydney Human Research Ethics Committee. Exposure-outcome relationships estimated from the 45 and Up Study data have been shown to be consistent with another large study of the same population, regardless of the underlying response rate or mode of questionnaire administration.17 All of the data used in this study were acquired from the 45 and Up Study baseline questionnaire. Women were in-

cluded in this study if: they were age 45 years or more; had never given birth or had given birth after 18 years of age and before 45 years of age; had not had a hysterectomy or both ovaries removed; and had responded No to the question Has a doctor ever told you that you have: high blood pressurewhen pregnant? (Figure 1). Women were dened as having high blood pressure if they answered Yes to the question In the last month have you been treated for: high blood pressure. Women were excluded if: they answered Yes to the question Has a doctor ever told you that you have: high blood pressure when not pregnant? and the Age when condition was rst found was younger than, the age reported on the question How old were you when you gave birth to your FIRST child?; answered Yes to Has a doctor ever told you that you have: high blood pressure when not pregnant?, but were not being treated for high blood pressure; they failed to provide an age of onset for high blood pressure; they provided invalid data for family history; or they provided invalid data for the number of children they had given birth to in their specied age range (Figure 1). Classication of demographic and lifestyle characteristics have been described elsewhere.18 Women were classied as never having given birth if they answered 0 to the question How many children have you given birth to?, with the further instruction to please include stillbirths but do not include miscarriages, please write 0 if you have not had any children. Total breastfeeding duration was obtained from the response to the question For how many months, in total, have you breastfed?. Average breastfeeding duration was obtained by dividing the total breastfeeding duration by the reported number of children for each woman. Odds ratios (ORs) and 99% condence intervals (CIs) for the association between giving birth, breastfeeding, lifetime breastfeeding duration, and average breastfeeding per child with high blood pressure were estimated using logistic regression. For the analysis of whether giving birth is associated with having high blood pressure, women who had never 454.e2

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given birth were the reference group. Analysis of lifetime breastfeeding and breastfeeding duration included only women who had given birth, with women who had never breastfed as the reference group. Both crude and adjusted OR were calculated and descriptions refer to adjusted OR unless otherwise specied. OR were adjusted for demographic and lifestyle factors using the categories in Table 1, with an additional category for missing values. There was a signicant interaction between whether a woman breastfed and current age, with having high blood pressure. As a result, women were stratied according to current age and divided into 3 groups (45 to 54 years, 54 to 64 years, 64 years or older) when testing the association between lifetime breastfeeding and breastfeeding duration with high blood pressure status. All statistical tests were 2-sided, using a signicance level of P .01 to partially account for multiple testing issues.19,20 All statistical analyses were carried out using SPSS software (version 20; SPSS, Inc, Chicago, IL).

TABLE 1

Sociodemographic factors associated with past breastfeeding behavior

Characteristics Current age, y Groups 45 to 54 54 to 64 64 Country of origin Income Australia Other $30K Casesa (% column) 22,361 (35) 21,454 (33) 20,384 (32) % BFa 93 87 87 ORc (99% CI) 1.00 0.58 (0.530.64) 0.60 (0.540.66)

.......................................................................................................................................................................... d .......................................................................................................................................................................... d

.............................................................................................................................................................................................................................................. .......................................................................................................................................................................... d

48,291 (75)

90

1.00

.............................................................................................................................................................................................................................................. .......................................................................................................................................................................... d

15,368 (24) 15,984 (25) 16,327 (25)

86 90 86

0.78 (0.720.84) 1.29 (1.171.42) 0.94 (0.861.02)

16,416 (26)

86

1.00

$30$70K $70K Family history of HBP BMI No

.......................................................................................................................................................................... d .......................................................................................................................................................................... .............................................................................................................................................................................................................................................. ..........................................................................................................................................................................

15,472 (24)

94

2.09 (1.862.35)

Not disclosed Yes

31,098 (48) 29,344 (46)

89 90

1.00 1.00

..............................................................................................................................................................................................................................................

33,101 (52)

89

1.01 (0.941.08)

25

.......................................................................................................................................................................... d

25-30 30 Past Alcohol (drinks/wk) 1 1-5 Smoking status Never

.......................................................................................................................................................................... d .............................................................................................................................................................................................................................................. .......................................................................................................................................................................... d .......................................................................................................................................................................... d .............................................................................................................................................................................................................................................. .......................................................................................................................................................................... d .......................................................................................................................................................................... d

18,868 (29)

89

0.88 (0.810.95)

10,839 (17) 17,909 (28) 4272 (7)

86 89

0.69 (0.630.75) 0.86 (0.800.93)

41,733 (65)

90

1.00

Current

83

0.57 (0.500.64) 1.00

24,191 (38)

86

17,760 (28) 12,990 (20) 7963 (12)

91 91

1.55 (1.421.69) 1.52 (1.371.67)

R ESULTS
A total of 74,785 women aged 45 and over were included in the analysis of which 64,199 gave birth (85.8%), and 12,456 (16.7%) reported current treatment for high blood pressure. Of the women who had given birth, 57,097 (88.9%) reported they had breastfed, with the youngest women in the cohort (45 to 54 year olds) having the highest prevalence of breastfeeding (92.7%) (Figure 1). Demographic and lifestyle characteristics of women who had given birth are shown in Table 1. Women who were born in Australia, had an income greater than $30,000, consumed greater than 1 alcoholic drink per week, never smoked, had sufcient physical activity levels and had a current body mass index (BMI) of less than 25, had higher odds of having breastfed. Increasing number of children was also associated with increased odds of having breastfed. There was an association between parity and high blood pressure, with women who had given birth having signicantly 454.e3
Physical activity Oral contraceptive use HRT use Number of children

6-10

.......................................................................................................................................................................... d ..............................................................................................................................................................................................................................................

11

90

1.36 (1.221.53) 1.00

Insufcient Sufcient Ever Ever 2 3 Never Never 1

.......................................................................................................................................................................... d

19,792 (31)

87

.............................................................................................................................................................................................................................................. ..........................................................................................................................................................................

44,407 (69)

90

1.19 (1.111.28)

11,277 (18) 44,261 (69)

87 90

1.00 1.00

.............................................................................................................................................................................................................................................. ..........................................................................................................................................................................

51,964 (81) 18,674 (29) 6908 (11) 26,371 (41) 19,078 (30) 11,842 (18)

90 87 88 92 92

1.02 (0.931.12) 0.93 (0.871.01) 1.90 (1.732.09) 2.94 (2.653.27) 3.66 (3.244.13)

.............................................................................................................................................................................................................................................. .......................................................................................................................................................................... d .......................................................................................................................................................................... d .......................................................................................................................................................................... d ..............................................................................................................................................................................................................................................

79

1.00

BF, breastfed; BMI, body mass index; CI, condence interval; HBP, high blood pressure; HRT, hormone replacement therapy; OR, odds ratio.
a

Percentages do not consistently total to 100% because of missing values;bThe percentage of women who responded yes to having breastfed; c Analysis adjusted for current age, country of origin, income level, family history of HBP, BMI, smoking status, alcohol consumption, physical activity, oral contraceptive use, HRT use, and number of children; d P .01.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

lower odds of high blood pressure when compared with women who had never given birth (adjusted OR, 0.91; 99% CI, 0.84 0.99; P .004). Further analysis, stratifying mothers according to whether they had breastfed, found mothers who

breastfed had signicantly lower odds of having high blood pressure, compared with women who had never given birth (adjusted OR, 0.89; 99% CI, 0.82 0.97; P .001), whereas the odds of having high blood pressure for mothers who did

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TABLE 2

Parity, breastfeeding history, and the odds of having high blood pressure
Variable Given birth No Yes Cases, n 10,586 64,199 Crude OR (99% CI) 1.00 (reference) Adjusted OR (99% CI)a

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... b

..............................................................................................................................................................................................................................................

1.00 (0.931.07)

0.91 (0.840.99)

Given birth stratied by breastfeeding No

..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... b

10,586 7102 57,097

1.00 (reference)

Yes, never breastfed Yes, breastfed

a

..................................................................................................................................................................................................................................... b

1.31 (1.181.45)

1.06 (0.951.18)

0.96 (0.891.03)

0.89 (0.820.97)

..............................................................................................................................................................................................................................................

CI, condence interval; OR, odds rstio. Analysis adjusted for current age, country of origin, income level, body mass index, smoking status, alcohol consumption, physical activity, family history of high blood pressure, history of oral contraceptive use, and history of hormone replacement therapy use; b P .01.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

not breastfeed were not signicantly different from women who had never given birth (adjusted OR, 1.06; 99% CI, 0.95 1.18; P .195) (Table 2). Analysis including only women who had given birth, stratied by current age, found no association between the number of children a woman gave birth to and having high blood pressure. There was a signicant association between lifetime breastfeeding duration and having high blood pressure. Lifetime breastfeeding duration of 6 months or greater was associated with lower odds of having high blood pressure in women aged 45 to 64 years, when compared with parous women who did not breastfeed. The odds of having high blood pressure decreased with longer durations of breastfeeding. The lowest odds were observed in women aged 45 to 54 years whose lifetime breastfeeding duration was 24 months or greater (adjusted OR, 0.58; 99% CI, 0.44 0.77; P .001). No significant association between lifetime breastfeeding duration and high blood pressure was observed in women aged 64 years and over (Figure 2). The average breastfeeding duration per child was also associated with having high blood pressure, with 3 months or more breastfeeding per child associated with lower odds of having high blood pressure, in women aged 45 to 64 years, when compared with parous women who never breastfed. The odds of

having high blood pressure within these women decreased with longer durations of breastfeeding per child. Within the 64 years and over age group, there was a signicant association between average breastfeeding duration per child and having high blood pressure, only for women who had breastfed for 18 months or more per child (adjusted OR, 0.38; 99% CI, 0.17 0.84; P .002), compared with parous women who did not breastfeed (Figure 3). A nal analysis including only participants with a family history of high blood pressure, stratied by age, found that breastfeeding is signicantly associated with reduced odds of having high blood pressure in women aged 45 to 64 years (Table 3).

C OMMENT
This study showed the combination of giving birth and breastfeeding was associated with lower odds of having high blood pressure in later life, compared with women who had never given birth. There was no signicant difference in odds of having high blood pressure in women who had given birth and did not breastfeed, compared with women who had never given birth. We also showed that within parous women, the number of children a woman gave birth to was not associated with her odds of having high blood pressure. In addition, 6

months or more lifetime breastfeeding duration, and 3 months or more average breastfeeding per child, were associated with signicantly lower odds of having high blood pressure in later life. The association between breastfeeding duration and high blood pressure diminished with increasing age, demonstrating age as a signicant predictor for having high blood pressure. Previous studies examining the association between parity and high blood pressure have been inconclusive, with some studies showing no association8,9 and others showing decreased odds of having high blood pressure with increasing numbers of pregnancies.7 Our large cohort study, which included 74,785 women, showed that the number of children a woman gave birth to was not associated with having high blood pressure. Previous studies did not account for breastfeeding duration among the mothers when examining the association between parity and high blood pressure and this may explain the inconsistent results between studies, because of varying rates of breastfeeding in different populations. Our study had a breastfeeding rate of 88.9% with women born outside Australia having lower odds of having breastfed (adjusted OR, 0.78; 99% CI, 0.72 0.84; P .001) compared with women born in Australia. Only parous women who breastfed had signicantly lower odds of having high blood pressure, when compared with nulliparous women. The reduced odds of having high blood pressure in these women are therefore more likely to be a result of breastfeeding, rather than parity alone. Breastfeeding may modify the risk of having high blood pressure through alterations in vessel structure or in the maternal hormonal and lipid proles. These alterations may induce changes in the maternal cardiovascular system because of the repeated oxytocin exposure produced by each feeding.21 Exposure to oxytocin has an inhibitory effect on adrenocorticotropic hormones and cortisol secretion, reducing sympathetic nervous system stimulation and reducing blood pressure.22 Within rats there is evidence that repeated oxytocin exposure affects central 2-adrenergic activity, de454.e4

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creasing sympathetic nervous system drive on both the heart and arteries, lowering blood pressure.23 The positive social interactions and emotions induced in the mother by breastfeeding, including the touching sensation and warmth created by the offspring, may also have long-term benets to the mothers cardiovascular health because of the psychologic antistress effects produced by breastfeeding.21 The relationship between breastfeeding duration and blood pressure has been reported in 4 large cohort studies to date.2-5 All studies have found an association between breastfeeding and maternal high blood pressure, with increased durations of breastfeeding associated with reduced likelihood of having high blood pressure. The WHI study was the only study to include women over 60 years of age,4 and reported that the association between increased duration of breastfeeding and reduced cardiovascular risk diminished as women aged. The WHI study did not specically examine the interaction between age and high blood pressure. Our study supports the above mentioned studies, and extends the research by showing that the association between breastfeeding duration (both lifetime and per child) and having high blood pressure is only signicant in women up to 64 years of age. The 1 exception being women aged 64 years and over had signicantly lower odds of having high blood pressure if they breastfed each child for an average of 18 months or more (OR, 0.38; 99% CI, 0.17 0.84; P .002), compared with parous women of the same age who never breastfed. The per child breastfeeding duration is reported in the present paper to make the results more accessible for physicians and midwifes when discussing the benets of breastfeeding to a mother after a single pregnancy. A recommendation of at least 3 months of breastfeeding per child is advocated by the authors and is more meaningful to a mother than a recommendation about how long she should breastfeed in her lifetime. A family history of high blood pressure is known to increase an individuals risk of having high blood pressure, possibly because of the inheritance of a 454.e5

FIGURE 2

Association of lifetime breastfeeding with high blood pressure

A, 45 to 54 years of age, B, 54 to 64 years of age, C, 64 or more years of age.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

number of genetic polymorphisms that make the individual susceptible to high blood pressure.24 We showed that breastfeeding signicantly reduces the odds of having high blood pressure in women with a family history of high

blood pressure (Table 3), up to 64 years of age. Women who have a family history of high blood pressure could be encouraged to breastfeed their children to help delay the onset of high blood pressure.

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FIGURE 3

Breastfeeding per child associated with high blood pressure

A, 45 to 54 years of age, B, 54 to 64 years of age, C, 64 or more years of age.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

Ageing is the single largest risk factor for high blood pressure because of the stiffening of elastane in the internal lamina of arteries andcalcicationofthearterialintima.25 Both of these factors cause an increase in peripheral resistance, leading to an increase in the pressure wave reection and a rise in systolic blood pressure as individuals age.25,26 Our

results show that the benets afforded to the cardiovascular system by breastfeeding are no longer present in the majority of older women. The current WHO recommendations for breastfeeding encourage breastfeeding for a minimum of 6 months per child.27 This study provides further sup-

port for these recommendations, as both the lifetime and per child durations of breastfeeding were associated with signicant reduction in the odds of future maternal high blood pressure. Our study showed that 3 months or more of breastfeeding per child, and 6 months or more lifetime breastfeeding, signicantly decreased a womans odds of having high blood pressure, and the odds continued to lower with longer breastfeeding durations. Women should therefore be encouraged to breastfeed for as long as possible to reduce the likelihood of high blood pressure before 64 years of age. A womans breastfeeding history is also important when assessing her likelihood of having high blood pressure in later life. The key strength of this study is the large cohort size, which enabled us to examine the duration of breastfeeding in different age groups. This study used self-reported data, which is prone to recall bias, and may have led to under- or overreporting of breastfeeding duration. It has been reported in the literature that women who breastfeed are more likely to have a healthy BMI28 and are less likely to smoke.29 Our study showed that women who currently had a lower BMI, had never smoked, had sufcient levels of exercise, and had a higher income were more likely to have breastfed. Women who breastfeed may therefore represent a healthier cohort. From our data it is not possible to determine whether women who breastfed were a healthier cohort during their childbearing years, or whether breastfeeding results in healthier behaviors beyond a womans childbearing years. Either way, there is no difference in odds of having high blood pressure in women over 64 years of age when comparing women who breastfed with women who never breastfed. In conclusion, women who breastfed their children had signicantly reduced odds of having high blood pressure, compared with women who had never given birth and varying rates of breastfeeding in different populations may account for inconsistent reporting of the association between parity and high blood pressure. Women who breastfed for longer than 6 months in their lifetime, or greater than 3 454.e6

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later blood pressure among children: cardiovascular risk in young Finns. Pediatr Res 1996;40:627-32. 14. Owen CG, Whincup PH, Odoki K, Gilg JA, Cook DG. Infant feeding and blood cholesterol: a study in adolescents and a systematic review. Pediatrics 2002;110:597-608. 15. Kark JD, Troya G, Friedlander Y, Slater PE, Stein Y. Validity of maternal reporting of breast feeding history and the association with blood lipids in 17 year olds in Jerusalem. J Epidemiol Community Health 1984;38:218-25. 16. Banks E, Redman S, Jorm L, et al. Cohort prole: the 45 and Up Study. Int J Epidemiol 2008;37:941-7. 17. Mealing NM, Banks E, Jorm LR, Steel DG, Clements MS, Rogers KD. Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs. BMC Med Res Methodol 2010;10:26. 18. Chiu CL, Lujic S, Thornton C, et al. Menopausal hormone therapy is associated with having high blood pressure in postmenopausal women: observational cohort study. PLoS ONE 2012;7:e40260. 19. Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990;1: 43-6. 20. Geissinger JD. Letter: medical treatment of subdural hematomas challenged. Arch Neurol 1975;32:69. 21. Uvnas-Moberg K. Oxytocin may mediate the benets of positive social interaction and emotions. Psychoneuroendocrinology 1998;23:819-35. 22. Amico JA, Johnston JM, Vagnucci AH. Suckling-induced attenuation of plasma cortisol concentrations in postpartum lactating women. Endocr Res 1994;20:79-87. 23. Petersson M, Alster P, Lundeberg T, Uvnas-Moberg K. Oxytocin causes a long-term decrease of blood pressure in female and male rats. Physiol Behav 1996;60:1311-5. 24. Lupton SJ, Chiu CL, Lind JM. A hypertension gene: are we there yet? Twin Res Hum Genet 2011;14:295-304. 25. Mitchell GF, Parise H, Benjamin EJ, et al. Changes in arterial stiffness and wave reection with advancing age in healthy men and women: the Framingham Heart Study. Hypertension 2004;43:1239-45. 26. ORourke MF, Nichols WW. Aortic diameter, aortic stiffness, and wave reection increase with age and isolated systolic hypertension. Hypertension 2005;45:652-8. 27. Feig C. Exclusive breastfeeding for six months best for babies everywhere. World Health Organisation Online 2011. 28. Lepe M, Bacardi Gascon M, CastanedaGonzalez LM, Perez Morales ME, Jimenez Cruz A. Effect of maternal obesity on lactation: systematic review. Nutr Hosp 2011;26:1266-9. 29. Gerd AT, Bergman S, Dahlgren J, Roswall J, Alm B. Factors associated with discontinuation of breastfeeding before 1 month of age. Acta Paediatr 2012;101:55-60.

Breastfeeding history and high blood pressure among women with reported family history of blood pressure, stratied by age
Age group, y 45 to 54 54 to 64 64
a

Cases, n 12,730 11,721

Crude OR (99% CI) 0.59 (0.460.76)b 0.69 (0.590.82) 1.00 (0.841.18)

Adjusted OR (99% CI)a 0.68 (0.520.89)b 0.80 (0.670.95) 1.00 (0.841.18)

.............................................................................................................................................................................................................................................. b b ..............................................................................................................................................................................................................................................

8650

..............................................................................................................................................................................................................................................

CI, condence interval; OR, odds ratio. Odds ratios refer to the odds of high blood pressure among breastfeeding compared with nonbreastfeeding women, adjusted for country of origin, income level, body mass index, smoking status, alcohol consumption, physical activity, history of oral contraceptive use, history of hormone replacement therapy use, and number of children; b P .01.

Lupton. Parity, breastfeeding, and high blood pressure. Am J Obstet Gynecol 2013.

months per child, had signicantly lower odds of having high blood pressure when compared with parous women who had never breastfed. This held true in women with a family history of high blood pressure. The odds were lower with longer breastfeedingdurationsandtheassociationdiminished in women over 64 years of age. Women should be encouraged to breastfeed for as long as possible, and a womans breastfeeding history should be taken into account when assessing her likelihood of high blood pressure in later life. f
ACKNOWLEDGMENTS
The 45 and Up Study is managed by the Sax Institute in collaboration with major partner Cancer Council New South Wales; and partners the National Heart Foundation of Australia (NSW Division); NSW Ministry of Health; beyondblue: the national depression initiative; Ageing, Disability and Home Care, NSW Family and Community Services; and Australian Red Cross Blood Service. We thank the many thousands of people participating in the 45 and Up Study. J.M.L. is supported by a National Health and Medical Research Council - Australian Biomedical Fellowship. S.J.L. is the recipient of a University of Western Sydney Postgraduate Research Award and an Ingham Health Research Institute scholarship.

REFERENCES
1. Winkelstein W Jr, Stenchever MA, Lilienfeld AM. Occurrence of pregnancy, abortion, and articial menopause among women with coronary artery disease: a preliminary study. J Chronic Dis 1958;7:273-86. 2. Lee SY, Kim MT, Jee SH, Yang HP. Does long-term lactation protect premenopausal women against hypertension risk? A Korean womens cohort study. Prev Med 2005;41: 433-8.

3. Ram KT, Bobby P, Hailpern SM, et al. Duration of lactation is associated with lower prevalence of the metabolic syndrome in midlifeSWAN, the study of womens health across the nation. Am J Obstet Gynecol 2008;198:268.e1-6. 4. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol 2009;113: 974-82. 5. Stuebe AM, Schwarz EB, Grewen K, et al. Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study. Am J Epidemiol 2011;174:1147-58. 6. Franklin SS, Gustin Wt, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997;96:308-15. 7. Ness RB, Kramer RA, Flegal KM. Gravidity, blood pressure, and hypertension among white women in the Second National Health and Nutrition Examination Survey. Epidemiology 1993; 4:303-9. 8. 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 Womens Heart and Health Study and the British Regional Heart Study. Circulation 2003; 107:1260-4. 9. 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. 10. Kramer MS. Do breast-feeding and delayed introduction of solid foods protect against subsequent obesity? J Pediatr 1981;98:883-7. 11. Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol 2005;161:15-26. 12. Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. Lancet 2001; 357:413-9. 13. Taittonen L, Nuutinen M, Turtinen J, Uhari M. Prenatal and postnatal factors in predicting

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