Maturitas 73 (2012) 295–299

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Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Marital status, health and mortality

James Robards a,∗ , Maria Evandrou a,b,c , Jane Falkingham a,b , Athina Vlachantoni a,b,c
a
EPSRC Care Life Cycle, Social Sciences, University of Southampton, SO17 1BJ, UK
b
ESRC Centre for Population Change, Social Sciences, University of Southampton, SO17 1BJ, UK
c
Centre for Research on Ageing, Social Sciences, University of Southampton, SO17 1BJ, UK

a r t i c l e i n f o a b s t r a c t

Article history: Marital status and living arrangements, along with changes in these in mid-life and older ages, have
Received 6 August 2012 implications for an individual’s health and mortality. Literature on health and mortality by marital
Accepted 13 August 2012 status has consistently identified that unmarried individuals generally report poorer health and have
a higher mortality risk than their married counterparts, with men being particularly affected in this
respect. With evidence of increasing changes in partnership and living arrangements in older ages,
Keywords:
with rising divorce amongst younger cohorts offsetting the lower risk of widowhood, it is impor-
Older people
tant to consider the implications of such changes for health in later life. Within research which has
Marital status
Living arrangements
examined changes in marital status and living arrangements in later life a key distinction has been
Informal care between work using cross-sectional data and that which has used longitudinal data. In this context,
Health two key debates have been the focus of research; firstly, research pointing to a possible selection of
Mortality less healthy individuals into singlehood, separation or divorce, while the second debate relates to the
extent to which an individual’s transitions earlier in the life course in terms of marital status and liv-
ing arrangements have a differential impact on their health and mortality compared with transitions
over shorter time periods. After reviewing the relevant literature, this paper argues that in order to fully
account for changes in living arrangements as a determinant of health and mortality transitions, future
research will increasingly need to consider a longer perspective and take into account transitions in living
arrangements throughout an individual’s life course rather than simply focussing at one stage of the life
course.
© 2012 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
2. Changes in marital status and living arrangements in mid- and later life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3. Marital status, living arrangements and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3.1. Quality of relationship matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3.2. Selection matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3.3. Cohort matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
3.4. Life history matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
4. Marital status, living arrangements and mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

∗ Corresponding author. Tel.: +44 023 8059 4744.

E-mail addresses: james.robards@soton.ac.uk (J. Robards), maria.evandrou@soton.ac.uk (M. Evandrou), j.c.falkingham@soton.ac.uk (J. Falkingham),
a.vlachantoni@soton.ac.uk (A. Vlachantoni).

0378-5122/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.maturitas.2012.08.007
296 J. Robards et al. / Maturitas 73 (2012) 295–299
1. Introduction
Numerous studies within demographic research have high-
lighted that health and mortality outcomes for married persons
are better than for unmarried persons [1,2], and this is particularly
the case for men [3,4]. Subsequent research has sought to explore
the extent of ‘marriage selection’ by which healthier persons are
selected into marital unions, while less healthy individuals either
remain single or are more likely to become separated, divorced or
widowed [5,6]. Research has also examined the extent to which
marriage provides ‘protection’ against adverse health outcomes,
through modified health behaviours and social networks arising
from the union [7]. In some cases evidence for both theories has
been identified [8,9].
In the context of social changes at older ages, marital status
and living arrangements in mid- and later life are crucial in rela-
tion to subsequent forms of informal care provision (and receipt)
and health and mortality outcomes [10,11]. Recent increases in
single-person households are not confined to younger ages, with
the trend towards rising solo living also noted among older people
[12]. Moreover, transitions in marital status at younger old ages
with, for example, higher rates of divorce amongst cohorts born in
the 1960s than their parental generation born in the 1930s [13],
look likely to have longer term impacts given the increased life
expectancy and wealthier, longer and healthier lives which have
still to play out for those cohorts currently in mid-life or early old
age.
This paper discusses research on health and mortality outcomes
for different marital states and transitions between states. Based
on changes in marital status and living arrangements taking place
at middle and older age, this paper argues that future research
should take into account marital status and living arrangements
across the life course when considering the health and mortality
outcomes from different living arrangements. Some research has
already taken a longer period of the life course into consideration
in estimating mortality and health outcomes at older ages [14–16];
further research building on this evidence base is required.
2. Changes in marital status and living arrangements in
mid- and later life
Within the United Kingdom (UK) and elsewhere, there is
increasing diversity in living arrangements and marital status in
the mid-life and at older ages. In part this reflects the rise in the
divorce rate at mid and older ages [17,18], along with changes in the
patterns of repartnering [19] and the reduced risk of widowhood.
Internationally, the proportion of older people living alone was
rising until the early 1990s [20], since which there has been a slow-
down [18]. This slowdown is related to increasing life expectancy
at young old ages, which in turn has led to increasing proportions of
older people living in couple-only households. However, as those
cohorts born in the 1950s and 1960s begin to enter old age, it is
unclear whether this trend towards living in a couple will con-
tinue, or whether more future elders will enter later life living solo.
Recent statistics for the UK identify that in the 45–64 years age
group there has been an increase in the percentage living alone by
36% between 2001 and 2011, reflecting the lower proportion of this
age group who are married (77% in 2001 to 70% in 2011) and the
increase in those who never married or are divorced (18% in 2001
to 27% in 2011) [21]. Similarly, Demey et al. has found a rise in the
proportion of people currently in mid-life who are living without a
partner, either through divorce or through never having partnered
[22].
Recent changes in divorce patterns at middle and older ages
are likely to lead to an increasing diversification of living arrange-
ments at older ages. Given this, cross-sectional indicators of current
marital status are likely to become of less conceptual use as dif-
ferent individuals with the same current marital status may have
experienced very different trajectories in reaching that state, with
some being in the same union throughout their lives whilst others
may have experienced multiple partnership formation and dissolu-
tion. Understanding the relationship between living arrangements
and health across the life course may therefore be of increasing
importance.
3. Marital status, living arrangements and health
A consistent finding from research investigating health out-
comes of different marital statuses and transitions in marital
statuses, is evidence of the poorer health of divorced and single men
relative to their married counterparts; moreover there also appears
to be a gender effect with divorced and single men experienc-
ing poorer health outcomes than single women [3,4,23–25]. These
findings have provoked questions on whether there is some form
of selection of less healthy individuals into non-marital states or
whether being married offers a ‘protective effect’ for health and the
transition from being married into being unmarried has an adverse
impact on health. The picture is further complicated by the fact
that such transitions in partnership status may be accompanied by
temporary changes (for example, health may undergo a temporary
decline around the time of the marital dissolution) which are not
adequately captured in cross-sectional data. Additionally, caution
is needed in treating both the unmarried and married as homoge-
nous groups as both the route into being ‘unmarried’ and the quality
of the marital relationship have both been found to matter.
Goldman et al., using data from the US Longitudinal Study of
Aging (1984–1990), identified that marital status is associated with
health and survival outcomes at the oldest ages, with widowed men
being at a higher risk of being disabled than married men [26]. How-
ever, unmarried persons at older ages were found to have variations
in health outcomes; widowed persons had poorer health but this
was not the case among divorced or single persons. The paper sug-
gests that frail single persons may have died before reaching older
ages (the selection effect) and that the surviving older single per-
sons would not have experienced stresses and strains associated
with divorce and widowhood. Therefore it is argued that because of
their diversity of experiences, the unmarried should not be treated
as a homogenous group.
3.1. Quality of relationship matters
It may also be the case that the married should not be treated
as a homogenous group. Looking only at a sample aged 50+ and in
their first marriage, Bookwala found that uncaring and unhelpful
spousal behaviours was associated with poorer physical health and
that such behaviours outweighed positive spousal behaviours in
contributing to poorer physical health [27].
3.2. Selection matters
The degree to which less healthy persons are ‘selected’ into
singlehood, separation or divorce is best investigated using lon-
gitudinal data, with information on health both before and after
changes in marital status. Among studies exploring health status
pre-transition, Joung et al. found that only divorce was associated
with health status [5]. This research showed that married persons
with four or more health complaints and two or more chronic
conditions were 1.5 and 2 times more likely to become divorced
than persons without these problems at the baseline. Williams and
Umberson make similar findings using data from the US [28]. A life
course perspective was used to assess the impact of marital sta-
tus and marital transitions on subsequent changes in self-assessed
 J. Robards et al. / Maturitas 73 (2012) 295–299 297

Table 1
Odds-ratios from logistic regression analysis of long-term illness 1991 (ages 60–79).

Men Women

Model 1 Model 2 Model 1 Model 2

OR OR OR OR

Age 1.03*** 1.03*** 1.07*** 1.07***

Marital history
1st marriage – long term (20+ years) 1.00 1.00 1.00 1.00
1st marriage – since 1971 0.77 0.74* 0.85 0.83
Remarried – long term (20+ years) 1.24*** 1.26*** 1.40*** 1.34***
Remarried since 1971, previously widowed 0.91 0.93 1.05 1.00
Remarried since 1971, previously divorced 1.05 1.01 1.25** 1.16*
Widowed-long term (20+ years) 1.33* 1.10 1.18*** 1.01
Widowed-intermediate (10–19 years) 1.35*** 1.18* 1.11** 0.96
Widowed-recent (<10 years) 1.26*** 1.12* 1.07* 0.96
Divorced-long term (20+ years) 1.40* 1.14 1.42*** 1.15
Divorced-intermediate (10–19 years) 1.59*** 1.35*** 1.37*** 1.15
Divorced-recent (<10 years) 1.53*** 1.39** 1.72*** 1.49**
Never-married 1.22*** 0.97 1.17** 1.04

Socioeconomic variables
Educational qual.1971 (ref. none) 0.84*** 0.88***
Tenure/car score 1971–91 0.94*** 0.92***
Social class score 1971–81 0.89***

Current marital status

All in 1st marriage 1.00 1.00 1.00 1.00
All remarried 1.12** 1.13** 1.26*** 1.20***
All widowed 1.29*** 1.14** 1.10*** 0.97
All divorced 1.54*** 1.33*** 1.45*** 1.21***
Never-married 1.22*** 0.97 1.17** 1.04

N 33,686 41,341

Source: Grundy and Tomassini [14], adjusted from Table 3.

Note: This table was produced using the ONS Longitudinal Study with help provided by staff of the Centre for Longitudinal Study Information & User Support (CeLSIUS).
CeLSIUS is supported by the ESRC Census of Population Programme (Award Ref: RES-348-25-0004). Census output is Crown copyright and is reproduced with the permission
of the Controller of HMSO and the Queen’s Printer for Scotland.
*
Significant at 10%.
**
Significant at 5%.
***
Significant at 1%.

physical health of men and women aged 24 and over. Results indi-
cate that there are negative physical health consequences of divorce
or widowhood which increase with age, and that the health of
women is less impacted upon by dissolution, without any dis-
cernible protective effects from marital unions. Finally, research
which has considered the impact of transitions out of marriage
(separation and widowhood) on self-reported mental health found
that such transitions were significantly associated with a deterio-
ration mental health [29].
3.3. Cohort matters
Moreover the relationship between health and marital status
may not be constant over time, reflecting differences in the life
histories of men and women from different birth cohorts. Focusing
on cohort differences in changes to marital status in the US context,
Liu found that older persons born in the 1950s who experienced
a divorce were relatively more likely to report poorer health than
divorcees who had been born in the 1940s. By contrast, widowhood
was associated with poorer health for the 1910s cohort than for the
1920s cohort. It is suggested that the economic context for those
born in the 1950s may have an influence; inhospitable economic
conditions in the 1970s making for weaker employment prospects
resulting in adverse health outcomes [16].
Taking a similar cohort approach, Waldron et al. selects a
younger sample using data from the US National Longitudinal Study
of Young Women. Women aged 24–34 at the beginning of two
successive 5-year follow-up intervals (1978–1983 and 1983–1988)
were followed over time to explore the relationship between ini-
tial health status and subsequent health. Although there were
differences in health by marital status amongst the first cohort,
no differences were found amongst the second, highlighting the
importance of taking into account the external context faced by
each cohort at the same stage of the life course [30].
3.4. Life history matters
With the identification that persons who make a transition to a
non-marital status have a poorer health status, there is a growing
body of work on the short- or long-term impact of marital transi-
tions on health according to the timing of such transitions. Among
the body of work taking a long-term perspective on marital his-
tory is the work of Grundy and Tomassini. This used the Office for
National Statistics Longitudinal Study to explore the health bene-
fits of marriage for 75,000 men and women aged 60–79 years in
1991 taking into account individual’s marital status reported in
1971, 1981 and 1991. Table 1 presents results from Grundy and
Tomassini and shows the odds of reporting a long-term illness at
the 1991 census. Two features stand out: first that marital history
matters (as highlighted in model 1) and second that, in line with
other research, the relationship between marital experience and
later life health and mortality is modified by socio-economic fac-
tors. The odds of reporting a long-term illness for never married
and long-term divorced or widowed men were not significantly
raised once socio-economic background was controlled for (model
2). For women, however, raised odds for the recently divorced,
long-term remarried and those remarried since 1971 remained
even after controlling for socio-economic background (model 2).
The inclusion of socio-economic status considerably modified asso-
ciations, especially for women and the never-married. The research
298 J. Robards et al. / Maturitas 73 (2012) 295–299

identifies both marital protection and selection effects; marriage 2 discussed changes in marriage status and living arrangements in
having the potential to bring socio-economic advantage, while mid and later life. Although levels of solo living in later life have
remaining unmarried or marital termination making achievement recently declined because of increasing life expectancy meaning
of socio-economic advantage less likely [14]. that partnerships have been more likely to survive to older ages,
The benefit of a marital history approach is evident in the detail this trend may be expected to reverse as the cohorts currently
provided for the remarried groups. Given recent changes in patterns in mid-life (born in the 1950s and 1960s) enter old age. These
of partnership formation and dissolution, the consideration of the groups are more likely to have experienced partnership dissolu-
past marital history will become even more important for future tion and a significant proportion of those living solo in mid-life,
cohorts of elders. particularly men, have never partnered [22]. Section 3 showed
that negative health outcomes have been consistently identified for
single and divorced persons. Within this research area the weak-
4. Marital status, living arrangements and mortality
ening of current (cross-sectional) marital status as a measure in
relation to mortality was shown, and the merits of a life course
A particular focus within work on marital status and health has
or long-term marital history perspective were illustrated through
been on the detrimental effect on the life chances of men who
the work of Grundy and Tomassini [14]. In the last section, it was
remain unmarried or experience marital dissolution [2–4,31,32].
shown that research has consistently identified an adverse mor-
This relationship has been consistently identified, within the British
tality risk for men who remain unmarried or experience martial
context and internationally.
dissolution.
Among the most cited papers looking at mortality differences
Research on the relationship between marital status and health
by marital status is that by Gove which paid particular attention to
is complicated by data limitations, especially with regard to the
the adverse mortality outcomes for single men relative to women.
timing of events, uncertainty on exposure for identification of
It is argued that the differences in mortality can be attributed to
‘effects’, multiple transitions associated with events (e.g. separated
the characteristics associated with psychological state. Men living
to divorced) and mediating factors (employment, general state of
alone are more likely to be lonely than women with similar part-
the economy). Given the changes in living arrangement norms
ner histories [33]. Among recent analysis using a cross-national
among younger cohorts, research will increasingly need to make
approach, Murphy et al. found that the mortality advantage of mar-
use of longitudinal data in order to embrace a wider conceptualisa-
ried persons continues up to the oldest age groups (85–89) and
tion of partnership, living arrangements and marital status and to
that, the largest absolute differentials in mortality levels between
take into account changes in living arrangements and the long-term
marital statuses are at higher ages [34]. This finding parallels other
impacts of transitions. This paper has argued that with changes
work describing the “powerful and pervasive health benefits” of
in marital status and living arrangements taking place at middle
marriage at older ages (Pienta et al. [35], p. 583). Murphy et al.
and older age, future research will need to consider the longitu-
find that over the 1990s the advantage of married people increased
dinal living arrangements and partnership status of older people
for almost all the countries studied. An increasing body of work
in the context of their life course to fully account for the health
has used long-term marital history to account for current mortality
and mortality outcomes of different living arrangements. Indeed,
[14–16].
Murphy et al. identified that the increasing number of cohabiting
Given increasing cohabitation and rising divorce at older ages,
couples at older ages will necessitate use of de facto rather than de
the consideration of cohabitation at older ages is an important con-
jure marital status in the future [34]. Within the current body of
tribution to the literature. Lund et al. studied mortality in relation
work there is research which has taken long-term marital history
to cohabitation, living with or without a partner and marital status,
into consideration, notably Grundy and Tomassini and Blomgren
and demonstrated that in Denmark there is a high and significantly
et al. [14,15]. Although at the current time marital status remains
increased mortality for persons living alone. Compared with mari-
an important health and mortality predictor, research concerned
tal status, cohabitation status was a stronger predictor of mortality,
with partnership status will increasingly need to consider non-
and no age or gender differences were identified [36]. In the context
marital living arrangements such as ‘living apart together’, as well
of other work focusing on a person’s lifetime marital history [15],
as the quality of the ‘marital’ relationship and those who maybe
this paper highlights the weakening of marital status as an indica-
thought to be ‘living together but apart’. The country-specific con-
tor of health status over time, and suggests that a broader measure
text of such living forms should also considered in analysis using
of partnership or living arrangements may be a more effective indi-
living arrangements. Although longitudinal data is not available in
cator. However, Manzoli et al. used 53 independent comparisons,
all contexts, the richness which this data provides for research on
mainly in Europe and North America, in order to estimate the over-
the relationship between marital status, and health and mortality,
all risk of mortality for different categories of marital status and
is of significance for research in this area and will need to be further
marriage showed a significant protective effect similar in magni-
utilised in the future.
tude across countries [37].
Providing important insights with regard to mortality after the
death of a spouse is work by Martikainen and Valkonen. This study
Contributors
estimated mortality after bereavement of a spouse for the entire
population of Finnish men and women aged 35–85. In the first six
The authors wish to acknowledge the support of colleagues in
months after the death of a spouse an excess mortality of 30% for
the Engineering and Physical Sciences Research Council (EPSRC)
men and 20% for women was identified which was separate to any
Care Life Cycle (CLC) project (grant number EP/H021698/1) and the
common incident or illness [38]. Given the increase in an individ-
Economic and Social Research Council (ESRC) Centre for Population
ual’s mortality after the death of their spouse, research has found
Change (CPC) (grant number RES-625-28-0001) at the University of
that emotional support tends to decrease such risk [39].
Southampton.

5. Conclusions
Competing interests
Living arrangements and marital status have been shown to
have a significant effect on a person’s health and mortality. Section None.
 J. Robards et al. / Maturitas 73 (2012) 295–299
Provenance and peer review
Commissioned and externally peer reviewed.
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