Born out of wedlock and never married—it breaks a man's heart

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Abstract

This study examines whether men who were born outside marriage in early twentieth century Sweden run a higher risk of dying from ischaemic heart disease (IHD) in middle and old age compared to men who were born inside marriage. Analyses are based on the male half of the Uppsala Birth Cohort Study, Sweden, consisting of all 7411 boys who were born alive at the Uppsala Academic Hospital during the period 1915–1929. The statistical method used is Cox regression. The results demonstrated a statistically significant excess mortality among men born outside marriage, which could not be explained by either social class of origin or birth weight for gestational age. Instead, this elevated mortality was largely explained by the more than doubled mortality risk among those men born outside wedlock who never married in relation to the corresponding group of men born to married parents. Even when three indicators of adult socio-economic status were adjusted for, men who never married and were born outside marriage still ran a 93 per cent higher risk of dying from IHD than men who never married but were born inside marriage. This intervening effect of adult marital status was restricted to the category of never married men. Thus, although divorcees demonstrated an even higher mortality risk in relation to the married than did those who never married, this was equally true for men born inside and men born outside marriage. In the concluding section of the paper I argue that these findings should be understood in terms of the childhood social stigma that the illegitimate children experienced. This stigma may have resulted in an increased susceptibility, which in combination with the “failure” in adulthood to comply with the established norms of society regarding matrimony led to higher levels of IHD mortality in middle and old age.

Introduction

Life-course studies have become increasingly advocated for in research into adult disease and mortality. Studies based exclusively on mid-life tend to overlook the fact that the origin of good health is often to be found in early life (Kuh & Ben-Shlomo, 1997). The following study, based on all the boys who were born alive at the Uppsala Academic Hospital in Sweden during the period 1915–1929, will adopt a life-long perspective. The focus will be on boys who were born outside marriage. During the early part of the twentieth century these children constituted a disadvantaged group in many ways. The social circumstances that the so-called illegitimate children experienced during upbringing in terms of shortage of economic resources and social stigma are here assumed to have led to long-term consequences with regard to their cardiovascular health.

More specifically, I will examine whether an association exists between the mother's marital status at the time of childbirth, and male mortality from ischaemic heart disease (IHD) in middle and old age (55–80 years). My primary interest is whether such an association works via these males’ own marital status. Previous research has indicated that marital career may be transferred across generations, and this has proved to be the case also with regard to the subjects of the present study (Vågerö & Modin, 2002). Thus, while children from broken homes seem to run a higher risk of becoming divorced themselves as adults (Levinger, 1965; Mott & Moore, 1979; Amato, 1996), they are also less likely to enter marriage in the first place (Vågerö & Modin, 2002). The excess mortality of unmarried persons in relation to those who are married is, in turn, a well-documented fact (Hemström, 1996; Hu & Goldman, 1990). Independently or in combination with adult marital status, being born outside marriage is hypothesised to involve an increased risk of male mortality from IHD in middle and old age.

Section snippets

Early life influences on adult cardiovascular disease

IHD is a leading cause of death in Sweden and in many other industrialised countries. In 1996, about 50 per cent of all male deaths in Sweden were due to cardiovascular disease, of which 56 per cent occurred as a result of IHD. The underlying cause is pathological changes in the coronary arteries, depriving the myocardium of oxygen (Wamala, 1999). An individual's risk of developing cardiovascular disease is partly determined by the social circumstances under which he or she lives. Thus, factors

Being born outside marriage

About 20 per cent of the babies delivered at the Uppsala Academic Hospital during the period 1915–1929 were born outside marriage. Besides the fact that these children generally belonged to the lower social classes, they were also, on average, lighter, shorter and had a lower ponderal index at birth compared to babies who were born inside marriage (Vågerö, Koupilová, Leon, & Lithell, 1999). Although previous research has demonstrated several health related disadvantages among children and young

Marital status and mortality

The tendency for married persons to live longer than unmarried ones has been demonstrated for a large number of countries (Hu & Goldman, 1990) and several hypotheses have been put forth in order to explain these findings. Many researchers argue that marriage, to a greater or lesser extent, is a process of selection whereby a considerable share of individuals with serious health problems become and/or remain single (Kiernan, 1988; Goldman, 1993; Goldman, Takahashi, & Hu, 1995). A selection may

Population under study

The study is based on the Uppsala Birth Cohort Study (UBCoS) database, consisting of all 14,192 live births at Uppsala Academic Hospital that took place in 1915–1929. In the present study only the male half of the cohort will be analysed, of whom 5868 were born to married mothers and 1464 to unmarried mothers.3

Analytical strategy

In the analyses, control variables will be added stepwise into new models in order to see whether the initial effect of the mother's marital status on IHD mortality is altered. First, the effect of the mother's marital status will be presented, adjusted only for birth year and mother's age. The latter is an important control variable since unmarried mothers were on average 6.6 years younger than married mothers in the studied material.4

Dependent variable

Ischaemic heart disease mortality was classified according to the International Classification of Diseases (410–414), and the 8th and 9th revisions were used (1970–1995).

Independent variables

The mother's marital status at the time of childbirth constitutes two categories: married or single. Sons of mothers who were divorced (n=18) or widowed (n=45) were excluded from the study together with the 16 boys for whom data on mother's marital status was missing. Birth weight for gestational age serves as an indicator of

Methods and data management

Cox's proportional hazards model was applied in the mortality analyses (Clayton & Hills, 1996). In order to distribute years at risk as accurately as possible with regard to marital career, the file was “expanded” so that each marital status entered by an individual constitutes one observation in the data set. This procedure can result in a maximum of four states (observations) stemming from one person: (1) being single, (2) being married, (3) being divorced or widowed and (4) being remarried.

Results

Table 1 presents the relative risk of IHD mortality for men aged 55–80 years. The bivariate analyses reveal a significantly higher risk of IHD mortality for men born outside marriage compared to those born inside marriage. This is also true for men who have never married or are divorced in relation to married men. Model 1 shows that men born out of wedlock run a 32 per cent higher risk of IHD mortality than men born inside marriage when birth year and mother's age are adjusted for. Controlling

Conclusions

The present study showed that men born outside marriage had a statistically significant higher risk of dying from IHD in middle and old age compared to men who were born inside marriage. This elevated mortality risk was caused neither by their generally slower growth rate in utero, nor was it a result of their generally lower social class of origin. Instead, it was largely explained by the increased mortality risk among the men born out of wedlock who never married in relation to the

Acknowledgements

This study was financed by the Swedish Council for Working Life and Social Research and the vulnerability research programme of the Margaret and Axel Axsson Johnson's Foundation. I am very grateful to Denny Vågerö for valuable ideas and comments during the whole progress of this study. I am also indebted to Örjan Hemström from whom I received useful advice regarding data management, to Ingemar Kåreholt for inestimable help in various statistical matters, and to Pär Sparrén for shrewd comments

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