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Reseach - Divorce
cost of divorce on women's health.
Centre for Epidemiology, National Board of Health
and Welfare, 106 30
Stockholm, Sweden (G Ringbäck Weitoft BA, B Haglund DMSc,
M Rosén DMSc); and Department of Public Health and
Clinical Medicine, Umeå University, Umeå, Sweden
(G Ringbäck Weitoft, M Rosén)
Background An increasing number of lone mothers are experiencing
financial and health disadvantages. Our aim was to assess
mortality among lone mothers compared with mothers with partners.
Methods In this population-based study, overall and cause-specific
mortality, between 1991 and 1995, was estimated for 90 111
lone mothers and 622 368 mothers with partners from data collected
in the Swedish Population and Housing Census 1990. We estimated
relative risks by Poisson regression, adjusted for socioeconomic
status, and, to handle health-selection effects, we adjusted
for previous inpatient history from 1987 to 1990. Findings
Lone mothers showed an almost 70% higher premature risk of
death than mothers with partners. The excess risk remained
significantly increased (relative risk 1•2 [95% CI 1•11•4])
after adjustments for socioeconomic status and previous severe
somatic and psychiatric inpatient history. Increased mortality
was especially pronounced for suicides (2•2 [1•53•1]),
violence (3•0 [0•910•6]), and alcohol-related
mortality (2•4 [1•44•1]) among mothers who
were without a partner in 1985 and in 1990.
The increase of lone mothers in society shows financial, social,
and health disadvantages. Nevertheless, the increased mortality
risk of lone mothers seems to be partly independent of socioeconomic
status and
health selection into lone motherhood. For long-term lone
mothers the risks may be underestimated when adjusting for
selection bias by taking hospital discharge history into account,
since these events may be part of the consequences of the
stress of lone motherhood. Lancet 2000; 355: 121519
During the past few decades the proportion of lone-parent
families has
increased substantially in Western countries. In Sweden, lone
parents now constitute about 20% of all families with children.1
Most lone parents are women. Although studies show that Swedish
lone mothers have an economically more favourable situation
than their counterparts in other countries, many findings
show that their situation is disadvantageous.14 Relying on
only one income, lone-parent families are to a larger extent
dependent on public subsidy. Social welfare and housing allowance
are far more common for lone-parent families than for other
families.1 The proportion of lone mothers who had difficulties
in paying their household expenses increased from about 30%
in 1979, to more than 50% in 1995. For couples, proportions
were 12% in 1979, and 20% in 1995.3
There is a well-established link between socioeconomic status
and health.59. Furthermore, the relation between marital status,
parenthood, and health is well known.10,11 White-collar workers
and high-income groups have better health than blue-collar
workers, unemployed people, and those in low-income strata.
Married people live longer and report better health conditions
than unmarried and divorced people. Given the circumstances
of lone mothers, it is not surprising that studies have found
a high proportion of lone parents with poor health.4,1216
In a comparison of self-perceived health among lone mothers
and mothers with partners, in Great Britain and Sweden,17
the increased relative risk for lone mothers was of the same
size in both countries despite a more favourable social policy
in Sweden. There are few studies on mortality, although in
some analyses of the effect of occupational, marital, and
parental roles on mortality, lone mothers were found to have
an increased risk of premature death.18,19
The explanations offered for these health disadvantages are
mainly divided between theories of social causation and health
selection. Social causation suggests that the psychological
stress, stigma, and financial difficulties associated with
lone parenthood have adverse health consequences. For previously
married people the stress suffered during marital breakdown
also contributes. The health-selection argument suggests that
the "healthy state of marriage" is due to a lower
probability for unhealthy people to get married, stay married,
or remarry. Previous studies have mainly focused on elucidating
the processes of social causation.14 Studies that examine
health-selection mechanisms are rare, probably because of
the scarcity of the data required for this kind of research.
We analysed the mortality of lone mothers in Sweden compared
with mothers with partners on the assumption that the poor
socioeconomic status of lone mothers contributes to higher
mortality. We adjusted for previous inpatient history to handle
health-selection factors. This was done for overall and cause-specific
mortality. In addition, we assessed the modifying effects
of social position, social welfare, and number of children
on the association between mortality and lone motherhood.
The population was generated from the Swedish Population and
Housing Census 1990. In Sweden, it is mandatory for every
household to answer and return a census questionnaire (from
1960 to 1990, the census was every 5 years). The drop-out
rate in the 1990 census was 2•5%.20 We selected women
aged 2954 years, living alone or with a partner, and with
children aged 015 years, by using a variable about household
type. We combined this variable with information about marriage
or consensual union. For each individual in the census there
is information about the oldest member of the household. To
check our classification and to count the number of children
in a family, we linked the members of each household and excluded
all women classified as mothers who had no matching children.
Information on country of birth, age, socioeconomic status,
housing situation, and geography was also obtained
from the 1990 census. Socioeconomic status was defined according
to a
classification used by Statistics Sweden, which is based on
occupation but also takes educational level of occupation,
type of production (wares or services), and position at work
into account.21
Information on social welfare and unemployment benefits for
each participant was obtained from the Total Enumeration Income
Survey 1990 (Statistics Sweden), which comprises information
about the taxes and incomes for the entire population. We
had access to the annual totals, and women who received any
amount of allowance were classified as receiving either social
welfare or unemployment benefit. The linkage procedure generated
1010 drop-outs (0•14%). We also linked data to the 1985
census to get data on family situation from an earlier period.
Information on mortality for 199195 was obtained from the
National Cause of Death Registry. To control for a history
of morbidity (psychiatric and somatic) we linked data to the
Swedish Hospital Discharge Register for 198790, which comprises
all discharges from Swedish hospitals (National Board of Health
and Welfare, Centre for Epidemiology).
Analyses were made on total mortality and the following broad
cause-of-death groups, as defined by the International Classification
of Diseases, ninth revision (ICD-9): ischaemic heart disease
(410414, 429.2), cancer
(140209), respiratory diseases (460519), and injuries and
poisoning
(E800E999). External causes of death were further divided
into the
following categories: suicide (E950E959 and E980E989); violence,
assault, and homicide (E960E969). Alcohol-related mortality
was defined as ICD 291, 303, 305.0, 357.5, 425.5, 535.3, 571.0571.3,
E860, E980+980, on the basis of either underlying or contributing
causes of death. Former illness was defined and divided into
two categories: women who had been discharged from hospital
between 1987 and 1990 with a psychiatric diagnosis (291319);
and women who had been discharged during this period with
a somatic diagnosis--ie, with a diagnosis other than a psychiatric
or maternity-care (630679) diagnosis.
We assessed person-years at risk by adding up the years the
individuals were alive and living in Sweden during the follow-up
period (199195). The year of death contributed 6 months for
that specific calendar year. We obtained an indicator of the
duration of lone or couple motherhood by taking into account
the civil status 5 years previously from the Population and
Housing Census 1985.
Multivariate analyses were done by Poisson regression with
mortality as the dependent variable. Age was entered as a
continuous independent variable and was present in all models.
Adjustments were also made for different groups of variables:
those mainly reflecting the health status of the individuals
before entering the study, and those mainly reflecting the
social situation of the mothers. Health-status variables were
used to control for possible confounding from selection of
physically and psychologically vulnerable persons into lone
motherhood, and social-situation variables served as explanatory
variables of a possible excess mortality rate. We used SAS
version 6.12 for statistical analyses.
After preliminary analyses, the categories country of birth,
living in a big
city, and receipt of unemployment benefit were excluded from
all models
because they did not seem to be confounders.
We studied 90111 lone mothers and 622368 mothers who had partners.
The socioeconomic status of lone mothers in comparison to
mothers with partners is shown in table 1. A slightly higher
proportion of lone mothers than mothers with partners were
manual workers or high and medium non-manual workers, and
were more likely to lack information about occupation. We
also analysed the level of education (data not shown), and
found a lower degree of higher education (ie, >12 years
in school) among lone mothers (22687 of 90111 [25%]) than
among mothers with partners (189940 of 622368 [31%]). Lone
mothers were six times more likely to receive social welfare
and two times more likely to receive unemployment benefits
in 1990 than were mothers with partners. A higher proportion
of lone mothers lived in one of the three largest cities in
Sweden (Stockholm, Gothenburg, and Malmoe), and most rented
their homes; more than 80% of mothers with partners owned
their homes. Lone mothers had fewer children on average than
mothers with
partners. Lone mothers were more likely than mothers with
partners to have had a psychiatric diagnosis, whereas the
relative differences in somatic diagnoses were small. 25•4%
of lone mothers and 22•8% of mothers with partners had
been hospital inpatients during 1987/90.
The crude mortality rate (number of deaths/person-years
at risk) indicated an overall excess mortality risk for lone
mothers irrespective of
stratification (table 1). For lone mothers, the risk of dying
within a
5-year period was almost 70% higher than for mothers with
partners when adjustments were made for age (table 2). However,
the risks were reduced when hospital data indicating previous
severe somatic or psychiatric morbidity were entered into
the model. When socioeconomic conditions (socioeconomic status,
social welfare, number of children, type of dwelling) were
entered into the model, there was a greater decrease in the
mortality risk (table 2). There was an excess risk for ischaemic
heart disease among lone mothers when we adjusted only for
age. However, when we adjusted for socioeconomic factors and
previous psychiatric disease, which were highly correlated
to smoking, the significant effects diminished. The greatest
risks were found among external causes (E800E999), including
suicide, with an almost 60% increased risk for lone mothers
after adjustment for both hospital inpatient care and socioeconomic
conditions.
By grouping the lone mothers and mothers with
partners in 1990 according to their family situation in 1985,
we took the duration of lone and couple motherhood into account
(table 3). Women with children and who were without a partner
at both times had the highest total mortality risk, both when
age was controlled for, and when somatic and psychiatric inpatient
history from 1985 to 1990 and socioeconomic variables (socioeconomic
group, social benefits) were entered into the analysis (table
3). Having a partner on both occasions or changing from the
single to the couple status was associated with lower mortality.
There was no significant difference between lone mothers and
mothers with partners for ischaemic heart disease, probably
due to small numbers. For cancer mortality only mothers who
had been separated
from their partner during the past 5 years had a significantly
increased
risk after adjustment for age. The risk of death from external
causes,
injuries, and poisoning doubled for mothers who were alone
in 1985 and 1990, compared with mothers who had a partner
in 1985 and 1990, after controlling for hospital and socioeconomic
variables (table 3).
Women who were with partners on both occasions had the smallest
risk of dying from suicide, violence, assault, homicide, or
alcohol-related causes (table 3). When age was taken into
account, mothers without partners in 1985 and 1990 had an
almost four-fold risk of committing suicide and a five-fold
risk of being a victim of violence (although the absolute
numbers are quite small) or dying of alcohol-related causes.
After controlling for hospital and socioeconomic variables
the excess risks were lowered.
An expected dose-response relation was apparent for many causes
of death. Mothers who were living with a partner in both 1985
and 1990 had the lowest risks, followed by women who were
alone in 1985 and cohabitant in 1990. Cohabitant women who
separated from their partner during 198590 had higher risks,
and the highest risks were found among women who were lone
mothers in both 1985 and 1990. Analyses were also done to
assess whether the relation between lone
motherhood and mortality varied by socioeconomic group, receipt
of social welfare, and number of children. The effects of
lone motherhood on all-cause mortality were similar in all
socioeconomic categories and among those who received social
welfare as well as those who did not. We found a slight increase
of the relative risks with increasing number of children (one
child, 1•21 [95% CI 1•071•37]; two or three
children, 1•29 [1•091•53]; at least four
children, 1•49 [0•683•29]). We could not
exclude that this effect modification was random, since the
confidence limits around the interaction-term were wide and
included 1•0.
Our study of more than 90 000 lone mothers showed an increased
premature death risk for lone mothers compared with mothers
living with partners. The highest risks were for suicide,
violence, and alcohol-related mortality, although absolute
numbers of violent deaths were small.
Some of the mortality differences in the multivariate analyses
were
accounted for by differences in socioeconomic status. To some
extent we have controlled for health selection by inclusion
of previous psychiatric and somatic morbidity in the models.
However, after these adjustments there was still a significant
increase in all-cause mortality, suicide, inflicted violence,
and alcohol-related mortality.
Use of the variable household by type alone in a definition
of lone mothers and mothers with partners results in the misclassification
of 8% of lone mothers and 2% of mothers with partners, according
to the Population and Housing Census 1990.20 However, we combined
different variables, linked the members of each household
and excluded all women classified as mothers but with no matching
children in the register (n=930). The risk for misclassification
should have been minimised by this procedure and does not
imply systematic bias.
The likelihood that a woman is married or living with a partner
may be
influenced by the health status or earlier illness of the
woman. To control
for this potential selection bias, we analysed whether the
woman was
admitted to hospital at any time in the 4 years preceding
the study period; however, this period may have been too short.
We had information about family situation for only the years
1985 and 1990 (census data) and no information on the exact
timepoint for change of civil status. For long-term lone mothers,
hospital admissions might have resulted from the stresses
of lone motherhood. In that case, adjustment for hospital
discharge will give an underestimation of the effect of lone
motherhood on mortality.
Furthermore, we had no information about health problems that
do not need medical attention in hospital. The limitations
of the data available did not allow us to extend collection
of morbidity data. The sociodemographic variables were measured
at one timepoint and merely
served as indicators of socioeconomic situation. Although
a broad range of variables was available, many aspects of
a life situation cannot be
elucidated from register data. For instance, we had no information
about
existing, or lack of, confiding/intimate relationships, or
any experienced
stress and stigma, all of which are factors suggested by Benzeval14
as
related to lone mothers' health.
The use of multivariate models and a longitudinal approach
gives an
understanding of the relative importance of different factors
that may
explain the health differences between lone mothers and mothers
with
partners. The interpretation needs to be made with care so
that the
substantial public-policy problem of the poor health of lone
mothers is not thought unimportant, just because it can be
explained away by other
factors.14 However, from a policy perspective it is important
to ascertain
whether the increased mortality of lone parents is primarily
a result of
their being disadvantaged or whether there is something else
in lone
motherhood that is damaging to health and leads to an increased
risk of
premature death.
Studies among lone mothers with dependent children have shown
that mothers in full-time employment have poor psychosocial
health.12,22 In Sweden, an important cornerstone of family
policies has been the goal of full employment for both men
and women and the possibility of combining
parenthood and salaried work. Lone mothers in Sweden are more
likely to work full time than are married mothers, and on
average they work more hours per week.1 Although full-time
employment gives the opportunity to increase the family income,
and increases confidence and self-esteem, it may also lead
to role overload,17 because of the strain of combining work
and parental roles without the emotional or financial support
of a partner. Gähler2 found that divorced mothers had
lower access to social support than other women. Although
this finding was based on small numbers, another Swedish study
reported that lone mothers, compared with mothers with partners,
were more likely to be daily smokers, took less exercise,
had a lower quality of their social network, and were more
likely to work full time (52•2% vs 35•6%).23 There
are economic reasons for the longer working hours of lone
mothers, since although shorter hours are sanctioned by Swedish
law for parents of small children, the mother may still have
to work longer hours to support herself and her children.
The investigators suggested that lone mothers should be given
the financial incentives to work less.23 Whitehead and colleagues
have also suggested that lone mothers suffer from time poverty.18
The expectations to work, despite a relatively weak position
in the labour market, often in poor-quality jobs, and lower
access to social support are factors that contribute to the
poorer health of lone mothers.
However, an intact marriage is no guarantee of an emotionally
healthy,
well-supervised home environment. Thus, lone parenthood is
for some people an escape from a different set of problems
and becoming a lone parent may actually improve their health
chances. For example, in the UK, 20% of lone parents indicate
violence and 15% give alcoholism and drug abuse as major factors
in the breakdown of the relationship with their partner.24
So there might even be a positive health selection linked
with lone motherhood, because it takes strength and power
of initiative to leave a marriage that is not functioning.
A divorce leading to lone motherhood might not necessarily
be an entirely negative experience.
The strengths of our study were the completeness of the study
population, the longitudinal approach, and the wide set of
individual background characteristics, which enabled a multivariate
approach. Other studies have also shown increased morbidity
and mortality for lone mothers, but our study lends further
support to the hypothesis that lone motherhood or separation
are stressful events that lead to premature mortality. The
increased mortality risks seem to be partly independent of
a previous history of severe illness, socioeconomic status,
&c. The analysis of mortality and changes in civil status
also gives further support to this hypothesis.
Gunilla Ringbäck Weitoft was responsible for study design,
analyses, and
writing of the paper. Bengt Haglund contributed to discussion
about study design and data analyses. Måns Rosén
contributed to data analyses and writing of the paper.
1 Nyman H. An economic analysis of lone motherhood in Sweden
(doctoral thesis). Göteborg: Department of Economics,
Göteborg University, 1998.
2 Gähler M. Life after divorce. Economical and psychological
well-being
among Swedish adults and children following family dissolution.
Dissertation series 32 (doctoral thesis). Stockholm: Swedish
Institute for Social Research, 1998.
3 Vogel J. Economic problems. Living conditions and inequality
19751995 (in Swedish with English summary). In: Levnadsförhållanden,
rapport no 91. Stockholm: Statistics Sweden, 1997.
4 Burström B, Diderichesen F, Shouls S, Whitehead M.
Lone mothers in Sweden: trends in health and socio-economic
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One of the most consistent findings about suicide is the lower
rate among women than men. In England and Wales, for example,
the male to female ratio is around 3:1 but higher in the younger
age-groups. Similar sex differences are reported from many
countries in the developing and developed worlds.1 A notable
exception is China (where the sex difference is reversed),2
and in several countries rates are high among immigrant women
born in the Indian subcontinent.3
A male preponderance is found in other kinds of unnatural
mortality.
Homicide is an offence usually committed by men, with men
as their victims; in England and Wales only a quarter of homicide
victims and a tenth of perpetrators are female.4 Those who
die in accidents too are most likely to be male, and in England
and Wales only 6% of accident deaths occur in women aged under
35. But it is the suicide figures that most need to be explained
as suicide becomes an international health priority, and two
questions arise. Why are suicide rates lower in women? And
what are the factors that put certain women at risk?
Two papers in today's Lancet address the risk of unnatural
mortality,
particularly suicide, in women in two diverse cultural settings--Bangladesh
and Sweden. In Bangladesh half the unnatural deaths in women
identified by a painstaking case-finding exercise were by
suicide, most by poisoning. The largest numbers were in women
aged under 30, and there was an association with being married.
The investigators conclude that their findings are consistent
with the view that economic adversity and marital and family
discord are important causes of suicide in Bangladesh. The
Swedish study, a population-based examination of deaths among
single mothers, also highlights the importance of psychosocial
adversity in suicide and other causes of premature death among
women. However, the higher rates of mortality overall
and of suicide specifically that were found among lone mothers
persisted
after the analysis was adjusted for social and economic factors
and (as a marker of previous health) for hospital admission
for psychiatric and
somatic illness. The vulnerability of lone mothers could not
be attributed
to these factors alone. The disparity between men and women
in suicide rates has been most apparent in the past three
decades, during which suicide rates among young men but not
young women have increased substantially in many countries.
In England and Wales in 1970 the population suicide rate was
just over 10 per 100 000, similar to recent figures. But in
1970 the rate for men was 12•2 and that for women was
8•7, a male to female ratio of 1•4:1. Now the
rate for men is over 15 and that for women has fallen to under
5, so the excess of deaths among men has doubled. Three broad
explanations are possible. The causes of
the increased suicide rate among men may be less common among
women, or they may be experienced differently, or they may
be counterbalanced by other factors.
These possibilities are not mutually exclusive, and examples
of each are
apparent in the links between suicide and unemployment, divorce,
and misuse of alcohol and drugs. Increases in the prevalence
of these factors may have contributed to the rise in suicide
rates among men in recent years and the widening gap between
the sexes.5 Alcohol and drug misuse has also risen among women,
although rates remain lower than among men. By definition
divorce happens as commonly among men as among women, but
the experience is often different. In particular, women are
more likely to retain responsibility for the care of young
children, a factor that seems to be protective against suicide.6
Although population unemployment rates may be associated with
suicide in both sexes,7 the effect of rising unemployment
rates among men in the 1980s on the socioeconomic circumstances
of women, and therefore their risk of suicide, may have been
offset by the increasing entry of women into the job market,
another possible protective factor.8
What, then, is different about those women who do take their
own lives?
Inevitably they have high rates of these key risk factors.
They also have
high rates of mental illness. Furthermore, the impact of severe
mental
illness, such as schizophrenia, on suicide rates may be greater
in women
than in men.9 This point may be one reason for the higher
rate of recent
contact with psychiatric services among women who have committed
suicide--29% compared with 19% among men4--although similar
findings on contact with primary care10 suggest that such
figures also reflect a greater readiness to recognise and
accept the need for mental-health care.
Suicide rates can also be influenced by the lethality of available
methods
of self-harm. In general this fact protects women because
they are less
likely than men to use violent methods,4 more likely to take
non-fatal
overdoses of drugs,11 and more likely to survive their first
episode of
self-harm.12 However, violent methods are a feature of suicide
by women with severe mental illness; the proportion dying
by hanging or jumping from a height is greater among women
with severe mental illness than among the female population
as a whole.4 Certain violent methods are also associated with
suicide in particular cultures: in Asian women in England
and Wales burning is disproportionately common.13 In Bangladesh,
women who commit suicide do so mainly by poisoning, and they
are thought not to use psychotropic drugs or analgesics, as
in most western countries, but to take pesticides, which are
widespread in a rural economy.
Suicide among women, as in every other group, has neither
a single cause nor a single solution, but the components of
a prevention strategy are universal. They include the alleviation
of social hardship, reduction in
access to the main methods of suicide, and specific measures
for high-risk groups. Suicide rates in women overall may be
comparatively low but concern over rates in men should not
disguise the high risk that some women also face.
Louis Appleby
School of Psychiatry and
Behavioural Sciences, University of Manchester,
Withington Hospital, West Didsbury, Manchester M20 8LR, UK
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3 Patel SP, Gaw AC. Suicide among immigrants from the Indian
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4 Appleby L, Shaw J, Amos T, et al. Safer services. Report
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self-harm in Oxford, 19851995: implications for clinical services
and the
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12 Isometsä ET, Lönnqvist JK. Suicide attempts preceding
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