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Logue, Jessica

© 2018 Logue. This open access article is distributed under a Creative Commons Attribution 4.0 License (https://
creativecommons.org/licenses/by/4.0/)
ISSN 1526-0569 | Essays in Philosophy is published by the Pacific University Libraries
Book Review
Taking Back Philosophy: A 
Multicultural Manifesto
Volume 19, Issue 2 (2018)
Jessica Logue
University of Portland
Essays Philos (2018)19:2  |  DOI:  10.7710/1526-0569.1618
Correspondence:  logue@up.edu
Essays in Philosophy
Taking Back Philosophy: A Multicultural Manifesto
Bryan Van Borden, New York: Columbia University Press, 2017. 248 pp., $26.00 
ISBN 9780231184373 
Volume 19, Issue 2Essays in Philosophy
2 | eP1618 Essays in Philosophy
Philosophy departments in America are at a crossroads. Current conditions have made 
it the case that most students are learning primarily—or exclusively—about Western 
philosophy. And most professors are trained to teach theories and concepts from the 
Western tradition only. This means philosophical ideas from outside this tradition are 
largely undervalued or overlooked, if not outright ignored, and this deficit means that 
few students graduate with much knowledge of other philosophical traditions (e.g. Af-
rican philosophy). Contributing to this deficit is the fact that few trained philosophers 
teaching in America have been trained in these areas and are therefore qualified to teach 
material from these traditions. But that in itself does not justify overlooking the rich 
philosophical traditions around the globe. If we are to improve this status quo, we must 
take action. But how do we diversify? Bryan Van Norden offers one suggestion in his 
book Taking Back Philosophy. 
Van Norden begins with a provocative claim: “philosophy must diversify or die” (8). 
While this may sound drastic to some, Van Norden careful in both his diagnosis of the 
current status of American training of philosophers and also in his prognosis and appeal 
for change.
Prior to publishing this book, Van Norden and Jay Garfield (who wrote the foreword of 
this book) published a piece in “The Stone,” the philosophy column of the New York Times. 
In this piece, titled “If Philosophy Won’t Diversify, Let’s Call It What It Really Is,” the 
authors suggested that American philosophy departments that refuse to diversify should 
be forced to change the name of their departments from “Department of Philosophy” to 
“Department of Anglo-European Philosophy.” This piece netted an astounding number 
of comments and a fair amount of backlash, which is perhaps why Van Norden describes 
his book as “polemic and intentionally provocative in the hope that it will incite discussion 
and raise awareness” (xxiii). I imagine he has already succeeded in doing both. 
Van Norden begins with a sharp assessment of the current status of philosophy in main-
stream America, namely in the view of the American public. He points out that phi-
losophy is not just looked down upon by politicians and pop culture figures, but that 
data regarding the high performance of philosophy majors on exams like the LSAT and 
MCAT is ignored. Philosophy, like other areas of the humanities, is not respected pub-
licly for its value—inherent or instrumental. And yet, despite the often stellar perfor-
mance of philosophy majors on these and other exams, the discipline’s lack of diversity 
is failing those we are training. This lack of diversity is often paired with a prioritizing 
of a narrowly Western canon that ignores and devalues all other philosophical thought 
that has occurred in the history of human thought. Van Norden is deliberate in pointing 
out that this current set of conditions is the byproduct of both a rewriting of the history 
of philosophy that occurred in the nineteenth century and also a growing justification 
Logue | Review: Taking Back Philosophy
 commons.pacificu.edu/eip eP1618 | 3
of philosophy as a discipline for white European intellectuals (21). Reckoning with these 
details will likely be uncomfortable for some readers, as is often the case with confront-
ing privilege and racism. But if diversifying is seen as better than death, then this con-
frontation is a necessary step in moving forward. To sweep aside the racist history of 
Western philosophy and ignore the beliefs held by philosophical giants like Kant would 
be disingenuous. Van Norden’s book does not mince words. He clearly and concisely 
documents the supremacist attitudes of canon philosophers such as Kant and Hegel, il-
lustrating precisely how their words laid a foundation for racism that continues today. 
This recognition is a step in the right direction, paving the way toward diversity and 
inclusion of other non-Western philosophies and traditions. 
As a product of this system—my own graduate training in philosophy included no 
courses in non-Western philosophy because none were offered—and as a professor at 
a university intending to combat this crisis head on (my department exchanged a logic 
requirement for a mandatory “critiques of Western philosophy” component in our intro-
ductory course), I see firsthand the problem created by this deficit in the system, and also 
the difficulties in correcting it. The toolbox of Western philosophy includes particular 
arguments and concepts that do not immediately map onto non-Western philosophical 
traditions, which have their own toolboxes. As though anticipating the struggles of phi-
losophers like me, Van Norden offers ways of creating dialogue between different tradi-
tions, providing a detailed discussion of the history of the Western concept of substance 
and using this to discuss the Buddhist conception of the Five Aggregates. Van Norden 
shows that to engage in a dialogue between these two traditions, one does not need to 
be a Buddhist scholar to understand the Five Aggregates, nor do the tools of Western 
philosophy need to perfectly map onto teaching non-Western ideas. This is but one of 
the examples Van Norden presents; the book is replete with other helpful pairings for 
discussion in multiple areas of philosophy. 
Van Norden anticipates resistance and readily volunteers both defenses against critics 
who may oppose the idea of teaching outside the Anglo-European tradition and help-
ful information regarding moving forward. For a short book (216 pages including the 
index), the volume is comprehensive, offering insights about the state of the field and 
plenty of wry humor. He refers to these overlooked philosophical traditions as Less 
Commonly Taught Philosophies (LCTP) and uses his own expertise as a scholar of Chi-
nese philosophy to show the enormous value of including Chinese philosophy in one’s 
course. Citing China as a world power, he details the different purposes for which Presi-
dent Xi has invoked the work of Confucius in many of his speeches, and raises helpful 
points of comparison between Chinese and Western traditions. The book also contains 
a thorough comparative analysis between nationalism and notions of “wall building”  in 
both China and the United States. In part a snapshot of current conditions in academic 
Volume 19, Issue 2Essays in Philosophy
4 | eP1618 Essays in Philosophy
philosophy and recent events, Taking Back Philosophy manages to pack a lot of helpful, 
relevant information into its pages.
Examples from recent current events are artfully used to demonstrate the book’s thesis. 
For instance, Senator Marco Rubio’s claim during a 2016 GOP debate that “we need 
more welders and less philosophers” speaks volumes about public attitudes toward 
philosophy, and Rubio’s claims about the average income of philosophers is false. Van 
Norden thus manages to illustrate how the very soul of philosophy is in jeopardy—
both from forces outside (i.e., the American public who denounce the value of studying 
philosophy) and within (i.e., philosophers who do not want to diversify the canon). The 
plea to save philosophy is there at the core of the book. Van Norden demonstrates how 
inherently valuable philosophy is to individuals and civilization as a whole, but that 
in itself does not make the discipline immune to problems that jeopardize its future 
survival. Thus, we must combat the problems from within. In an increasingly globalized 
world, there is little reason to cling to the Anglo-European canon, and Van Norden’s 
examples deftly epitomize how applicable non-Western philosophies can both bridge the 
gap and vaccinate the disease. Taking Back Philosophy is a road map for the survival of 
philosophy and philosophers in America. 
The main critiques of Van Norden’s book are, again, anticipated within the book. Those 
who fear change will be resistant to overhauling the canon. Those who are skeptical of 
the value of Eastern thought will be quick to dismiss its value. Those who follow Senator 
Rubio’s thinking will resist the insistence here that philosophy really is valuable, that its 
ideas have wide, comprehensive application. Those who dislike polemic discussions and 
criticism of anti-intellectualism will bristle at the information and how it is presented. 
But Van Norden is unshaken by these criticisms and does not apologize for his views. 
And if we truly value philosophy, his argument is compelling.  As Van Norden writes, 
“Studying philosophy makes people more informed and more thoughtful citizens, more 
comfortable with the fact that others disagree with them, less vulnerable to manipulation 
and deception, and more willing to resort to discussion rather than violence” (128). If 
we want to combat anti-intellectualism, we need to make a strong case for the value of 
philosophy in higher education. If we want to help our students become more thoughtful 
and less vulnerable to forces of manipulation, false narratives, “alternative facts,” and 
other methods of deception, then we should do all that we can to better our discipline 
and ensure its survival. This is not the only way forward, but it is certainly a viable, 
valuable one. 


English

Review of Bryan W. Van Norden\u27s  Taking Back Philosophy

Background:  Previous research has identified physiologic changes post-menopause with cardiovascular disease, but little research has been conducted investigating a link with heart failure or the influence of parity for risk stratification.    
Methods:  An exhaustive search of available medical literature was performed. MEDLINE OVID, CINAHL, and Web of Science databases were searched using the keywords nulliparity, postmenopause, and heart failure. The articles were evaluated using GRADE.
Results:  The search resulted in 2 studies evaluating the incidence of heart failure in a postmenopausal population and accounting for gravidity.
Conclusion:  There is an association between nulliparity, grand multiparity, and increase in risk of heart failure in the postmenopausal population.  The strongest association can be seen in development of heart failure with preserved ejection fraction

Dingman, Erin

Pacific University 
CommonKnowledge 
School of Physician Assistant Studies College of Health Professions 
Summer 8-11-2018 
Parity and Heart Failure in Postmenopausal Women 
Erin Dingman 
Recommended Citation 
Dingman, Erin, "Parity and Heart Failure in Postmenopausal Women" (2018). School of Physician 
Assistant Studies. 639. 
https://commons.pacificu.edu/pa/639 
This Capstone Project is brought to you for free and open access by the College of Health Professions at 
CommonKnowledge. It has been accepted for inclusion in School of Physician Assistant Studies by an authorized 
administrator of CommonKnowledge. For more information, please contact CommonKnowledge@pacificu.edu. 
Parity and Heart Failure in Postmenopausal Women 
Abstract 
Background: Previous research has identified physiologic changes post-menopause with cardiovascular 
disease, but little research has been conducted investigating a link with heart failure or the influence of 
parity for risk stratification. 
Methods: An exhaustive search of available medical literature was performed. MEDLINE OVID, CINAHL, 
and Web of Science databases were searched using the keywords nulliparity, postmenopause, and heart 
failure. The articles were evaluated using GRADE. 
Results: The search resulted in 2 studies evaluating the incidence of heart failure in a postmenopausal 
population and accounting for gravidity. 
Conclusion: There is an association between nulliparity, grand multiparity, and increase in risk of heart 
failure in the postmenopausal population. The strongest association can be seen in development of heart 
failure with preserved ejection fraction. 
Degree Type 
Capstone Project 
Degree Name 
Master of Science in Physician Assistant Studies 
Keywords 
nulliparity, postmenopause, grand multiparity, heart failure 
This capstone project is available at CommonKnowledge: https://commons.pacificu.edu/pa/639 
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pg. 1 
 
 
 
Parity and Heart Failure in Postmenopausal Women 
 
 
 
 
 
 
 
 
 
Erin A. Dingman 
 
 
 
 
 
 
 
 
 
A Clinical Graduate Project Submitted to the Faculty of the 
School of Physician Assistant Studies 
Pacific University 
Hillsboro, OR 
For the Masters of Science Degree, August 11, 2018 
 
Faculty Advisor: Craig T. Turner, MD 
Clinical Graduate Project Coordinator: Annjanette Sommers, PA-C, MS 
  
pg. 2 
 
Abstract    
 
 
Background:  Previous research has identified physiologic changes post-menopause 
with cardiovascular disease, but little research has been conducted investigating a link 
with heart failure or the influence of parity for risk stratification.     
 
Methods:  An exhaustive search of available medical literature was performed. 
MEDLINE OVID, CINAHL, and Web of Science databases were searched using the 
keywords nulliparity, postmenopause, and heart failure. The articles were evaluated using 
GRADE. 
 
Results:  The search resulted in 2 studies evaluating the incidence of heart failure in a 
postmenopausal population and accounting for gravidity. 
 
Conclusion:  There is an association between nulliparity, grand multiparity, and increase 
in risk of heart failure in the postmenopausal population.  The strongest association can 
be seen in development of heart failure with preserved ejection fraction. 
 
Keywords:  Nulliparity, postmenopause, and heart failure 
pg. 3 
 
Table of Contents 
 
Abstract ............................................................................................................................... 2 
List of Tables ...................................................................................................................... 4 
List of Figures ..................................................................................................................... 4 
List of Abbreviations .......................................................................................................... 4 
BACKGROUND ................................................................................................................ 5 
METHODS ......................................................................................................................... 6 
RESULTS ........................................................................................................................... 6 
DISCUSSION ..................................................................................................................... 8 
CONCLUSION ................................................................................................................... 9 
References ......................................................................................................................... 10 
Table I: Quality Assessment of Reviewed Articles .......................................................... 11 
Table II. Heart Failure Incidence in Female populations based on parity ........................ 11 
Table III. Nulliparity and Differentiated Heart Failure Incidence .................................... 12 
Figure I. PRISMA Flow Diagram ..................................................................................... 13 
 
 
  
pg. 4 
 
List of Tables  
 
Table I:      Quality Assessment of Reviewed Articles 
Table II:     Heart Failure Incidence in Female populations based on parity 
Table III:    Nulliparity and Differentiated Heart Failure Incidence 
 
 
List of Figures 
 
 
Figure I:    PRISMA Flow Diagram 
 
 
List of Abbreviations 
 
HF…………………………………………………………………….........…Heart Failure 
HFrEF…………………………………...…. Heart Failure with reduced Ejection Fraction 
HFpEF………………………………...…. Heart Failure with preserved Ejection Fraction 
ICD...........................................................................International Classification of Disease 
HR………………………………………………………………………….…Hazard Ratio 
WHI…………………………………………………………….Women’s Health Initiative 
 
 
 
pg. 5 
 
Parity and Heart Failure in Postmenopausal Women 
 
BACKGROUND 
 Nulliparity is defined as never having been pregnant or never completing a 
pregnancy beyond 20 weeks gestation.  High (or grand) parity is classified as greater than 
or equal to 5 births. Heart failure (HF) may be classified as either diastolic HF (also 
termed heart failure with preserved ejection fraction (HFpEF)) or systolic HF (also 
termed heart failure with reduced ejection fraction (HFrEF)). 
With the increase in incidence of HF in the US population, determining risk 
factors in female patient populations can enable better management of care.  The 
Framingham Heart Study1 reported a lifetime risk of heart failure development in women 
at 1 in 6, with poorly managed hypertension identified as the major risk factor in 
development of future disease. Furthermore, the incidence of heart failure diagnosis 
increased with advancing age.1 Coronary heart disease, tobacco abuse, hypertension, 
obesity, diabetes mellitus, valvular disease and ethnicity are the typical qualities noted in 
a patient history that may influence one’s risk for heart failure diagnosis.2  
Heart failure is also known to occur in women in the peripartum setting, most 
commonly brought on by peripartum cardiomyopathy or hemodynamic changes, leading 
to exacerbation of symptoms in those with a previous diagnosis of heart failure.3  This 
raises the question, how does parity influence the risk for development of HF in a 
postmenopausal population? 
pg. 6 
 
METHODS 
An exhaustive search of available medical literature was performed. MEDLINE-
OVID was searched, utilizing the terms “parity or nulliparity”, “heart failure or 
cardiovascular diseases”, “adult” and “aged”. CINAHL and Web of Science databases 
were searched using the terms “parity or nulliparity”, “heart failure or cardiovascular 
diseases”, and “aged”.  Eligible articles included cohort studies published within the last 
10 years with postmenopausal women as the population of interest.  Studies referenced 
incidence of heart failure, postmenopause, in relation to the number of pregnancies of 
participants to infer risk assessment. The articles were assed for quality using Grading of 
Recommendations, Assessment, Development, and Evaluation (GRADE).4 See Figure I. 
RESULTS 
The MEDLINE-OVID search yielded 139 results when limited to articles 
published in the English language. Two articles5,6 were identified evaluating the 
incidence of heart failure in a postmenopausal population and accounting for gravidity. 
CINAHL yielded 13 results with one identified article which was a duplicate. The Web 
of Science search yielded 56 results with 2 articles of interest, again duplicates. See Table 
I. 
In 2009, publication6 of research directly addressing a relationship between parity 
and incident HF in a population of Swedish postmenopausal women was published. 
Results from this analysis demonstrated risk association with development heart failure in 
older women (≥50 years) in a J-shaped pattern.  In a study population of 1 332 062 
women, 6069 heart failure events were identified during the study period by International 
pg. 7 
 
Classification of Diseases, Ninth Revision (ICD-9) or International Classification of 
Diseases, Tenth Revision (ICD-10) diagnosis obtained from a first hospitalization or 
death of an identified participant as recorded in the Hospital Discharge Register and 
Cause of Death Register. Women with 2 births were used as the reference. Women who 
were nulliparitus, had one birth, or more than 4 births were more likely to have a reported 
ICD-9 or ICD-10 diagnosis for heart failure than women with 2 or 3 births. Hazard ratios 
(HR) for incident heart failure based on parity (0, 1, 2, 3, 4, and ≥5 births), in an age 
adjusted model were reported as 1.71, 1.36, 1.0, 1.13, 1.39, and 2.21 (p<0.0001) 
respectively.  Hazard ratios (HR) for incident heart failure based on parity (0,1,2,3,4, and 
≥5 births), in an age, birth year, and socioeconomic adjusted model were reported as 
1.78, 1.35, 1.0, 1.10, 1.31, and 1.91 (p<0.0001) respectively.6  See Table II. 
 In 2017, a second study5 focused on HF and parity was published. Using data 
from the Women’s Health Initiative (WHI), investigators examined data to identify a 
relationship between parity, reproductive duration, and age at first pregnancy with HF in 
a postmenopausal population. The WHI population of 28 516 postmenopausal women 
identified 1494 incidents of heart failure either by confirmed HF hospitalization or 
patients self-reporting, and subsequent adjudication by a physician review of records.  
Results demonstrated nulliparity was associated with a statistically significant increased 
risk of HFpEF in both age-adjusted (HR: 2.57; 95% CI:1.22 to 5.44) and multi-variable 
adjusted models (HR 2.75; 95% CI: 1.16 to 6.52)5. See Table III.  When assessing for 0, 
1, 2, 3, 4, and ≥5 births the respective age adjusted HRs were 1.80, reference, 1.05, 1.03, 
1.12, and 1.13 and multivariable –adjusted HRs of 1.70, reference, 1.13, 1.17, 1.19, and 
1.155. See Table II. 
pg. 8 
 
DISCUSSION 
Analysis of both cohorts have shown low and high parity are associated with 
more pronounced risks for heart failure5,6 with the least risk identified at 1-2 births. 
Stronger evidence of this phenomena is demonstrated in the Swedish cohort than in the 
WHI cohort, see Table II. High parity holds the greatest risk of heart failure events5,6. 
Interestingly, when data was analyzed to identify risk in women whose children were all 
parented by the same partner, the extent of risk was slightly reduced as compared to 
women with children by multiple partners. Both populations retained the J-shaped risk 
distribution.6  
The studies 5,6 included in this review have demonstrated a moderately strong 
increase in risk of HFpEF diagnosis, hospitalization, or cause of death in women without 
history of pregnancy. Evaluation of the Swedish cohort6 was able to demonstrate a 
statistically significant relationship between total incident HF/total number of events (P 
<0.0001; HR 1.71, CI: 1.59-1.84), whereas the WHI cohort did not have a statistically 
significant correlation (HR 1.70, CI: 0.95-3.03). 
Despite the results, both studies5,6 had limitations. In the WHI cohort,5 results 
comparing nulliparitus women and Total Incident HF, Incident HFrEF and Incident 
HFpEF all demonstrated small sample sizes for nulliparitus women, ranging from 182-
188 women out of study populations in excess of 28 000.  The small sample size may 
limit the significance of the statistical findings of this study population.  While the WHI 
population represented a more ethnically diverse sample population, the Swedish cohort 
did not provide a racial breakdown of participants, and recognized the rather homogenous 
pg. 9 
 
nature of the Swedish population. Future research with a focus population of women of 
varying ethnic backgrounds may yield data with greater validity for a risk relationship.  
Neither study identified contraceptive methods used by nulliparitus women.  Future 
research could include hormonal contraceptive usage data to identify if treatment with 
estrogen, progesterone, or a combination therapy influences future diagnosis of HF. 
CONCLUSION 
Both nulliparity and high parity have been shown to increase the risk of 
development of heart failure in a postmenopausal population.  Hazard ratio estimates 
ranging from 1.70 – 1.78 demonstrate nullliparitus women have slightly less than a two-
fold increase in risk of developing heart failure at older ages than women with 1-4 live 
births. Women whom have had given birth 5 or more times have a 2-fold increase in risk 
of heart failure events, as compared to women with 1 or 2 births.  Hormonal or 
hemodynamic changes which take place during pregnancies may lead to cardioprotective 
characteristics in women who have bore children, but this protective effect seems to be 
offset in the setting of high parity. This research may assist health care providers in 
recognizing other qualities in a patient’s social history that play a role in risk 
management.  
 
 
pg. 10 
 
References 
 
1. LloydJones DM, Larson MG, Leip EP, et al. Lifetime risk for developing 
congestive heart failure: the Framingham Heart Study. Circulation. 
2002;106:3068-3072. 
2. Vasan RS., Wilson PWF. Epidemiology and causes of heart failure. In: Colucci 
WS, Yeon, SB, ed. UpToDate. Waltham, Mass.: UpToDate, 2018. 
https://www.uptodate.com/contents/epidemiology-and-causes-of-heart-failure. 
Accessed January 26, 2018. 
3. DeCara JM, Lang RM, Foley MR. Management of heart failure during pregnancy. 
In: Colucci WS, Lockwood CJ, Yeon SB, ed. UpToDate. Waltham, Mass.: 
UpToDate 2018. https://www.uptodate.com/contents/management-of-heart-
failure-during-pregnancy. Accessed January 3, 2018. 
4. GRADE working group. GRADE website. http://gradeworkinggroup.org/. 
Accessed June 10, 2018. 
5. Hall PS, Nah G, Howard BV, et al. Reproductive factors and incidence of heart 
failure hospitalization in the women’s health initiative. Journal of the American 
College of Cardiology. 2017;69(20):2517-2526. doi:10.1016/j.jacc.2017.03.557. 
6. Parikh NI, Cnattingius S, Dickman PW, Mittleman MA, Ludvigsson JF, Ingelsson 
E. Parity and risk of later-life maternal cardiovascular disease. American Heart 
Journal. 2010;159(2):215-221.e6. doi:10.1016/j.ahj.2009.11.017. 
 
 
 
pg. 11 
 
 
Table I: Quality Assessment of Reviewed Articles 
Study Design 
Downgrade Criteria 
Upgrade 
Criteria 
Quality 
Limitations Indirectness Inconsistency Imprecision 
Publication 
bias 
Hall, et 
al  
Observ
ational 
Not 
Serious 
Not 
Serious 
Not Serious Not 
Serious 
Unlikely  Low 
Parikh, 
et al2 
Observ
ational 
Not 
Serious 
Not 
Serious 
Not Serious Not 
Serious 
Unlikely  Low 
 
 
 
Table II. Heart Failure Incidence in Female populations 
based on parity 
Study Parity Recorded  
HF 
Events 
Recorded 
HF Events 
per 1000 
Person-
Years 
Age Adjusted 
Model 
 
HR (95% CI) 
P value 
Across 
Group 
Multivariable 
Adjusted Model 
 
HR (95% CI) 
P value 
Across 
Group 
Parikh et 
al 
       
 0 1064 0.59 1.71 (1.59-1.84) <0.0001 1.78 (1.65-1.93) < 0.0001 
 1 1094 0.48 1.36 (1.26-1.46)  1.35 (1.25-1.45)  
 2 1950 0.34 1  1  
 3 1166 0.40 1.13 (1.05-1.21)  1.10 (1.03-1.19)  
 4 464 0.53 1.39 (1.26-1.54)  1.31 (1.18-1.45)  
  5 331 0.88 2.21 (1.97-2.49)  1.91 (1.70-2.15)  
Hall et al        
 0 16 0.75 1.80 (1.07-3.03) 0.21 1.70 (0.95-3.03) 0.48 
 1 138 0.34 Reference (N/A)   Reference (N/A)  
 2 332 0.36 1.05 (0.86-1.28)  1.13 (0.91-1.41)  
 3 358 0.39 1.03 (0.84-1.25)  1.17 (0.94-1.45)  
 4 287 0.44 1.12 (0.91-1.38)  1.19 (0.95-1.50)  
  5 363 0.50 1.13 (0.92-1.38)  1.15 (0.92-1.45)  
Abbreviations: HF, heart failure; HR, hazard ratio 
Swedish cohort N = 1 332 062;  WHI cohort N = 28 515 
 
 
 
pg. 12 
 
Table III. Nulliparity and Differentiated Heart Failure 
Incidence 
Study HF 
Classification 
Reproductive 
Factor 
Number of Women Hazard Ratio 
 
(95% CI) 
Hall et al 
  
Total Incident HF 
 
 
Nulliparitus 
 
188 
 
1.70  (0.95-3.03) 
  
HFrEF 
 
 
Nulliparitus 
 
182 
 
1.27  (0.39-4.17) 
  
HFpEF 
 
 
Nulliparitus 
 
186 
 
2.75 (1.16-6.52) 
 
Abbreviations: HF, heart failure;  HFrEF, heart failure with reduced ejection fraction (systolic HF), HFpEF, heart 
failure with preserved ejection fraction (diastolic HF); CI, confidence interval 
WHI cohort N = 28 515 
HR adjusted for age at screening, household income, education level, ethnicity, U.S. region, body mass index, 
hypertension, diabetes, hyperlipidemia, smoking status, breastfeeding, history of pregnancy loss, prior 
hysterectomy, and usage of oral contraception or menopausal hormone therapy 
 
 
 
 
  
pg. 13 
 
Figure I. PRISMA Flow Diagram 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sc
re
en
in
g 
In
cl
u
d
ed
 
El
ig
ib
ili
ty
 
Id
en
ti
fi
ca
ti
o
n
 
Records identified through 
database searching 
(n = 208) 
Additional records identified 
through other sources 
(n =  0) 
Records after duplicates removed 
(n =205) 
Records screened 
(n = 205) 
Records excluded 
(n = 200) 
Full-text articles assessed 
for eligibility 
(n = 5 ) 
Full-text articles excluded, 
with reasons 
(n = 3 ) 
Studies included in 
qualitative synthesis 
(n =  2) 


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