Results
In our study population, 41.0% (N=203,281) women were married in
childhood and 38.8% (N=195,707) gave birth during adolescence.
Adolescent childbearing was more likely among women wo were married as
children. Approximately 79.4% of the women married in childhood gave
birth by age 19 years, while only 10.7% of the women married as adults
gave birth during adolescence. Table 1 presents characteristics of the
study population by child marriage and adolescent childbearing groups.
Larger percentages of women married in childhood and who gave birth in
adolescence were from poor households, with lower educational
attainment, and living in rural areas. While the distribution of BMI
categories was comparable across the groups, the percentage of women
giving birth to 5 or more children was significantly higher among women
who were married before age 18 years and gave birth by age 19 years.
Prevalence of all-cause hysterectomy in our study population was 4.3%
(N=20,659). Among women married as adults, prevalence of all-cause
hysterectomy was 2.7% (95% CI: 2.6 – 2.8) for those who did not give
birth in adolescence, and 4.4% (95% CI: 4.1 – 4.8) for those who gave
birth in adolescence. Among women who were married in childhood, the
prevalence of hysterectomy was 5.5% (95% CI: 5.2 – 5.8) and 6.7%
(95% CI: 6.5 – 6.8) for those who did not and did give birth in
adolescence, respectively. Figure 1 presents the prevalence rates of
hysterectomy by the child marriage and adolescent childbearing groups
across respondents’ demographic and socioeconomic (e.g., religion,
household wealth) characteristics and risk-factors (e.g., BMI). Results
of the adjusted Wald tests suggest that across all attributes, women who
were married in childhood and who gave birth in adolescence had a
significantly higher prevalence of hysterectomy than that of the
reference group (i.e., women who were married as adults and did not give
birth in adolescence). In general, the prevalence rates were also higher
among women who were married in childhood and did not give birth in
adolescence and women who were married as adults but gave birth in
adolescence, compared to their counterparts in the reference group.
Unadjusted and adjusted odds ratios of hysterectomy for the child
marriage and adolescent childbearing groups are presented in Table 2.
After accounting sociodemographic attributes and risk factors (such as
parity), women married in childhood who gave birth in adolescence were
1.87 times more likely to have a hysterectomy compared to women who were
married as adults and did not give birth in adolescence. The adjusted
odds were 1.53 and 1.40 times higher for women who were married as
adults but gave birth in adolescence, and women who were married in
childhood and did not give birth in adolescence, respectively.
The results for gynecologic problem specific hysterectomy outcomes were
very similar to those of all-cause hysterectomy outcome (Table 2). For
example, adjusted odds of hysterectomy due to excessive menstrual
bleeding or due to fibroids/cysts were 1.82 and 1.71 times higher,
respectively, for women who were married in childhood and gave birth in
adolescence compared to their counterparts who were married as adults
and did not give birth in adolescence.
Table S1 (in supplementary material) presents the results by sub-samples
of household wealth index quintiles. Of note, compared to women from
wealthier household, women from poorer households were more likely to
get married before age 18 years and to give birth by age 19 years. We
found that across all different wealth levels, women who were married in
childhood and/or gave birth in adolescence had a significantly higher
likelihood of having hysterectomy compared to women who were married as
adults and did not give birth in adolescence.
Along with wealth, educational attainment and urban/rural residence were
other factors considered to influence child marriage and adolescent
childbearing. To mitigate the influence of such heterogeneities, models
were also estimated by sub-samples of educational attainment and
urban/rural residence, results of which are presented in Table S2. The
greater likelihood of hysterectomy among women who were married in
childhood and/or gave birth during adolescent age was evident across all
educational levels and in both urban and rural areas.
Previous studies also indicated regional variations in hysterectomy
prevalence in India.8, 9 Table S3 presents the results
by samples of geographic regions in India. The relationship between
child marriage, adolescent childbearing, and hysterectomy persisted
across all regions despite differences in hysterectomy prevalence rates
across the regions. For example, in the Southern region where the
prevalence of hysterectomy was the highest, women who were married in
childhood and gave birth in adolescence were 1.99 times more likely to
undergo a hysterectomy compared to women who were married as adults and
did not give birth in adolescence. The odds of hysterectomy were also
higher (AOR: 1.56) for women who were married in childhood and gave
birth in adolescence in the Northeastern region, where the prevalence of
hysterectomy was the lowest.
Lastly, the K-M survivor functions for the event of having a
hysterectomy by child marriage and adolescent childbearing groups are
presented in Figure 2. Survival rates among women married as adults and
not giving birth in adolescence were 98.1%, 96.3%, 94.4% and 92.5%
at ages 35, 40, 45, and 44 years, respectively. Survival rates among
women married in childhood who gave birth in adolescence were 95.8%,
93.6%, 91.3%, and 89.0%, respectively. Results of the log-rank test
suggested that the survivor functions for different groups were not the
same (i.e., the null hypothesis of equality of survivor functions across
the groups was rejected). At any age (between 20 and 49), the survival
probability was the lowest for women who were married before the age of
18 years and gave birth by the age of 19 years.