Discussion
Main findings
In this study, we examined whether child marriage and adolescent
childbearing were associated with a greater risk of undergoing a
hysterectomy later in life among ever married women in India. Our
results suggested that women who were married in childhood and/or gave
birth during adolescent age had a significantly higher likelihood of
hysterectomy compared to women who were married as adults and did not
give birth during adolescence. The relationship was robust in
sub-samples of household wealth, educational attainment, urban/rural
residence, and geographic regions. Relationships were not differentially
impacted by gynecologic problem specific hysterectomy outcomes
experienced. Further, non-parametric estimates of survivor functions for
the event of having a hysterectomy suggested a lower survival
probability for women who were married in childhood and/or gave birth
during adolescence.
Interpretation
Of note, a previous study by Meher & Sahoo (2020) reported lower odds
of hysterectomy for women who were married during age 15-20 years and
after age 20 years compared to women who were married before age 15
years.8 Similar results were reported by Kumari &
Kundu (2022).9 Our study differs from those studies in
several ways. First and foremost, those studies did not model child
marriage as a risk factor for hysterectomy. The category denoting
marriage between age 15 to 20 years included both women married as
children and as adults. Further, neither of the studies extensively
explored the association within socioeconomic sub-groups with varying
prevalence rates of hysterectomy, nor did they consider adolescent
childbearing as a potential risk factor of hysterectomy.
Our findings indicate that risk of hysterectomy was the highest among
women who were married in childhood and gave birth in adolescent age
compared to both women who were married in childhood but did not give
birth in adolescence, as well as women who were married as adults but
gave birth in adolescence. The risks of hysterectomy were similar across
the latter two groups. These findings suggest that early marriage and
early childbearing independently influence the risk of undergoing a
hysterectomy later in life. However, it is likely that the compounding
effect of adopting adult roles after child marriage with physical toll
of childbearing during adolescence age may elevate the odds of
hysterectomy. Future research must further explore the relative
contributions of these life events to the risk of hysterectomy.
Our results were in accordance with the extant findings from studies
across multiple settings (England, Scotland, and Wales) suggesting that
earlier age at menarche, earlier age at first birth, and having 3+
children were associated with greater risk of hysterectomy among
women.17 Studies also reported positive associations
between early age at menarche and child marriage and early pregnancy in
women in low- and middle- income countries.18
A notable contribution of our study was that while previous studies on
hysterectomy among Indian women assessed all-cause hysterectomy only, we
extended the analysis to assess the risk for gynecologic problem
specific incidents of hysterectomy. The higher risk of hysterectomy
among women married in childhood and/or gave birth in adolescence was
evident for hysterectomy due to leading causes such as excessive
menstrual bleeding, and fibroids or cysts, as well as due to less common
causes in the Indian population such as cancer. These results indicated
that child marriage and adolescent childbearing were associated with
greater risk of different types of gynecologic disorders leading to
hysterectomy.
We also found that across all geographic regions, child marriage and
adolescent childbearing were associated with a higher risk of
hysterectomy. Previous studies on hysterectomy in Indian women have
demonstrated notable regional variation in prevalence of
hysterectomy.8, 9 For example, higher prevalence of
hysterectomy was observed in the South, whereas the rates were lower in
the Northeast. Studies also reported differential prevalence rates of
hysterectomy by household wealth, educational attainment, and
urban/rural.4, 8, 9 In our analyses, the higher odds
of hysterectomy for women who were married in childhood and/or gave
birth in adolescence were persistent across all sub-groups of wealth,
education, residence, and regions. Our results thus provided compelling
evidence that child marriage and adolescent childbearing might increase
the risk of hysterectomy in later life.
Strengths and limitations
Our findings, however, should be cautiously interpreted due to some data
limitations. First, information on hysterectomy was self-reported and
was not validated by medical records. Reporting of age at hysterectomy
and reasons for hysterectomy could be subject to some recall bias.
Second, we did not have data on participants’ socioeconomic conditions
before marriage, which could influence the selection on child marriage.
Third, data on age at first marriage and childbearing were also
self-reported. On the other hand, our study had some notable strengths.
First, we not only assessed the all-cause hysterectomy, but also
examined the relationship for gynecologic problem specific hysterectomy.
Second, we performed sub-sample analyses by socioeconomic status and
geographic regions across which the prevalence of hysterectomy as well
as the practice of child marriage varied. We observed a strong and
robust relationship between child marriage, adolescent childbearing, and
hysterectomy among ever-married women in India across all these
sub-groups. Lastly, we employed survival analysis techniques to assess
the risk of hysterectomy at an age (between 20 to 49), which further
showed the lower survival rates (for the event of hysterectomy) for
women married in childhood and gave birth in adolescence.