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.