Title: Key Drivers of Hysterectomy among women of reproductive age in Three States in India:
Comparative Evidence from NFHS-4 and NFHS-5
Version: 2 Date: 01 Oct 2023
Reviewer's report:
I thank the authors for the chance to review their very interesting manuscript. Please see below
for my specific comments:
Background
1. On line 59, please remove the word “surgically” after the phrase “the uterus is removed” as
it is redundant.
2. On lines 78-79, the authors might want to provide more information on some of the alternative
therapies for these medical conditions as well as their availability in India.
3. On lines 107-108, the authors write that having had a previous cesarian section, women’s
illiteracy rate, and women’s unemployment are state characteristics. While illiteracy rate and
unemployment prevalence can definitely be considered state characteristics, I do not think a
previous history of a cesarian section would fall in this category.
4. In the introduction section, I believe it is important for authors to make it clear that not all
hysterectomies are unwarranted/unnecessary. In cases when medical treatment does not treat
the gynecological issues, hysterectomy can be an important next step in treatment. Additionally,
some women may choose to undergo hysterectomy rather than other forms of treatments based
on various beliefs or potentially financial reasons. This is important to acknowledge as the
introduction almost implies that all hysterectomies are not necessary which is not true. Further,
this study is unable to assess the differences between warranted and medically-necessary
hysterectomies which I mention in the discussion section is something that should be mentioned.
5. Similar to comment 4, I would recommend the authors find additional evidence of the
following statement seen on lines 111-114: “Additionally, the majority of hysterectomies
are induced needless hysterectomies because, reproductive aged women particularly from
low-income households in India, suffering from excessive menstrual bleeding, fibroids,
endometriosis, and uterine prolapse are commonly advised to have their uterus removed”.
This case report, while presenting a compelling story of exploiting vulnerabilities to increase
hysterectomy prevalence, cannot solely be used to conclude the majority of hysterectomies in
India are induced needlessly.
Data and Methods
1. On line 147, SDG should be written out to “sustainable development goals”.
2. On line 150, the phrase “detailed information on a various” should have the word “a” removed.
3. On line 170, the authors may consider writing the options for reasons for the hysterectomy
being performed for women who indicated that they had received a hysterectomy. Also, authors
should write whether people could select more than one reason for having a hysterectomy.
Results
1. For Table 1B (in the supplemental materials), the authors should add a caption to the table
defining the significance values in the table. For example, I presume that *** means that p<0.001
but this should be added to the table.
2. On line 254, the authors should remove the comma after the word schooling in the phrase
“years of schooling, and wealth”.
3. In Figure 3a, the percentages for the NFHS-4 add to 110.5% and the percentages for the
NFHS-5 add to 117.3% for the various reasons for receiving a hysterectomy in Andhra Pradesh.
The same is seen in Figures 3b and 3c.   In my understanding, this would indicate that women
could select more than one reason for receiving a hysterectomy. The authors may consider
adding an additional group that consists of women that have reported more than one reason as
these women may have different motivations for seeking a hysterectomy than a woman who
only has to deal with one of these challenges. The authors may also consider doing some analysis
into what combination of reasons is most prevalent for those reporting multiple reasons as this
may provide additional context into the decision-making process these women undergo when
deciding to receive a hysterectomy.
4.
Discussion
1. On lines 357-358, the authors write “This means that women in Bihar remained most
vulnerable” following their discussion on the changes in predicted probability of undergoing
a hysterectomy by urban/rural residence. The evidence presented in Table 1 does not seem to
support this conclusion. In fact, using either the NFHS-4 or NFHS-5 (2015/16 or 2019-21) data,
the predicted probability of having a hysterectomy is lower for both urban and rural residents
of Bihar as compared to Andhra Pradesh and Telangana. If anything, this seems to imply that
women in Bihar are less vulnerable in both rural and urban settings.
2. On lines 358-361, the authors explore the wealth quintile differences in predicted probability
of undergoing a hysterectomy for the 3 states studied. They suggest that women in the poorest
and poorer wealth quintiles may not have the means to access healthcare, such as alternative
treatments or health facilities, and thus a hysterectomy may remain the best option. However,
Table 1 data indicates that the predicted probability of having a hysterectomy was the highest
among the higher wealth quintiles (richer and richest) for all 3 states which is what the authors
mention on lines 372-375. Thus, I am not understanding their interpretation that the poorest
wealth quintile in Andhra Pradesh and the poorer wealth quintile in Telangana remained the
most vulnerable. It seems entirely possible that those in the lowest wealth quintiles may not be
able to afford even hysterectomies thus leaving women in higher wealth quintiles more likely
to access this form of healthcare.
3. On lines 383-384, the authors state that “the highest rise of hysterectomies is among women
belonging to the poorest quintile”. This is not necessarily true given the data presented by the
authors. For example, in Bihar, it seems the women in the richer wealth quintile have the highest
rise in predicted probability, not those in the poorest wealth quintile.
4. On line 393-394, the authors write “However, it also makes women vulnerable to being
advised for surgery when less invasive options are available”. The authors certainly need to
include a citation here and provide a better explanation as to why private healthcare facilities
may be driving hysterectomy utilization rather than less invasive options.
5. The authors should consider adding a limitations section to the discussion section. For
example, given the cross-sectional nature of the study, the authors are working with limited
information regarding the medical history of the participants. For example, it is entirely
possible that the women in this study who received a hysterectomy have already tried
several other medical options (as suggested by : Desai S. Pragmatic prevention, permanent
solution: Women's experiences with hysterectomy in rural India. Soc Sci Med. 2016;151:11-18.
doi:10.1016/j.socscimed.2015.12.046). In this way, the hysterectomies are not “unnecessary”
or “unwarranted” but rather medically necessary. In addition, the authors may consider adding
some literature about women’s access to other medical options (such as common medications
or less invasive procedures) for the reasons presented in the paper. It is possible that in these
states, there is less infrastructure available for less invasive options and thus hysterectomy is
the only available option. In the recommendations section then, it would make sense to maybe
introduce gov. legislation to increase the access/availability of these alternative forms of care.
If however, these options are available but not getting utilized, more research may be needed
to understand why people are selecting hysterectomies over these other options and education
people about these options may be a better option.