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: 02 Oct 2023
Reviewer:  Danish Ahmad
Reviewer's report:
Overall a novel paper that was a pleasure to review and provided important theoretical and
methodological insights.
- Given the multidisciplinary nature of the research question and its established practice in
medical/surgical literature, there are issues in the framing of the study that I encourage the
authors to address in my comments below.  Given the sensitivities with the study and assumption,
the comments reflect an opportunity for authors to think through key assumptions and the
potential for insights to influence policy/health system strengthening in the chosen states in
India.
- Methodologically, the study presents vigorous analysis, but in a few places, gaps remain which
are also highlighted below.
Comments
Q1 The line about ‘surge’ in hysterectomies in India is alarming and needs revising. The sole
reference itself insufficiently supports this claim.  Kindly check the broader literature and modify
the language used here and in  other places where key claims are made
Q2. The opening lines are a bit medicalised. Please consider revising the opening lines for a
better contextual overview and topic introduction.
Q3 Kindly review the background fully to ensure in-text citations are provided wherever key
claims about external literature, especially regarding prevalence and trends, is used. For eg lines
76-79 miss important references.
Q4.  Lines 85-86 also need to be moderated.  Hysterectomy as a surgical indication has
known life-saving indications and is also noted to enhance the quality of life for recipients -
however incorrect hysterectomies(complete or partial) are also known to have negative effects
and associated harms. It would be good to review the paper to strike more of a  balance
so that a stronger balanced and objective presentation of views comes across.  This tends to
recur in different parts of the paper. Moreover, added care is needed when using single or 2
references to substantiate a subjective claim. This invites reader objections and questions and
is not recommended.
Q5 Pls provide references for claims in lines 91-92 as shown below:
“Various community-based research studies within India have highlighted that women with
no education but with health insurance are more vulnerable to unwanted and needless
hysterectomies’.
Q6. The increasing prevalence of Hysterectomies correlates with increasing age.  The question
is also important to consider whether women across the socio-economic groups in the
study’s(3) states are actually getting treated via hysterectomies as per medical diagnosis and
recommendations when needed or are this excess ( unwanted ) treatment. It may be unwanted in
some instances, but it won't be the case for all women who get treated. Surgical hysterectomies
are also higher in some Indian states and esp in public sector health facilities  as non-surgical
treatments for conditions where hysterectomy is also indicated may not be easily accessible.
Have the authors had the opportunity to evaluate that the higher hysterectomies in the study
sites(states)  chosen are indicative of better health services access for vulnerable women as
opposed to the framing of excess unwanted procedures
Q7. Additionally, the Southern States in India are documented to have better (state-
organised)health insurance provisions, which increases access to health services.  However, the
Northern state of Bihar also has known poor health outcomes due to higher poverty and weaker
health access.  The paper does well in capturing these states however they need to be better
contextualised in the paper
The introduction should provide context to differentiate the chosen three states based on key
socio demographic indicators.  A good attempt is made in lines 120-122 and 126-131 however,
please explicitly state the known health differences between the three states-you can club the
southern states and differentiate the northern state of Bihar. Their comparability is an issue
otherwise.
Q8- Care is needed in making inferences based on other references to this study
- Can the authors please review the claim about increased health risks for younger women who
received hysterectomy? The claim is substantiated by the reference (22). The reference makes a
point about the need for studies on malignancies to account for hysterectomy-corrected incidence
rates etc’. Please review the details in the reference where the inference for higher CAD risks
in younger women is made. The reference talks about higher heart disease in black women
in America even after adjusting for hysterectomies, as they have greater risk clustering and
increased health inequities linked to heart disease.
Methods Section  Comments
Q9  Can the authors please share the context to survey respondent inclusion criteria used in
NFHS.  Does NFHS collect data from 15 and over adolescent girls if they are unmarried, or is
there a survey criterion linked to marriage?
Q10. The younger age group, 15-19, may have different hysterectomy indications linked to
pubertal factors, and I wondered what informed the age categorisation used in the paper.
Comment. The author's efforts to present difference in risk factors across time periods using
different methods is appreciated.
Q11. The information presented in Tables 1 and 2 is useful. However, the key information
provided by using Fairlie decomposition isn’t highlighted well enough. Can the authors consider
the information in Table 1 and Table 2 and comment on how the results speak together?
Q12. Couldn’t a predictor variable e.g. survey round, be taken as an independent variable to
reflect the two survey years and interactions conducted by time variable and selected outcomes?
Q13. Given that health insurance in India is federally promoted and within states which cover
different economic groups, it was concerning to see the omission of health insurance as a
predictor variable in the regression. NFHS contains health insurance data, and using it in the
analysis would have provided the authors and the study with clearer and more important insights.
Results and Discussions
Q13. The use of figures is helpful, but there is scope to remove excess figures to comply
with journal requirements and to provide information succinctly, Extra figures can be added in
supplementary text
Q14. The ICC across the clustering levels within and between the three states is interesting.
Please provide added analytical insights using ICC data from Table 3 regarding similarities/
differences in ICC seen and how that informs the study results.   The discussion on 386-390 needs
additional insights to explain the ICC, especially the difference in HH levels. The suggested
reason may be true but needs more insight and reference- This is a very important place for the
paper to make substantial knowledge additions to the literature in India both from theoretical
and methodological lenses.
Q15. The paper is conspicuous for its results and discussion gaps in commenting on how the
predictor variable  ‘religion’ and its categories are reflected in the three states and the prevalence
of hysterectomy. The supplementary tables provide insights but the authors are asked to bring
these important sights clearly into the main paper