Title: Key Drivers of Hysterectomy among women of reproductive age in Three States in India:
Comparative Evidence from NFHS-4 and NFHS-5
Version: 3 Date: 30 Nov 2023
Reviewer's report:
Thank you to the authors for their thoughtful responses to the initial reviewer comments. While
the manuscript has certainly moved in the right direction, I have a few additional concerns that
should be addressed before this article is suitable for publication.
1. On lines 64-66, the authors state “It is generally estimated that hysterectomy rates are higher
in high-income countries than in low-and-middle income settings, even though they are now
increasing in low-and-middle income countries (2).”. Citation 2 deals with the prevalence and
determinants of hysterectomy in India using longitudinal data and as such is not appropriate to
make such a claim (however true). The authors should find additional literature to substantiate
the claim that high income countries have greater hysterectomy rates than LMICs. The authors
should also consider utilizing citation 2 in their discussion as the study findings on reasons for
hysterectomy and correlates of hysterectomy could help add more weight to the study’s findings.
2. On lines 68-69, the author’s write “Deans and Abbott (2022) suggest that Australia should aim
for net zero hysterectomies (3).”.  I strongly believe the authors should not include a statement
like this within their introduction. First, in the article cited (citation 3), the authors add an
important caveat at the end stating that “many OECD countries [are moving] toward a ‘net
zero hysterectomy for benign disease”. As mentioned by the previous reviewers, I believe the
authors need to be cautious about not making it seem as though hysterectomies do not have
their place within medical practice. In fact, an article published in the same journal expressed
the opinion that a “net zero” goal is not appropriate with the authors arguing that simply
reducing the hysterectomy rate may be a better option (see Nicklin J. Time to stop the hand-
wringing. 'Net zero' hysterectomy is not an appropriate goal. Aust N Z J Obstet Gynaecol.
2022;62(6):925-926.)doi:10.1111/ajo.13613).
3. Similar to the first comment, I think that the authors should consider whether to soften
statements such as those made on lines 83-84 (“There is  medical evidence that removing
the uterus and ovaries is extremely damaging psychologically and physiologically”) as for
women with abnormal bleeding who were unresponsive to other treatment options or who have
more severe conditions, hysterectomies are actually associated with improved quality of life. I
understand the intent of trying to highlight the risks of having a hysterectomy and the idea that
we should consider not using it as first-line treatment but I also think that needs to be balanced
with the idea that hysterectomies can be beneficial for some women, and I believe the authors
should present that in the introduction as well.
4. On line 126, “hysterectomies were” should be replaced with “the prevalence of hysterectomies
was”
5. On lines 133-137, the authors write “It is hypothesized that more hysterectomies are taking
place in these states due to better health infrastructure and more ‘effective’ implementation of
health insurance schemes. Equally, it could also be easily argued that more hysterectomies are
occurring due to poor counselling, lack of medical facilities and/or due to poor state health
infrastructure”. I believe the authors need to add some references to justify these two hypotheses
in the states they selected for their study.
6. In the methods section, the authors state that they only selected “ever married” women who
completed the NFHS-4 and NFHS-5 surveys. I believe that a justification is warranted as to
why the sample was limited to married women, rather than including those not in a partnership
(single as I’d assume divorced women would be included in the analytic group).
7. On lines 349-351, the authors state that in Andhra Pradesh and Telangana, higher literacy
drove hysterectomy prevalence while in Bihar, the opposite was true. The authors put together a
nice discussion on how low literacy may drive hysterectomy prevalence. They should consider
also discussing why there was a different trend between states as well as why higher literacy
(more education) may be associated with greater use of hysterectomy.
8. On lines 368-370, the authors write “It may be conjectured that women in Bihar belonging to
poorer and poorest wealth quintile remained less vulnerable for having hysterectomy because
they feared losing more money either on alternative treatments, and/ or having to visit the health
facility repeatedly (28)”. First, citation 28 was a mixed methods study done in Gujarat (a different
state). But more importantly, if women in the poorer and poorest wealth quintiles felt as though
alternative methods would be ineffective or that they would require repeated visits to a healthcare
facility, would it not make sense that they would be at a higher risk of having a hysterectomy?
In this case, the women would seek out hysterectomies as it represents the lesser of two evils
under the premise of your argument.
9. On lines 393-394, the author should revise the statement “However, in the study among
women above 45 years of age, nulliparous women had the highest number of hysterectomies
(2).”. Based on that study, it does not appear that parity was a significant predictor of
hysterectomies (multiparous had a significantly higher aOR than uniparous, but nulliparous had
a nonsignificant OR and aOR).
10. The authors should strengthen the statement on lines 425-426: “We also looked at the trends
on whether more hysterectomies were conducted in private facilities than in public hospitals”.
Instead of stating that they looked at whether trends were present, they should state the trend;
otherwise, the next sentence doesn’t make sense.
11. The authors need to add more support for the statement on lines 427-428 as the current
citation (citation 26) is not sufficient: “However, it also makes women vulnerable to being
advised for surgery due to lack of equipment and skills for less invasive options (26).”
12. In the discussion on health insurance, the authors make the claim that government sponsored
health insurance schemes are contributing to the hysterectomy rate. Given the surveys used in
this study asked respondents about the form of insurance they have, the authors may consider
adding this element to their analysis as it would strengthen their claims in the discussion on how
government sponsored schemes are influencing the hysterectomy rate.
13. In the conclusions and recommendation section (lines 474-476), the authors write that
healthcare providers need to make sure that alternative treatment to hysterectomy are available
to women. To the author’s knowledge, have there been any studies investigating provider
awareness of alternative treatments? From the way the authors frame their discussion, it seems
as though they argue that providers are pushing/guiding women toward hysterectomies and
the women are choosing it, but the “problem” if you want to call it that could simply be that
providers are unaware of alternative therapies that could be utilized instead in these states. While
definitely not within the scope of this article, adding a citation like that would help the discussion/
recommendations section.