Reproductive Health and Women’s Well-being at Older Ages

Abstract

Currently, women comprise 55.7% of adults aged 65 and older. The leading causes of death and disability among these women are chronic diseases, including ischemic heart disease, stroke, and low back pain. A growing body of literature highlights the importance of examining women’s health across their entire lifespan, particularly the links between reproductive health and chronic diseases in later life. Understanding the long-term impact of women’s reproductive health carries significant public health implications. It enables a deeper understanding of sex-specific health risk factors, informs the development of early-stage health interventions, and helps identify modifiable risk factors during midlife. These topics remain underexplored in low- and middle-income countries (LMICs), partly due to limited data availability, especially long-term cohort studies that track participants from youth to older age. Nonetheless, studying these issues in LMICs is highly valuable. The unique reproductive health experiences of women in LMICs may reveal novel drivers of later-life well-being. Additionally, the diverse social, economic, and cultural norms in LMICs may alter the relationship between reproductive health and later-life well-being observed in high-income countries. Furthermore, LMICs face a dual burden of malnutrition—high rates of both underweight and overweight populations—and the simultaneous challenges of infectious and non-communicable diseases. These complex dynamics highlight the need for new public health investigations, with women’s reproductive health potentially being a contributing factor. This dissertation aims to investigate the health and well-being of older women in China and India, two countries that have undergone rapid demographic transitions in part due to nationwide family planning campaigns. The well-being of these older women is assessed through measures of mental health, physical health, and the onset of menopause. Utilizing a life course approach, I examine the relationship between older women's mental health and their early and mid-life reproductive experiences. This includes factors such as early marriage, early parity, contraceptive use, sterilization, and exposure to family planning policies that have permanently altered reproductive behaviors. Like many other LMICs, China and India have limited panel data tracking individuals over their full life course. To address this challenge, I utilize statistical methods, such as synthetic cohort analysis, that match women from different birth cohorts in cross sectional studies in different years. The first paper investigates the impact of exposure to family planning policies targeting strict birth control during reproductive years on Chinese women's mental health in later life. It is well-documented that older Chinese women experience significant mental health problems (Lei, Sun, et al. 2014; Chen et al. 2024), yet few studies have examined the role of China's stringent family planning policies in this context. Given that current older Chinese women spent most of their reproductive years under these policies, this study addresses a crucial gap in the literature. Using data from 8,024 women aged 45 or older from the China Health and Retirement Longitudinal Study (CHARLS), I assessed their exposure to three key policies during their reproductive years (ages 15 to 45) by utilizing province-level variations in policy initiation years. The findings reveal that exposure to the 'Later-Longer-Fewer' Policy (LLFP) and the 'One-and-a-Half-Child' Policy (OHCP)—which permitted a second child in rural areas under the One-Child Policy—is associated with worse mental health outcomes in older women, including higher depressive symptoms and cognitive impairment. Furthermore, the study indicates that these policies have a direct effect on mental health problems, beyond potential mediating mechanisms such as education, marriage, and parity. The second paper examines the impact of total fertility on the physical health of older Indian women. To address potential confounding factors, I used the sex of the first-born child as an instrumental variable, to create a quasi-random variation in total fertility, leveraging India's prevalent son preference culture. Utilizing data from 30,067 women and 25,950 men aged 45 or older, each with at least one biological child, from the Longitudinal Aging Study in India (LASI), I found that a higher number of births is associated with reduced grip strength among mothers. Contrary to previous studies, I also discovered that more births are associated with a lower body mass index (BMI) and a reduced likelihood of being overweight. This effect is possibly due to a nutrition deprivation mechanism, as the association is stronger among mothers without schooling, an indicator of poor economic status. Among fathers, an increased number of births is associated with a reduced waist-hip ratio. The third paper examines the relationship between women's early life reproductive experiences and the onset of menopause before age 45. Early natural menopause is associated with increased risks of premature mortality and various chronic diseases. In India, 20% of women experience early menopause (Kundu and Acharya 2023), compared to less than 10% in high-income countries (Mishra et al. 2017; Zhu et al. 2018). Despite this significant disparity, there are few studies on the determinants of early menopause in India, and the reasons behind its high prevalence are unclear. In this paper, I investigate the risk factors associated with early menopause among 155,353 women aged 35-44, surveyed in the National Family Health Survey (NFHS) in India 2019-2021 (NFHS-5). Existing studies of earlier menopause in India (Meher and Sahoo 2021; Ahuja 2016; Jungari and Chauhan 2017) use cross-section data such as this, but the cross-section approach means the risk factors for menopausal women might be measured after they have experience menopause, giving rise to possible reverse causality. To address this potential threat of reverse causality, I measure women's reproductive characteristics in 2005 approximately 15 years prior to the 2019-21 data collection on menopause status, to create a synthetic panel. This method utilized data from women surveyed in NFHS-3, matching them to the women in 2019-21 based on year of birth, and other time invariant characteristics. The findings reveal that giving birth before age 20, nulliparity, and having more than two births are associated with higher odds of early menopause. Conversely, sterilization and the use of oral contraceptives or IUDs are linked to a lower risk of early menopause. In summary, this dissertation reveals the long-term impact of early life reproductive experiences on women's well-being in later life. The findings, situated in the contexts of China and India, contribute to a global comparison in life course studies on women's health.