Seizure (2006) 15, 409—415

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Epilepsy in India: Nuptiality behaviour and fertility

P. Agarwal *, M.M. Mehndiratta, A.R. Antony, N. Kumar,R.N. Dwivedi, P. Sharma, S. Kumar

Neurology unit, PG Institute of Medicine, GSVM Medical College,CSJM University of Kanpur, 208002 U.P., India

Received 7 November 2004; received in revised form 16 March 2006; accepted 18 April 2006

KEYWORDSEpilepsy;Nuptiality behavior;Fertility;Marital status;Mean age at marriage

Summary

Purpose: The study was conducted to assess the marital status and fertility in adultswith epilepsy.Methods: The study group consisted of 240 subjects with epilepsy aged 15 and above,Unmarried males (m) 55, unmarried females (f) 73 and married males 48, marriedfemales 64. Data was collected according to standard protocol regarding age, sex, ageat marriage and onset of seizure, effect of epilepsy on marriage, type of seizure andcontrol, fertility pattern and abortions. The study group was followed up for 30months. The data was compared with latest available state and national data usingStudent’s ‘t’-test, chi square, Fisher Z-test.Results: The mean age of married subjects was 26.19 + 6.2 years and of the unmar-ried was 24.94 � 7.1 years. People with epilepsy had significantly ( p < 0.05) highermean age at marriage, significantly ( p < 0.05) lower rate of marriage (m 46.6% f46.72%), significantly ( p < 0.05) higher divorce rate and withheld marriage. Femalescompared to males had higher divorce rate (f 5.84%) and withheld marriage (m 5.45% f10.96%).

The marriage rate of subjects with onset of epilepsy in the first decade (m 38.71% f34.09%) and second decade (m 33.33% f 35.42%) was significantly lower ( p < 0.05)than that of subjects with age at onset of epilepsy greater than 20 years (m 66.67% f71.11%). Subjects with epilepsy not in remission had significantly ( p < 0.05) highermean age at marriage, lower marriage rate and lower fertility per person-year ofmarriage than those in remission. Majority (95.54%) did not disclose epilepsy beforemarriage. Total fertility rate (TFR) in males (4.56) and females (5.45) with epilepsywas comparable to general population. Abortions per pregnancy were 4.76%.Conclusion: Subjects with epilepsy had lower marriage prevalence rate, delayedmarriage (especially females), withheld marriage and higher divorce rate comparedto general population. Marriage rate was lower in people with age at onset of epilepsy

* Corresponding author. Tel.: +91 512 2535617; fax: +91 5016488897.E-mail address: agpuneet@hotmail.com (P. Agarwal).

1059-1311/$ — see front matter # 2006 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.seizure.2006.04.005

410 P. Agarwal et al.

less than 20 years and in whom seizures were not in remission. Majority of people withepilepsy did not disclose epilepsy before marriage. Though fertility was not affectedin people with epilepsy as compared to general population, males had lower fertilitythan females.# 2006 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Introduction

The prevalence of epilepsy is 5—8.3 per 1000 popu-lation in India in different studies.1—3 Although thesocial effects vary from country to country andculture to culture, it is clear that all over the worldthe social consequences of epilepsy are more diffi-cult to overcome than the seizures themselves.Studies on nuptiality behaviour and fertility on peo-ple with epilepsy are mainly from developed coun-tries.4—6 They show that people with epilepsy areless likely to marry than general population7 andpersons with early onset of epilepsy had the poorestchance of marriage.8,9 Decreased fertility trends,both in males (m) and females (f) with epilepsy werereported in many studies conducted in developedcountries.10,11

There are very few studies on this aspect ofepilepsy from developing countries and no studyhas been done from India till now to the best ofour knowledge. Studies conducted in developingcountries like Pakistan showed that marriage rateis lower in illiterate people with epilepsy.12 Similarresults have been reported in other studies con-ducted elsewhere like Taiwan.8 We attempted toevaluate nuptiality behaviour and fertility in rela-tion to age of onset of seizure, seizure type andseizure remission status in males and females withepilepsy.

Materials and methods

Subjects with epilepsy were selected from thosevisiting outpatient clinics or wards of neurology unitin a University Hospital at Kanpur from February 2002to August 2004. The subjects belonged to rural andurbanareasaroundKanpur,which is consideredas thelargest city of the state of Uttarpradesh in India.

Fifty five (55) unmarried males and seventy three(73) unmarried females, aged 15 or above, havingepilepsy of more than 3 months duration wereselected randomly. Forty eight (48) married malesand sixty four (64) married females, aged 15 yearsand above, having epilepsy of more than 3 monthsbefore marriage were also selected for the study.The patients in both the groups were age matchedwithin 5 year age group. Informed consent was takenfrom all subjects.

The study group consisted of 240 subjects with103 males and 137 females. The subjects wereinterviewed according to a preset standard proto-col. Data was collected in personal interviewregarding–—(1) age; (2) address (urban and rural);(3) marital status and effect of epilepsy on mar-riage; (4) epilepsy disclosed before marriage or not;(5) age at marriage; (6) age at onset of seizure; (7)reproductive history; (8) divorce; (9) family dis-putes; (10) type of seizures and (11) seizure control.

The study was conducted for 30 months to eval-uate seizure control and effect of epilepsy on mar-ital status and fertility. Mean age at marriage,marriage prevalence rate, family disputes, divorcesand total fertility rate (TFR) in males and femaleswith epilepsy were compared to latest availablenational data. Median age at marriage of malesand females of different age groups was comparedto state data. The effect of age at onset of seizures,seizure remission status and type of seizure onmarriage rate, age at marriage and fertility (preg-nancy per person-year of marriage) was studied.

Fertility was assessed by measuring total fertilityrate (TFR), pregnancies per person-year of mar-riage, and abortions per pregnancy in married sub-jects with epilepsy. TFR is the number of childrenthat would be borne to each woman if she were tolive to the end of her child bearing years and bearchildren at each age in accordance with prevailingage specific fertility rates.

Pregnancies per person-year of marriage wascalculated as pregnancies in married female sub-jects or spouses of married male subjects divided byduration of marriage in years. Continuous and nor-mally distributed variables were analyzed by Stu-dent’s ‘t’-test. Proportions were compared by chisquare test, Fisher Z-test.

Results

The mean age of females and males with epilepsywas 25.20 � 5.6 years and 24.07 � 4.8 years,respectively. The mean age of married subjectswas 26.19 � 6.2 years and of the unmarried was24.94 � 7.1 years. Mean age at the time of marriage(Table 1) was found to be 21.5 � 0.88 years and21.76 � 0.90 years for males and females with epi-lepsy, respectively. (National mean age at marriage

Epilepsy in India 411

Table 1 Mean age at time of marriage

No. Patientgroup

Patientdata

Nationaldata (NFHS-2)

1 Male 21.5a 24.92 Female 21.76b 19.7

NFHS 2-National family health Survey-2 (1998—1999).a p-value > 0.05(comparison between male and female

patients).b p-value < 0.05(comparison of patient data with national

data).

Table 2 Proportion of currently married

Agegroup

Malesubjects

Femalesubjects

State data(females) a

15—19 18 18 NA20—24 21 20.5 NA25—29 21.5 22.5 18.730—34 20 20 18.235—39 20.5 21 17.140—44 18 18 16.745—49 18 18 16.4>49 20.5 21.5 NA

NA, not available.a National Family Health Survey-2 1998—1999.

Graph 1 Relation to onset of seizures.

for male 24.9 years, female 19.7 years.) The meanduration of epilepsy was 4.2 � 4.1 years in marriedsubjects and 4.6 � 4.2 years in unmarried subjects.

Table 2 showsmedian age at marriage of male andfemale subjects. It was higher in female subjectscompared to median age at marriage of females inthe state.

Table 3 shows proportion of currently married,never married and divorced males and females inthe study group and in general population. 46.6% ofmales with epilepsy in our study were marriedcompared to 69.91% in general population, accord-ing to National Family Health survey-2 (1998—1999).Only 46.72% of females with epilepsy in our studywere married compared to 89.28% in India. Nodivorce was seen in married males in our study.

Table 3 Median age at time of marriage

Marital status Patient data(males)

National(males)

Never married (%) 53.4b (55/103) 29.6Married (%) 46.6d (48/103) 69.91Divorced (%) 0 0.49a Data from census-2001 and National Family Health Survey-2 (19b p < 0.05.c p < 0.05.d p < 0.05.e p < 0.05.f p < 0.05.

There were eight divorces among female subjects.The divorce rate observed as 5.84% was significantlyhigher ( p < 0.05) than that of general population(National data 0.92%). Three males (5.45%) and 8females (10.96%) had withheld marriage due toepilepsy ( p < 0.05).

Marital status was further analyzed in relationto age of onset of seizure (Graph 1). 38.71% (12/31) of males and 34.09% (15/44) of females withonset of seizure in the first decade were currentlymarried. This was significantly lower ( p < 0.05)than the marriage rate of general population.33.33% (12/36) of males and 35.42%(17/48) offemales with onset of seizures in the second dec-ade were currently married. This too was signifi-cantly lower ( p < 0.05) than that of generalpopulation. The marriage rate of males andfemales with onset of seizures after the age oftwenty was 66.67% (24/36) and 71.11% (32/45),respectively. This was not significantly different( p > 0.05) than that of general population in caseof males. In the case of females this was signifi-cantly lower ( p < 0.05) than that of general popu-lation. But the rate of marriage of males andfemales with onset of epilepsy after the age of20 years was significantly higher ( p < 0.05) com-pared to subjects with age at onset of epilepsybefore the age of 20.

dataa Patient data(females)

National dataa

(females)

47.45c (65/137) 9.846.72e (64/137) 89.285.84f (8/137) 0.92

98—1999).

412 P. Agarwal et al.

Table 4 Pregnancies

Remission onmedications

Remission offmedications

Not in remission

Males, % (n = 103) 72.82 (75/103) 12.62 (13/103) 14.56 (15/103)Females, % (n = 137) 69.34 (95/137) 13.14 (18/137) 17.52 (24/137)Propotion of currently married

male subjects (%)50.67% (38/75) 53.85% (7/13) 20%a (3/15)

Propotion of currently marriedfemale subjects (%)

53.68% (51/95) 55.56% (10/18) 12.5%b (3/24)

Mean age at marriage (males) 21.08 � 0.71 21.00 � 0.9 23.60 � 1.10c

Mean age at marriage (females) 21.66 � 0.98 20.25 � 0.76 26.5 � 1.22d

Fertility (male) perperson-year of marriage

0.246 � 0.014 0.247 � 0.020 0.203 � 0.028e

Fertility (female) perperson-year of marriage

0.275 � 0.024 0.271 � 0.014 0.164 � 0.024 f

a p < 0.05.b p < 0.05.c p < 0.05.d p < 0.05.e p < 0.05.f p < 0.05.

Table 4 compares the seizure remission status ofsubjects with marriage rate, mean age at marriageand fertility (pregnancies per person-year of mar-riage). Out of the 103 male subjects, 75 (72.82%)were in remission on medications, 13 (12.62%) werein remission off medications and 15(14.56%) werenot in remission. Out of the 137 female subjects,95(69.34%) were on remission on medications, 18(13.14%) were on remission off medications, 24(17.52%) were not in remission. Out of those havingremission on medications, 50.67% (38/75) males and53.68% (51/95) females were married at the time ofstudy. Out of those having remission off medica-tions, 53.85% (7/13) males and 55.56% (10/18)females were married. Only 20% (3/15) males and12.5% (3/24) females were married among those notin remission. The marriage rate was significantly lowin male and female subjects not in remission com-pared to subjects having remission on medicationsor off medications ( p < 0.05 for males, p < 0.05 forfemales).

The mean age at marriage of male subjects onremission with treatment, on remission with outtreatment and not in remission was 21.08 � 0.71years, 21.00 � 0.9 years, and 23.60 � 1.10 years,respectively, and of female subjects was 21.66 �0.98 years, 20.25 � 0.76 years, and 26.5 � 1.22years, respectively. The mean age at marriage ofmales and females not in remission was significantlyhigher ( p < 0.05) than those in remission on or offmedications. Fertility rate of males calculated aspregnancies in their spouses per year of marriage insubjects on remission with treatment, on remissionwith out treatment and not in remission was

0.246 � 0.014, 0.247 � 0.020, and 0.203 � 0.028,respectively. Fertility rate of females calculated aspregnancies in per person-year of marriage in sub-jects on remission with treatment, on remissionwith out treatment and not in remission was0.275 � 0.024, 0.271 � 0.014, and 0.164 � 0.024,respectively. The pregnancies per person-year ofmarriage were significantly lower ( p < 0.05) inmales and females not in remission compared tothose in remission.

Table 5 shows effect of various types of epilepsyon marriage rate, mean age at marriage and fertilityrate (pregnancies per person-year of marriage). Inour study 45 males and 68 females suffered fromgeneralized seizures, 55 males and 62 females suf-fered from partial onset epilepsy, and 3 males and 7females had undetermined or special epileptic syn-dromes.46.67%(21/45) of males and 47.06% (32/68)of females with generalized seizures were married,while 45.45% (25/55) of males and 46.77% (29/62) offemales with partial onset epilepsy were married.Themean age at marriage of males and females withgeneralized seizures was 21.36 � 0.57 years and21.55 � 0.48 years, respectively. The mean age atmarriage of males and females with partial onsetseizures was 21.13 � 0.56 years and 21.61 � 0.57years, respectively.

Fertility in male subjects calculated as pregnan-cies in their spouses per person-year ofmarriage was0.247 � 0.021 in those with generalized seizuresand 0.251 � 0.032 in those with partial onset sei-zures. Fertility in female subjects was found to be0.252 � 0.022 in those with generalized seizuresand 0.253 � 0.021 in those with partial onset sei-

Epilepsy in India 413

Table 5 Seizure remission status of subjects

Generalized seizures Partial seizures Others

Total male (n = 103) (%) 43.69 (45/103) 53.40 (55/103) 2.91 (3/103)Total female (n = 137) (%) 49.64 (68/137) 45.26 (62/137) 5.11 (7/137)Propotion of married subjects (males) (%) 46.67 (21/45) 45.45a (25/55) 66.67 (2/3)Propotion of married subjects (females) (%) 47.06 (32/68) 46.77b (29/62) 42.86 (3/7)Mean age at marriage (male) 21.36 � 0.57 21.13 � 0.56c 25.5 � 1.08Mean age at marriage (female) 21.55 � 0.48 21.61 � 0.57d 25.0 � 0.91Fertility (male) per person-year of marriage 0.247 � 0.021 0.251 � 0.032e 0.177 � 0.068Fertility (female) per person-year of marriage 0.252 � 0.022 0.253 � 0.021 f 0.31 � 0.087a p > 0.05.b p > 0.05.c p > 0.05.d p > 0.05.e p > 0.05.f p > 0.05.

Table 6 Effect of various types of seizures

S no. Reproductive outcome Spouses of married males (n = 48) Married females (n = 64)

1 Total pregnancies 113 1682 Total abortion 0 8 (12.5)3 Pregnant at interview 0 44 Total fertility rate 4.56 5.455 Live birth per

person-year of marriage0.241 � 0.01a 0.259 � 0.02

Value in parenthesis is percentage.a p < 0.05 (comparison between male and female).

zures. Studies from developed countries showedthat people with partial onset epilepsy were repro-ductively more disadvantaged.13 But in our studymarriage rate, age at marriage and fertility rate didnot differ significantly (p > 0.05) between subjectswith different types of epilepsy. Disclosure of epi-lepsy before marriage in majority of the subjects(95.54%) and this tendency was not significantlydifferent ( p > 0.05) between males and females(males 91.66% females 98.44%).

Table6 showsthat totalnumberofpregnancieswas113 and 168 in spouses ofmale subjects and in femalesubjects, respectively. The females who were preg-nant at the time of interview were also included.There was no abortion in spouses of males with epi-lepsy in our study, but there were eight abortions infemale subjects accounting for 4.76% abortions perpregnancy, while the national abortion rate was 6.1(NFHS1998—1999).Noneofthesubjects reportedstillbirth. TFR observed in spouses of male subjects waslower than that of female subjects (4.56 in maleversus 5.45 in female). TFR was not low comparedtonational data (2.85;NFHS1998—1999) inmales andfemales with epilepsy. Fertility rates were also mea-sured as pregnancies per person-year of marriage. Itwas found to be 0.241 � 0.01 in male subjects in

comparison to 0.259 � 0.02 in female subjects(p < 0.05).Nocongenitalmalformationwasreportedin babies of any males and females with epilepsy.

Discussion

The present study shows the implications of epilepsyon nuptiality behaviour and fertility. This is the firststudy of its kind from India to the best of our knowl-edge. In India, the age at marriage continues to below especially in northern states (National Familyhealth survey-2, 1998—1999). The mean age atmarriage of female subjects in our study was sig-nificantly higher ( p < 0.05) than general popula-tion, although there was no significant difference(p > 0.05) in mean age at marriage between malesand females with epilepsy (Table 1). The delayedage at marriage of female subjects can be attrib-uted to the stigma associated with epilepsy insociety, larger number of married females includedin this study (48 male versus 64 female) and lowersocial status of females in male dominant society.

The marriage rate of male (46.6%) and female(46.72%) subjects with epilepsy was lower as com-pared to national data (Table 3). The marriage rate

414 P. Agarwal et al.

was significantly low ( p < 0.05) in males andfemales who had earlier onset (<20 years) of epi-lepsy than late onset (>20 years) of epilepsy (Graph1). Recent studies from developed countries haveshown similar finding of decreased marriage preva-lence rates in people with earlier age of onset ofepilepsy, especially in males.9,13 Divorce rate wassignificantly higher in the present study than that ofgeneral population and all the subjects experiencingdivorce were females with epilepsy, who statedepilepsy being amajor factor for divorce. This showssocial stigmatization of epilepsy affecting femalesmore than males. Studies from developed countriesalso have shown that females were more likely toexperience divorce than males.9,14

One reason for seeing no divorce in males withepilepsy may be social obligations and dependencyof their life partners on them. The social stigmati-zation of epilepsy is further supported by the factthat majority of subjects did not disclose epilepsybeforemarriage and females have significantly morewithheld marriage than males. Studies from devel-oped countries have reported lower marriage ratesin people with epilepsy regardless of remission sta-tus.4 In our study, male and female subjects whoseseizures were not in remission had significantly( p < 0.05) lower marriage rates and higher age atmarriage than those in remission (Table 4). Fertilityrates (pregnancies per person-year of marriage)were also lower in those not in remission comparedto subjects in remission. Ounsted et al. has reportedthat early remission of seizures was associated withmarriage in men.19 Marriage rate, age at marriageand fertility rates of subjects in remission on med-ications and off medications were similar.

Studies from developed countries showed thatmen with partial onset epilepsy are reproductivelyat more disadvantage; but type of seizures did nothave any effect on fertility in women.13 But, in ourstudy, fertility rate, marriage rate and age at mar-riage did not differ significantly between subjectswith generalized or partial onset epilepsy showingthat type of seizures did not have any effect onfertility and nuptiality behaviour (Table 5). Thetotal fertility rate of female subjects were compar-able to national or state data showing that epilepsyhad no effect on fertility. The abortion rate inmarried female subjects was equivalent to nationaldata (Table 6). This is in contrast to studies fromother parts of the world showing decreased fertilityin males and females with epilepsy.7

Decreased fertility rate in people with post trau-matic epilepsy has been reported from India.15

These studies have attributed reduced fertilityamong people with epilepsy to organic brain lesionor anticonvulsant treatment or both.16 But Olafsson

and co-workers found no evidence of altered ferti-lity among people with idiopathic/cryptogenic epi-lepsy or remote symptomatic epilepsy.17 Our studyshowed higher fertility in married males with epi-lepsy like study conducted by Danskey et al.18 It maybe also due to regional variation in fertility patternor selection bias.

Social stigmatization of epilepsy is high particu-larly in developing countries.20—24 Both felt andenacted type of stigma as described by Scramblerand Hopkins 25 are seen in India though enacted oneis more common because family overprotects peo-ple with epilepsy and less is expected from them incertain families. In conclusion, we state that sub-jects with epilepsy have lower marriage prevalencerates, delayed age of marriage (especially infemales), higher divorce rates and withheld mar-riage in comparison to general population in India.The most affected are those with earlier age ofonset of epilepsy (<20 years) and in whom epilepsyis not in remission. Type of seizures did not have anyeffect on fertility. Epilepsy is still regarded, as socialstigma in this part of the world and efforts should bemade to enable subjects with epilepsy to come outof the shadow.

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