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Oxfam calls for new regulations to reduce unnecessary hysterectomies in private hospitals

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f852 (Published 08 February 2013) Cite this as: BMJ 2013;346:f852
  1. Soumyadeep Bhaumik
  1. 1Kolkata

The charity Oxfam has called for immediate action to stop doctors conducting unnecessary hysterectomies in Indian private healthcare facilities.

The private sector provides 80% of outpatient care and 40% of inpatient care in India, it said.1 However, evidence from recent scientific studies and surveys indicated that gynaecologists in private hospitals and clinics have been recommending and performing hysterectomies on women when the operations were not clinically indicated.

Araddhya Mehtta, global health spokesperson for Oxfam, said, “The trend is seen all over India but is particularly disturbing in Rajasthan, Bihar, and Chhattisgarh, where doctors simply abuse their power of being a doctor. When women come with abdomen pain, doctors prescribe hysterectomy to women from poor economic backgrounds, telling them that it might be a cancer or a hole or a stone in the uterus without doing any thorough necessary investigations.”

Oxfam has called for an end to further public-private partnership programmes until regulatory measures and services are “standardised to improve rationality of care, regulation of fees, and to uphold patient’s rights.” It also asked aid agencies and foreign donors “to support evidence-based strategies to expand government provision of health care and not promote scaling-up of private-sector health service delivery in low- and middle-income countries.”1

A right to information request from a local non-governmental organisation in the Dausa district of rural Rajasthan to investigate the matter found that 258 of 385 women (65%) investigated over six months in 2010 had had their uterus removed.1 It also found that many women who underwent the procedure were under 29, with the youngest just 18 years old.

Mehtta said, “These poor patients have been pushed to debt because of this unnecessary surgery, for which they have been charged about 20 000 [£240; €280; $375] to 30 000 rupees for a procedure they do not need at all. A special fact finding committee formed by the government [in 2011] to investigate the matter has not yet submitted its report.”

Research conducted by a non-profit organisation in Andhra Pradesh from 2008 to 2010 found that 60% of hysterectomies were carried out on women aged under 30 and that 95% of the operations were done in private hospitals (n=171).2 It also found that that hospital discharge summaries were mostly blank, with no information about the procedure or follow-up instructions.

Aniruddha Malpani, a fertility specialist and medical director of the Malpani Infertility Clinic and HELP (Health Education Library for People) in Mumbai told the BMJ, “It is unfortunate that doctors are taking out perfectly healthy uteruses for financial reasons. The solution lies in empowering patients and giving them the power of information therapy so that they can ask questions, take second opinions, and take part in shared decision making. Hysterectomies are very useful when done properly, and I just hope that this does not give all hysterectomies a bad name.”

However, he said that the rising number of hysterectomies that were not clinically indicated was a global phenomenon. The rate of hysterectomies in Canada was about 346 per 100 000 women in 2006-07, more than double the rate in the United Kingdom, Sweden, and the Netherlands.3

Malpani said that preaching to doctors about their ethical responsibilities would not help, because “good doctors are good anyway and bad doctors won’t improve through such advocacy programmes.”

A study on the effect of community based health insurance in Gujarat found that current reimbursement policies led to dangerous and unethical practices such as “performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology even when symptoms and signs are suggestive of disease.”4

Malpani said, “A change in the insurance reimbursement procedures, where a peer review of the hysterectomies performed is done routinely, will help to curb the bad apples. Insurance companies need to use data analytics to scrutinise medical records, to help prevent this kind of abuse of the system.”

Notes

Cite this as: BMJ 2013;346:f852

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