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Women’s groups and fertility experts campaign to reduce prevalence of hysterectomy in India

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f7551 (Published 17 December 2013) Cite this as: BMJ 2013;347:f7551
  1. Mohuya Chaudhuri
  1. 1New Delhi

In October 2011 30 of the 1142 women in Panthangi village in the Nalgonda district of Andhra Pradesh in south India had hysterectomies done. All 30 were in their late 20s. This trend of a rising number of surgical removals of the uterus in young women is happening across India, in economically high and low performing states.

The trend has led to an increasing number of women’s groups, non-governmental organisations, and experts questioning the need for the intervention, which they claim its driven more by commercial gain than medical necessity.

In Andhra Pradesh, where the rate of hysterectomies is very high, a study conducted by the non-governmental organisation the Life Health Reinforcement Group found that the median age of women undergoing the procedure was 29 years, globally among the lowest.

In Gujarat, too, a study done by the Self Employed Women’s Association, an organisation working with rural women, also found that a high number of women who had hysterectomies were below 35 years old. Several other states have begun to report the same pattern.

In most cases the women’s reported symptoms were abdominal pain, bleeding and vaginal discharge, inflammation of the pelvis, and back pain, conditions that can be treated without any surgical intervention.

Abha Majumdar, director of the Centre of IVF and Human Reproduction at Gangaram Hospital in New Delhi, said, “This trend is driven by commercialisation of such procedures. Doctors often don’t offer alternative solutions to patients, because each operation is very lucrative.

“Many women who have completed their family at an early age come to me for a second referral, claiming that they had been given only the one option of having their uterus removed because of heavy menstrual bleeding or fibroids. This unethical medical practice needs to be stopped everywhere.”

Rural women are particularly vulnerable, as a low level of literacy negatively affects their decision making. Doctors often cite the risk of ovarian cancer and fibroids to convince women of the wisdom of opting for surgery.

The Gujarat study also found that gynaecologists prescribed surgery instead of alternative treatment because they stood to benefit from the Union Health Ministry’s national health insurance programme, meant for women from households below the poverty line.

Each family in the programme receives an annual allowance of Rs30 000 (£300; €350; $485). For every operation a doctor earns around Rs12 500, a significant sum in rural areas. In some states such as Andhra Pradesh the sum can be as high as Rs60 000 an operation. The government pays the money directly to the medical practitioner.

Narendra Gupta, coordinator of the Prayas Centre for Health Equity in Rajasthan, said, “Healthcare providers are very insensitive towards patients. Since the incentives are so lucrative, and there is no monitoring mechanism, doctors do not hesitate to advise women to undergo hysterectomy even if the problem can be treated by drugs.”

Yogesh Jain, of Jan Swasthya Sahyog (the People’s Health Support Group), said, “The central government’s national health insurance programme has replaced comprehensive healthcare provision, which is more conservative and non-invasive and provides alternative treatments such as counselling and medications instead of surgery. The private sector, however, focuses more on treatment instead of preventive care, encouraging misuse of the provision of insurance.

“Patients are made to undergo hysterectomies even though indications are unclear. The impression is that it is fine to dispose of the uterus. The patient’s consent is often not taken. The scheme is clearly warped and is fuelling greed among medical practitioners”

In rural areas there is a very low level of primary gynaecological care for women. For routine symptoms such as pain, cysts, fibroids, and menstrual bleeding they often have to turn to the private sector. To avoid repeat visits and save money, women often agree to the gynaecologist’s advice for a permanent solution to their problems by undergoing hysterectomy.

If the government had strengthened universal healthcare and made access and appropriate care available at the primary level across the country, especially in rural areas, such unethical practices could be prevented, experts say.

Some campaigners against the rise in surgery say that social and cultural determinants also push women to have their uterus removed. S V Kameswari, from the Life Health Reinforcement Group in Hyderabad, said, “We found that a significant number of young girls who had hysterectomies had been married between the age of 13 to 16 years and completed their family by the early 20s. Since menstruation is seen as unclean culturally and it also prevents women from carrying out their responsibilities at work and at home as well as have sexual intercourse with their spouses, women choose to opt for hysterectomy. They are afraid they will lose their spouse otherwise.”

Hysterectomy had important long term effects on the health of young women, said Kameswari. Apart from reduced bone density, cardiovascular function can be affected, along with the possibility of decreased life expectancy.

Campaigners have pointed out that hysterectomy was not the only elective operation that was on the rise in India. Feeding fears of cancer, doctors were now advising women to have breast surgery, even if the patient just had swelling in the breast. Campaigners have urged the government to set up a robust monitoring mechanism to stop women being subjected to such unethical practice.

Notes

Cite this as: BMJ 2013;347:f7551