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- family planning service provision
- health economics
- health education
- service delivery
- reproductive health politics
Hysterectomy is the second most common surgery performed on women in India, after caesarean sections. An estimated national mean age at hysterectomy is 30–40 years, and this is as low as 24 years in Andhra Pradesh.1 However, India does not have a national surveillance mechanism in this regard. Fieldwork conducted among several tribes and rural communities in Odisha, West Bengal and Bihar witnessed high incidences of hysterectomy-related medical anomalies and narratives of women's suffering.
Normally, uterine fibroids, endometriosis, uterine prolapse, cancer and hyperplasia result in a hysterectomy.2 However, women suffering from reproductive tract infection or those seeking permanent sterilisation, particularly those from underprivileged, rural and tribal backgrounds, predominantly reported unethical medical practices in connection with hysterectomy; male patriarchy, women's low status in society, ignorance and superstitious beliefs are other major sociocultural factors that increase women's vulnerability to unnecessary hysterectomy. The 3rd National Family and Health Survey (NFHS) of India reported that 37% of women opted for sterilisation with <1% of the men.3
In most hysterectomy cases, women and their families are influenced by predatory hospitals and certain corrupt doctors who provide false information about the women's health status.4 Additionally, women from below the poverty line become primary targets as they are eligible to receive special governmental financial support and health insurance assistance towards the cost of such surgical procedures. For this reason, the Governments of Andhra Pradesh and Maharastra have banned compensatory hysterectomy in private hospitals.1
The pan-India rise of the incidence of hysterectomy has been of concern to the Indian parliament, Indian Supreme Court and the media at various times. The union health minister, responding to the >25% incidence of hysterectomies of all surgeries carried out in Bihar in a 1-year period, ordered an enquiry in August 2012. NDTV reported 11 000 cases of hysterectomy in Andhra Pradesh during an 18-month period. Gabsindhe reported more than 50% of the studied tribal and rural women witnessing hysterectomy in Bhopal District in Madhya Pradesh.5 Similar complaints were reported from Rajasthan, drought-hit areas of Maharashtra and several other Indian states. It is of further concern that most hysterectomies are carried out in women of early or mid-reproductive age and residing in rural and tribal areas.
The uterus has many benefits for a woman even after reproductive senescence. Conversely, hysterectomy carried out at an early age leads to premature menopause with further early aging,6 which results in a range of psychosocial issues and risks associated with lowered cardiovascular function and reduced bone density.6 Hysterectomy also has strong socioeconomic and gender dimensions. A daily life of discrimination has a serious effect on a woman's health and affects their nutrition, menstrual cycle as well as their reproductive health. Heavy physical labour in combination with undernutrition can result in the uterus prolaspsing into the vaginal canal, prompting a doctor to recommend its removal.
Furthermore, in Indian society the womb is strongly symbolic of many aspects of womanhood and female sexuality, including the highly regarded status symbol of being able to bear children. An illegal or undesired hysterectomy can cause stigmatisation at the societal level, and a sense of loss at the individual level, which can adversely affect a woman's personal self-image.
Consequently, regular surveillance and identification of areas of high incidence is necessary in order to break the organised menace of unnecessary hysterectomy. In 2013, the Government of India decided to include hysterectomy in the fourth round of the NFHS. However, public awareness campaigns are needed to ensure that hysterectomy is considered to be an important element in female sexual health, hygiene and sanitation campaigns. Addressing the shortcomings in healthcare governance at the grassroots level and women's health empowerment at an individual level are key to improving the current situation regarding unnecessary hysterectomy in India.
Competing interests None declared.
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