High incidence of hysterectomies among rural women in Chhattisgarh has been almost exclusively linked to privatisation of healthcare and the Rashtriya Swasthya Bima Yojna (RSBY) in a recent article in The Hindu ( >Diagnosis of a prolapse by Yogesh Jain and Raman Kataria, Op-Ed Page, July 16). Yet emerging research suggests that we take a broader view of hysterectomy, beyond privatisation to incorporate women’s health and rights.
In a recent study involving 3,855 low-income women (two-third rural agricultural workers and one-third urban labourers) in Gujarat, we found that 34 per cent of rural and 55 per cent of urban women who underwent hysterectomy had utilised a government hospital. Pre-RSBY, women who chose private hospitals went into debt to avail themselves of the operation. While public-private mixes will differ from State to State, it is nonetheless critical to recognise that private practitioners and insurance coverage are not necessarily the primary drivers of hysterectomy.
Without population data over time and the perspectives of women themselves, it is difficult to ascertain if RSBY has increased unnecessary hysterectomies — or if the surgeries would have happened anyhow. Our survey, one of the three systematic studies in India, revealed that seven to eight per cent of rural women and five per cent of urban women had already removed their uterus, at an average age of 37. While many may have been required, the women’s ages — as low as 23 — raise suspicion of unnecessary procedures, but not definitively without medical review.
In Gujarat, no clear predictors of who is more likely to undergo the surgery emerged. According to local health workers, some women demand the surgery to rid themselves of menstruation and its associated taboos. Several, but certainly not all, public and private providers regularly performed the surgery as first-line treatment for relatively simple conditions. This could easily be interpreted as a case of supply-induced demand, which RSBY could exacerbate. However, after qualitative research with women, their doctors and health workers, a different picture emerged.
Providers and women offered the same, overwhelming refrain: the uterus isn’t really necessary, after it has fulfilled its reproductive role. Almost all women had been sterilised several years before a hysterectomy. Yet, in the face of permanently curing a persistent ailment or in fear of cancer, most women and providers dismissed the side effects of removing a once-essential organ. What overall value system dismisses the utility of the uterus post-childbirth? Gender biases, the same that drive violence against women and sex-selective abortion, require equal attention in understanding hysterectomy. If it were privatisation alone, would not male organs face the same fate?
The physical and mental burden of persistent gynaecological morbidity such as infections or menstrual difficulties takes a serious toll on many women. Yet treatment for such ailments is virtually non-existent at the primary level — public or private. In most States, providers in rural areas do not perform regular pap tests, routine exams or first-line surgical procedures for lack of time or equipment, ethical inclination or profit motive. When a woman does seek care, it is likely to be when the problem is acute, and at a far-from-home tertiary or private facility.
Without affordable gynaecological care available closer by, the follow-up travel and cost required for alternative procedures unjustly prevents both doctors and rural women from considering longer term, less-invasive treatment. Both insurance (like RSBY) and government tertiary care facilitate what a biased system has already established for poor women in particular: remove the uterus and solve gynaecological problems once and for all.
Underlying drivers
Without doubt, improved monitoring and regulation of public and private providers is critical. But unnecessary hysterectomy will persist in both the public and private sectors if two core issues remain unaddressed: a lack of basic gynaecological care within primary care and a gender-biased view of women’s bodies and health. While Chhattisgarh and Gujarat may have different health systems, it is unlikely that these two underlying drivers differ. Until the major determinants — and side effects — of hysterectomy are identified and addressed, women’s ailments will turn serious by default, and be treated with extreme measures by necessity.
(Sapna Desai is an epidemiologist and women’s health specialist whose doctoral research at the London School of Hygiene and Tropical Medicine addresses unnecessary hysterectomy in Gujarat.)
