At 34, Sangeeta Kale from Maharashtra’s Beed district is a mother of two college-going sons, aged 19 and 17. Married off to a sugar-cane cutter at the age of 13 even before she had hit puberty, Kale had little inkling of the hard life ahead. Kale, who had her first child when she was just 16, worked through her pregnancy with husband Sadashiv in the fields of western Maharashtra, sometimes spending up to 16 hours cutting and loading the cane crop into trucks during the harvesting months — October to March. Her life remained the same after her first and second deliveries and subsequent years.
However, she found the routine backbreaking work daunting on days her menstrual cycle set in, as the fields had no toilets. She couldn’t take leave for fear of being heavily penalised. Finally, fed up with these troubles and other recurrent gynaecological issues ranging from white discharge to pain, Kale underwent hysterectomy — uterus-removal surgery — last July.
Just like Kale, many women, some of whom are just in their 20s, in Beed have undergone this life-altering procedure, which is otherwise prescribed only for a handful of medical conditions and often performed as a last resort.
What is even more shocking is that Kale was the seventh woman in her extended family, living in Beed’s Umrad Jahagir village, to have undergone the operation. “Frustrated with period pain, white discharges and foul smell, when I approached a doctor, I was told my uterus was damaged and hysterectomy was the way out,” says Kale.
The drought-stricken Beed district in Maharashtra’s Marathwada region came under the scanner this May after reports came to light about the unusually high rate of hysterectomies among its women, especially among those who migrate to neighbouring districts to work as sugar-cane cutters.
State figures say that in three years (2016-2019), as many as 4,605 women have had their uterus removed in Maharashtra. Civil rights organisations allege that the hysterectomy rate in Beed is 14 times more than that for the State or the country. In Umrad Jahagir village where the Kales reside, the number of ‘womb-less women’ now stands at 50.
Pushed into debt
Sitting on the floor of her tin-roofed shanty, Kale, slightly under five-feet tall, points towards her back and knees. “The uterus-removal surgery has no doubt relieved me from the menstrual cramps and vaginal discharge, but it has brought along back and joint pain. On many days, the pain is unbearable. It’s like I have aged at a greater speed,” she says.
“The doctor assured me that removing the uterus was the best option. Though I was taking medication, my infections were recurring. I had already undergone a sterilisation surgery, so there was anyway no scope of having more children. Hysterectomy seemed like the right thing to do. But later, the after-effects started,” rues Kale, who missed out on the last sugar-cane cutting season as she was bedridden for three months after the procedure. Her decision to undergo the procedure has brought not just health issues but severe economic distress to the already impoverished household.
Her husband holds her responsible for the debt of ₹2 lakh that has piled on them. At first, he blamed her one-off leaves from work. Then, he pointed fingers at her for the ₹30,000 that they had to borrow for the hysterectomy. The taunts have gotten worse since they missed out on the last season of sugar-cane cutting.
Kale relied on the testimonies of her four sisters-in-law and two of their mothers-in law, who had all been through the procedure, when she got admitted to the Veer Hospital located on the Beed-Jalna road for the surgery. “None of us has ever been to school. But the doctor is educated. His word was assuring for us,” she says.
Kale’s sister-in-law Vaishali, 33, was also advised a hysterectomy when she sought medical help after grappling with vaginal discharge and recurrent infections for years. “I was told my uterus was damaged and getting it removed was best. I had two sons, so we thought the most important job of the womb was done,” says Vaishali.
Scores of women in Beed offer a similar narrative. Shockingly, most don’t have medical reports or any papers to show the history of their treatment.
Their individual stories all follow a pattern. Women would commonly consult their doctors for health issues lasting up to a year, but then complain of recurrent infections. Sooner or later, hysterectomy would be recommended to them as a permanent solution.
However, they were never told how the surgery could lead to hormonal imbalance, calcium deficiency and constant body ache, among other things.
In Beed, open defecation remains a ground reality. Many households do have built toilet blocks built under the government’s Swachh Bharat scheme but their members still defecate in the open due to lack of water. For the women in the district, it is a vicious cycle as they have no sanitary facilities either at their workplace or at their homes. And the nature of work in a sugar-cane field has only worsened their situation.
An estimated 5-6 lakh people, including pregnant and lactating women, migrate from Beed to other parts of Maharashtra, and border areas of Karnataka, to work as sugar-cane cutters. Hailing from a region that is perennially under a spell of drought and not having many avenues of employment, Beed residents continue to live in abject poverty and have to rely on sugar-cane cutting to make a living. Traditionally, a couple is hired by a mukadam (contractor) as a single ‘unit’, known as ek koyta (one sickle). The contractor pays them uchal (a lump sum) in advance, ranging from ₹80,000 to ₹1.2 lakh, for a period of four to six months. The pairs migrate after Deepavali every year.
While a typical workday starts at around 6 a.m. for the couple, the woman gets up earlier, at 4 a.m., and cooks food for the entire family before she sets out. Children are left behind in temporary shanties near the sugar-cane farms as their parents toil under the sun.
Two-and-a-half tonnes a day
Laxmi Chauhan, 44, from Beed’s Vanjarwadi village and her husband Nanabhau, 45, have been migrating for sugar-cane cutting for the past 25 years. “We manage to cut about two-and-a-half tonnes of sugar-cane in a day. A tonne of sugar-cane earns us anywhere between ₹350 to ₹400 depending on the seasonal rate,” says Nanabhau, a father of two sons, both in their twenties.
Soon after the birth of their children, Chauhan began experiencing pain in the abdomen, which resulted in her frequent absences from work and low productivity. “Working during the menstrual cycle was anyway difficult,” says Chauhan, adding that she had to make multiple strikes with the sickle to cut a single cane, a process which made her feel further weak and unwell. It also meant lower earnings for the couple.
“We earned less than the uchal and had to repay the remaining amount to the mukadam . Also, when one failed to report to work, the mukadam demanded a fine of ₹500, which had to be paid in cash and was distributed among other workers who took the extra workload,” says Chauhan.
Troubled by her own dwindling productivity and the couple’s mounting debt, Chauhan finally decided to see a doctor at the Veer Hospital in 2014. Following a sonography, she was told that her uterus had got swollen and this could lead to cancer. Within the next few days, the couple hurriedly collected ₹25,000 and Chauhan got her uterus removed, as advised by the doctor. She was hospitalised for seven days.
“Since then, my body has begun swelling and I am in pain every day. But I feel better than before,” she says. Weight gain, which Chauhan has experienced, is another inevitable side effect of hysterectomy. When asked if the uterus removal was at the suggestion of a mukadam , the couple deny it. “We trusted the doctor’s word,” says Nanabhau, adding that they had sought help with the intention of getting medical treatment and not surgery. “When the doctor told us about the risk of cancer, we did not want to take any chances,” he says.
Coaxed by contractors?
Following reports on the high number of hysterectomies performed in Beed, the Maharashtra administration launched an investigation on June 18. Among the many aspects that the authorities are probing, one is whether the mukadam s push women to undergo the procedure to ensure better returns. “There could be a nexus between profit-driven doctors and the mukadam s. This definitely needs to be investigated, among other things,” says Neelam Gorhe, who is heading the seven-member investigation committee that will submit its report to the Chief Minister and Health Minister this month.
A mukadam is a well-connected villager who reaches out to prospective labourers from the nearby areas. With frequent droughts and failing crops, many couples prefer to migrate for income generation, even if they have acres of farmland back home.
“The poverty is so ingrained that the advance taken by couples is exhausted very quickly. When they fail to cut sugar-cane worth the advance paid to them, we are left with no choice but to pursue them to return the remaining money,” says Bappa Kotwade, 42, a mukadam from Beed’s Irla Dubba village. Having been a mukadam for the past 15 years, he supplies up to 200 koyata s (couples) to sugar-cane factories every season.
While some labourers are gadiwale (couples with a pair of bullocks and a rented cart), some work as toliwale (groups that transport harvested sugar cane in trucks or tractors).
“Some men are alcoholics and recovering money from them becomes a task. Some couples disappear midway. There are some who never pay back. We have to be taskmasters to deal with this,” says Kotwade, adding that they forge long-standing relationships with the labourers and keep paying them small amounts for food and health expenses to ensure that they come back every season.
But it is not always hunky-dory for the labourers, some of whom have been beaten up and even illegally detained in factories when they failed to cough up the money. “There have been murders too,” says Kotwade, citing a story of a mukadam who had a scuffle with a labourer while demanding the money. “The labourer died due to serious injuries and the mukadam landed in jail.”
Kotwade, however, rubbishes the allegation that mukadam s suggest hysterectomies to women. “It is a vicious cycle of hard manual labour, grinding poverty and bad living conditions. Uterus or no uterus, they have to work to earn. Why should we tell them anything?” he says, adding that women have been undergoing hysterectomies for years in Beed.
Let down by doctors?
A muddy pathway through a farm in Vanjarwadi leads to the house of Sarika Chandrasen Kurlekar, a frail 32-year-old. In the village, where 56 women have undergone uterus removal procedures, Kurlekar is the youngest to have been operated. She has never migrated for cane cutting but, like all other women, had been complaining of continuous white discharge that caused fatigue. Her medical record from Matoshri Hospital cites “bulky cervix and persistent demand by patient” as the reason for the hysterectomy.
Ashok Anand, head of gynaecology at the state-run J.J. Hospital in Mumbai, is amused at the reasons cited. “Neither a bulky cervix nor persistent demands by a patient warrant a hysterectomy. Her symptoms were more likely due to cervicitis, which could be treated through conservative medication,” says Anand.
Since news on the hysterectomies in Beed came to light, questions have been raised on the possible role of the medical fraternity in making women undergo the procedure. State data showed that 99 private hospitals in Beed district have carried out 4,605 hysterectomies since April 2016. Eleven of these hospitals have carried out more than 100 hysterectomies in the three-year period.
The top five in the list are: Pratibha Nursing Home (277); Tidke Hospital (196); Shree Bhagwan Hospital (193); Gholve Hospital (186); and Veer Hospital (179). In comparison, 2,000-odd hysterectomies have been performed in the public sector in the same period in Beed. “Instead of getting rational treatment in public health-care facilities, the women are pushed towards irrational treatments in the private sector,” says Abhay Shukla, national co-convenor of the Jan Swasthya Abhiyan. “It’s nothing but gross exploitation of vulnerabilities of women and a failure of the state,” he says. Activists also rue that the official count could be under-reported as the state banks on these same hospitals to furnish the figures.
Local doctors, however, feel the criticism is uncalled for and insist that for most of the women who underwent the surgery, their health warranted it. Gynaecologist Madhav Sanap, who has run the Shree Bhagwan Hospital since 1998, is prompt to assert that there may be doctors who conduct unindicated procedures, but he is not one of them. “Of the 193 surgeries that I have carried out, only four were of women under 35. I can provide history for each and every case,” he says, while arguing that the hype around hysterectomies in Beed requires an in-depth analysis. “It will prove that the district has rates comparable to other parts of the State,” he says.
Sanjay Veer, a gynaecologist and owner of Veer Hospital, says no one goes under the knife unless there is real suffering. “These women live in conditions of extremely poor hygiene. They don’t have access to toilets. They can’t afford sanitary pads. Open defecation is rampant in their villages as near the sugar-cane farms where they work,” he says.
“The core issues are poverty, illiteracy, lack of sanitation and access to water. Doctors are being made scapegoats in this issue, which is largely a socio-economic one and requires a larger solution,” he adds.
The National Family Health Survey data show that the rate of hysterectomies in Maharashtra is 2.6%, while the national average is 3.2%. But when it comes to Beed, a 2018 survey of 200 women by Maharashtra State Commission for Women revealed the extent of the problem as around 36% were found to have had undergone hysterectomies.
According to Beed’s civil surgeon Ashok Thorat, there is an absence of enough data to carry out comparisons with other districts in Maharashtra. “Our primary investigations have shown that the prevalence of hysterectomies is 17 per 1,000 women in Beed. In some parts of Andhra Pradesh, Telangana and other States, the prevalence is about 50 to 60 per 1,000 women,” says Thorat, adding that a detailed survey is under way to get to the root cause.
In fact, a circular dated April 16, has made it compulsory for private gynaecologists in Beed to seek permission from a civil surgeon for every hysterectomy procedure barring emergency procedures, which have to be reported within a span of 24 hours. The circular warns doctors against portraying all kinds of tumours, growths and swelling on uterus as cancers.
“The number of hysterectomies has gone down by 50% since we implemented the SOP [Standard Operating Procedure],” Beed’s collector Astik Kumar Pandey tells The Hindu . “Right now, all the hospitals are under our scanner. All hysterectomies in the past, especially of women who are under 35, are being scrutinised,” he says.
Activists say that the menace of unwarranted hysterectomies affects not just sugar-cane cutters but women in general. “Early marriages and child birth, fear of cancer and the loss of wages during menstruation have all culminated in the high rate of hysterectomies. The government has no clue about the ground reality as it has never maintained any data,” says health activist Abhijit More who terms Beed’s situation as a blatant violation of rights of women living in the district, who are uneducated and therefore ill-equipped to make the right health choices.