Why are women being coerced into removing their wombs?

The wombless women of Beed have emerged as talking points in the national and international media, in Maharashtra legislature and the Parliament. But Beed is only the tip of the iceberg. Wombless women are scattered across villages in India

Are women bearing the brunt of deepening rural distress in India?

Beed, a poor, backward, drought-phone patch of Maharashtra, suggests so. The district is in the spotlight in the wake of allegations of thousands of women being coerced into having hysterectomy – a surgical procedure to remove the uterus or the womb – by unscrupulous doctors.

Hysterectomies -- elective surgeries recommended for women usually above a certain age (35 and older) to treat symptoms like uterine firboids and post-menopausal bleeding -- are not illegal. But the poignant stories coming out of Beed are telling examples of continuing medical malpractices and the rampant misuse of hysterectomy in India.

During the sugarcane-cutting seasons, women in thousands from backward patches like Beed move to the more affluent 'sugar belt' of Maharashtra for work. Contractors and private doctors exploit their vulnerability and lack of awareness. They threaten the women by saying they won't be hired if they take time off during menstruation. Such is the plight of poor village women in these parts that they let themselves be pressured into parting with their wombs by unscrupulous doctors.

"Thin line between voluntary and coercive"

The uncomfortable truth is that there is a thin line between 'voluntary' and 'coercive', in this context. The relationship between doctor and patient is unequal. The women are too unaware and too scared to ask questions or seek better medical advice. So, the savagery of 'voluntary' hysterectomy. Contractors insist they don't force the women to have a surgery; rather, it is their families who make that choice for them.

Maharashtra Health Minister Eknath Shinde admits that 4,605 hysterectomies have taken place in Beed district alone in the past three years.

The wombless women of Beed have emerged as talking points in the national and international media, in Maharashtra legislature and the Parliament. The National Commission of Women is also concerned. The local administration has started taking corrective measures – no hysterectomies can now take place in Beed without prior authorisation from the district administration.

But Beed is only the tip of the iceberg. Wombless women are scattered across villages in India.

Illegal mass hysterectomies have been reported from not only Maharashtra, but also several other states – Chhattisgarh, Karnataka, Rajasthan, Bihar, Andhra/Telengana in recent years.

Reasons vary. However, there is a common thread in the stories of the wombless women – poverty and acute vulnerability. Poor and uneducated women working in the informal sector, often from landless families, are targeted for womb removal when they have minor ailments.

"No doctor has gone to jail"

Shamefully, no doctor has gone to jail for unethical womb removal.

The alleged misuse of hysterectomy prompted Dr Narendra Gupta, a Rajasthan-based doctor to investigate such malpractices in Rajasthan, Bihar and Chhattisgarh a few years ago. The facts that came out were horrifying; Gupta filed a petition in the Supreme Court in 2013, with support from the Human Rights Law Network (HRLN). The petition sought compensation for women who underwent the surgery unnecessarily.

Subsequently, the apex Court issued notices to the governments of Bihar, Rajasthan and Chhattisgarh to investigate and check the malpractice. Several states have taken some preventive measures. Andhra Pradesh, for example, forbade private hospitals from performing hysterectomy under public insurance schemes.

But the chilling reality of women's missing wombs continues. Gupta's petition makes a few things clear: many of the women interviewed during fact-finding missions in Bihar, Chhattisgarh, and Rajasthan had been misled into believing that there was an emergency and that the surgery was urgent. They were made to believe that they might get cancer if they did not comply with the doctors' advice."

In fact, a Right to Information Act (RTI) application filed in the Dausa District of Rajasthan revealed that between April and October 2010, out of a total of 385 operations reported by three private hospitals, 286 of these were hysterectomy operations. Sadly, the PIL filed in 2013, has not come up for hearing since past two years, says Gupta, who is currently associated with Prayas, an NGO.

Warnings ignored

Nearly 25 years back, Dr Arun Gadre, a Pune-based gynaecologist, who is part of The Alliance of Doctors for Ethical Healthcare, wrote an article in a local Marathi newspaper with the title – 'Epidemic of unnecessary hysterectomies'.

Very few people paid heed to his warning that unscrupulous private doctors were instilling fear in the minds of village women, telling them they may get cancer if they don't remove their wombs.

Networks working on health and women's issues in Maharashtra have been consistently making the point that a grossly unregulated private medical sector, and exploitative contractors and sugar factory owners were taking advantage of poor and gullible village women and goading them into removing their uteruses while doing almost nothing to ensure basic living conditions and sanitary facilities.

Dr Abhay Shukla, national co-convenor, Jan Swasthya Abhiyan, points to the web of vulnerabilities that are part and parcel of the lives of many women in rural India -- child marriages, early pregnancies, terrible working and living conditions, huge pressure to not skip work even during while they are menstruating.

On top of this, there is unhygienic surroundings which lead to frequent health problems and gynaecological complaints.

A key demand of the health activists in Maharashtra is the enactment of the long overdue Clinical Establishments Act, including standard treatment protocols to ensure rationality of procedures in private hospitals. They also say that all hysterectomies carried out by private hospitals in Beed in the past three years must undergo a clinical audit, based on standard protocols for gynaecological conditions.

The one thing that leaps out of this sordid saga of rural distress and wombless women is the urgent need to strengthen the regulatory framework in the healthcare industry in this country.

Hysterectomy is one of the 73 packages for obstetric care and treatment of gynaecological morbidities out of total 1,393 packages available under Governments flagship program on Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY). Recent data on PMJAY point to a large number of hysterectomies under this scheme in the private sector.

As of April 2019, data had been analyzed for twenty-four states and union territories implementing PM-JAY since September 2018.

"Over 75% of all hysterectomy claims under PM-JAY have been generated by 6 states: Chhattisgarh (21.2%); Uttar Pradesh (18.9%); Jharkhand (12.2%); Gujarat (10.8%); Maharashtra (9.0%); and Karnataka (6.6 %) according to the National Health Authority.

This has ramifications for women's health, and health systems. Even the government concedes there is need to keep track, monitor the situation.

Patralekha Chatterjee is an award-winning journalist/columnist, and photographer focusing on development issues. Currently, her writing focuses on the intersection of politics and public policy on a range of inter-linked development issues for Indian and international media.

(Views are personal)