Vulnerable young women pushed into hysterectomy

Devaki distinctly remembers the day when her family had to make a choice — between her mother and the land. “The doctor warned that there were chances of developing cancer if the uterus was not removed immediately.” The doctor’s words were powerful enough to instil fear among the family members who decided to mortgage their five-acre land in Kaddirampura village of Hosapete taluk in Ballari district for Rs 30,000 to pay for the surgery.

Devaki’s mother, Gangamma, who was in her thirties, had visited the doctor in a private hospital in Hosapete with complaints of white discharge. She was expecting some simple treatment and advice from the doctor. “It came as a shock to me. Though I was not at all prepared for the surgery, the hope of better health made me undergo the procedure,” Gangamma said. But backache, stomach pain and weakness made her fragile after the surgery.

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Chinnamma, 23, in Vaddarahatti of Kudligi taluk went to the doctor a year ago to get treatment for heavy menstrual bleeding. The doctor asked her only one question after the check-up, which included an ultrasound scan. “How many children do you have?” It didn’t take more than five minutes for the doctor to decide on hysterectomy after Chinnamma said she had two children.

Three years after the entire state stood against the practice of unwarranted hysterectomy, when thousands of such cases involving Dalit and Lambani women were exposed in the private hospitals of Kalaburagi, the situation doesn’t seem to have changed.

‘Permanent’ solution

Gynaecological problems such as white discharge, heavy bleeding or abdominal pain along with anaemia make these women visit doctors who set aside medical ethics to offer them an ‘easy’ and ‘permanent’ solution. “This malpractice stems from privatisation of the healthcare sector which is becoming increasingly profit-driven. The government lacks the political will to regulate the hospitals,” said K Neela, a grassroots activist in Kalaburagi.

As a result, a large number of women, particularly the rural poor and those from indigenous communities, lose their wombs at a very early age leading to many complications later in life.

“Hysterectomy has all the inherent risks of a major operation. That apart, it will have serious psychological and physiological implications. There is no counselling done before and after hysterectomy about the complications involved and how to deal with several issues that arise when a woman loses an essential organ at a young age. Ovaries produce estrogen hormones which are crucial for a woman’s health. If they are removed, women get exposed to a range of health conditions such as osteoporosis and cardiovascular disease,” said a gynaecologist in Tumakuru.

DH visited Vaddarahatti based on the information provided by a researcher about the high number of hysterectomy cases there. Just a casual enquiry about the uterine problems in this hamlet of 200 houses led to discussions on hysterectomy. In barely five minutes, around 20 women gathered to share their experiences.

“Young couples from about 170 households migrate to Malnad and coastal districts and engage in heavy manual labour. We have no choice but to work during menstruation, pregnancy and soon after childbirth. We generally start suffering from uterine problems in the mid-twenties. When we approach the doctors, they say removing uterus can relieve us from our sufferings,” Kanakamma, a resident of the hamlet, told DH. “But they don’t tell that we have to face a host of other health problems after hysterectomy.” The 45-year-old claims to be the first person in the hamlet to undergo the procedure 15 years ago. “Afterwards, at least 200 have undergone a hysterectomy.” The youngest to undergo a hysterectomy here is 22 years old.

When contacted, the local accredited social health activist, commonly known as an ASHA worker, said that the number of hysterectomies in the village was 40. Migration could be one of the reasons for the variation in numbers. As per the ASHA worker’s estimation, there are about 400 women in the age group of 19 to 49 in the village. Even with 40 hysterectomies, the number is more than the national and state average of 3%.

Of the 40, two had prolapsed uterus and four were said to have fibroid. These two are potential causes for hysterectomy. The rest approached the doctor for excessive bleeding and vague abdominal pain. The doctors’ explanation for prescribing hysterectomy included ‘swollen uterus’, ‘boils in the uterus’, and that ‘the uterus removal will free them of the monthly ordeal and possibilities of cancer’.

The surgery costs anywhere between Rs 40,000 and Rs 50,000. The families generally take loans to meet the expenses.

DH conducted a survey in 15 villages in Hosapete and Kudligi taluks, with the help of a nonprofit organisation and a few ASHA workers. Of the 248 women interviewed, 75 were below 30 years when they had undergone hysterectomy and 112 were between 30 and 40 years of age during the surgery. As many as 178 surgeries were done in private hospitals while 20 didn’t remember the hospital where the surgery was conducted. Almost all of them complained of health problems after the surgery.

Most of them went to private doctors as they didn’t have access to a public healthcare facility. The hospitals were referred by word of mouth and in some cases, through a person who had some association with the hospital. Interactions with the survivors of hysterectomy also point at the failure of the public healthcare system to ensure a preventive mechanism.

Records not kept

“Why do we need these details? What do we understand? It is good if it is in the hospital itself.” This was the reaction of an ASHA worker in a village in Kudligi taluk when asked about the discharge summary. She underwent a hysterectomy at the age of 27 for stomach pain, as per the suggestion of a doctor. Obviously, she hasn’t collected the report of the tests and the surgery.

The women of Vaddarahatti seem to be more aware. Most of them have kept the scan report and discharge summary safe. Unfortunately, they don’t understand what is mentioned in the reports as almost all of them are illiterate. Interestingly, some hospitals have provided handwritten discharge summary, in notebooks, while some reports don’t indicate that the problem warranted surgery.

“A large majority of the hysterectomies conducted in the state are not needed. In fact, less than 10% of women who complain of gynaecological problems require a hysterectomy. The rest can be treated without surgery, with good rest, nutrition supplements and proper medication,” said Dr Sanjeev Kulkarni, a gynaecologist in Dharwad. He is an active campaigner against unwarranted hysterectomy.

“What should have been the last intervention for gynaecological issues is now considered as the first option by medical practitioners, without offering alternatives to patients,” another gynaecologist said. A homoeopathic doctor in Hosapete shares numbers that support Dr Sanjeev’s statement. “In the past three years, about 60 women have approached me after their surgery date was fixed. Nearly 50 of them didn’t require a hysterectomy. They have recovered completely after treatment.”

Another issue that has to be immediately addressed, according to gynaecologists, is to have a system to ascertain the cause for hysterectomy, authorise it and ensure that ovaries are not removed unnecessarily during the procedure.

However, the Department of Health and Family Welfare doesn’t have data on the hysterectomies done in the state. “Only when there is a direction from a government agency, we get the details for that particular component from the specified place,” said a district health officer.

To make matters worse, it has been proved from previous instances that general surgeons also do a hysterectomy. “This is not allowed. The government has to ensure stringent actions to end this practice,” said Dr Veerabhadrappa, president, Karnataka Medical Council. He also suggested that the government should make it mandatory for doctors to take a second opinion before doing a hysterectomy on women below 40 years.

According to the National Family Health Survey 2015-16, the median age for having undergone the procedure in the country is 34. “This is about 15 years before the menopause age. This is an alarming trend and will have serious implications on women and also on society,” said Chittorgarh-based Dr Narendra Gupta, a public health expert, who moved public interest litigation on mass hysterectomy in the Supreme Court in 2013.

Early marriage, early motherhood, heavy work during pregnancy and the lack of menstrual hygiene are some social drivers that cause uterine problems. Menstrual taboo and the problems women face during menstruation make it easy for the healthcare providers to convince them for hysterectomy.

“Most of their gynaecological sufferings are stemmed from their lack of access to hygienic surroundings and proper rest. The healthcare providers, instead of addressing these issues, are spreading misinformation and creating fear among innocent women with profit motives. A decade ago, the doctors used the word ‘cancer’ to coerce them, over the years hysterectomy seems to have been normalised. In most of the cases, it has worsened the quality of life. The government is turning a blind eye to the sufferings of women,” said Bhagya, a social worker in Hosapete.

Deceiving the innocent

State Women’s Commission chairperson Nagalakshmi Bai told DH that over 200 women who had undergone hysterectomy had recently visited her with a request to create suitable livelihood opportunities as they are too weak to do farm labour after the surgery. “I have directed the district officials to do a survey of such women upon which suitable assistance will be provided,” she said.

A fact-finding study conducted by the Karnataka Janaarogya Chaluvali in Kalaburagi and Chikkamagaluru districts stated that there was a serious violation of professional integrity and ethics by doctors. It detailed how “Hysterectomies were performed even when they were not warranted; the women were provided with grossly unscientific information; a nexus was created to bring to the fold unsuspecting patients; problems evident in the test reports were wilfully ignored; the doctors undertook interventions about which the women were not given prior information; violent, humiliating means were used to extract money.”

At the other end of the spectrum are women of the Kadugolla community in Tumakuru district who endure multiple gynaecological issues that arise out of a poor lifestyle and the lack of personal hygiene. “There are at least 20 women in Bittanakurike who suffer from a third-degree uterus prolapse. Some don’t have access to doctors. Some can’t raise the money required to undergo a hysterectomy,” said Manjamma who hails from the hamlet.

As thousands of women lose their wombs due to government apathy and the failure of our public healthcare system, a business thrives.

(Names of hysterectomy survivors changed to protect their identity.)