The Indian women pushed into hysterectomies
Thousands of Indian women are having their wombs removed in operations that campaigners say are unnecessary and only performed to make money for unscrupulous private doctors.
Sunita is uncertain of her exact age but thinks she's about 25 years old. I met her in a small village in Rajasthan, north-west India, surrounded by chewing cattle and birdsong. She was covered in jewellery, from a nose-stud and rings to bangles which jangled when she gestured with her hand.
Her face hardens when she tells me about her operation.
"I went to the clinic because I had heavy bleeding during menstruation," she says.
"The doctor did an ultrasound and said I might develop cancer. He rushed me into having a hysterectomy that same day."
Sunita says she was reluctant to have the operation straightaway and wanted to discuss it with her husband first. She says the doctor said the operation was urgent and sent her for surgery just hours later.
More than two years have passed since that day but Sunita says she still feels too weak to work or look after her children.
When other local women crowded round, I asked how many of them had undergone hysterectomies. More than half raised their hands at once. Village leaders said about 90% of the village women have had the operation, including many in their 20s and 30s.
The doctors generally charge around $200 for the operation, which often means the families have to sell cattle and other assets to raise the money.
I tracked down the small private clinic where Sunita and some of the other women in the village said they had been advised to have hysterectomies, after suffering from symptoms such as heavy periods and period pain, bladder infections and backache.
End Quote Dr Narendra Gupta Health charity activist
It seems that private doctors see this as an opportunity to make a fast buck”
The owner, a doctor, was in the middle of an ultrasound scan when I arrived. When I put the women's allegations to him, he shook his head and smiled. They weren't telling the truth, he said. Unlike others in the area, his clinic was genuine and ethical.
When I asked him how he could diagnose a pre-cancerous or cancerous growth on the basis of an ultrasound scan, he admitted that he sometimes didn't do biopsies before removing the uterus, only afterwards.
Once the removed uterus - and any biopsy tissue - has been destroyed, it becomes hard to prove that the operation wasn't justified.
But it is clear that something strange and deeply worrying is happening.
Reports from a handful of Indian states, including Rajasthan, Bihar, Chhattisgarh and Andhra Pradesh, suggest that an extraordinarily high number of women are having their uteruses removed, including many below the age of 40.
- It's hard to compare Indian hysterectomy rates with other countries, as only one generation of reproductive-age women has had access to the procedure
- A study in Andhra Pradesh state concluded that women under 45 rarely needed the operation
- Canada has one of the highest rates in the world - 346 per 100,000 women in 2006-7 - double that of the UK, the Netherlands, Sweden and Norway
- Data from the UK suggests a hysterectomy rate of 150 per 100,000 women
The women often say the doctors frightened them into surgery by saying the uterus was cancerous. But in many cases, the diagnosis was made on the basis of a single ultrasound scan - which, according to independent doctors, cannot justify a decision to operate.
Dr Narendra Gupta, of the health charity, Prayas, a local partner of Oxfam, is one of many activists convinced that some private doctors are engaging in blatant malpractice.
"People say that in some places, there are whole districts without uteruses," he says.
"It seems that private doctors see this as an opportunity to make a fast buck. They're making money on ailments which could be treated in a simpler, less invasive way."
I met Dr Vineeta Gupta, a gynaecologist, in her consulting rooms in Rajasthan's state capital, Jaipur, her stethoscope dangling round her neck. She says she sees seven or eight women a week from villages in the region, who've been told they need hysterectomies but want a second opinion.
"In rural areas, doctors give a diagnosis of cancer very readily," she says.
"That's very wrong. When patients come to me, I tell them that an infection doesn't cause cancer. We'll cure the infection, I tell them, and you will be completely all right. Some are convinced but some are not convinced because they've been told: 'If you don't get your uterus removed you will get cancer and die.'"
Until recently, no data was kept on the number of hysterectomies performed, but anecdotal evidence suggests the operations have become much more prevalent in recent years.
This follows the rapid expansion of small private clinics and hospitals, especially in remote rural areas that are poorly served by the government health system.
"In the UK, a hysterectomy is very rarely performed to save life so other treatment options are usually explored first.
In order to confirm a diagnosis of cancer, doctors would first perform a biopsy and other lab tests. In some cases, they would treat with radiotherapy and/or chemotherapy before recourse to a hysterectomy.
The vast majority of hysterectomy cases in the UK involve women between the age of 40 and 50. It is rare for a woman in her 20s or 30s to have one.
Even when a hysterectomy leaves the ovaries intact, it may trigger menopause.
The operation can also lead to incontinence, irritable bowel syndrome, depression, back pain, loss of sexual pleasure, thrombosis and vaginal prolapse."
Ceri Averill, Oxfam's health policy advisor
Many campaigners accept that the clinics are necessary but they argue that the doctors must be properly monitored and regulated to ensure they provide a decent level of care - and do not swindle their patients or the state.
To ease the burden on the rural poor, the Indian government launched a national health insurance scheme, the RSBY, in 2008. Under the scheme, families living below the poverty line can receive treatment worth up to 30,000 rupees ($550) each year from designated private hospitals, which claim the costs directly from the state.
But in some states, critics say the scheme appears to be encouraging unnecessary hysterectomies, as unethical private clinics exploit the vulnerable poor, using them as a means to tap into government funds.
In Samastipur, a district in the northern state of Bihar, initial figures suggested that more than a third of operations carried out under the scheme were hysterectomies. The district magistrate, Kundan Kumar, became so concerned about these figures that he invited women who had had the operation to attend a government medical camp last August, where they received an independent evaluation from government doctors.
The report from the camp suggests that of 2,606 women who were examined, 316 - about 12% - had had their uteruses removed unnecessarily.
There were also cases of women whose doctors had claimed money for performing hysterectomy, but had in fact made only a superficial incision, leaving the uterus intact.
Mr Kumar accuses a number of private clinics of "excesses" carried out for "selfish gains" and is preparing to prosecute them.
"Instead of resorting to conservative techniques, they go straightaway for surgeries which meant more money for them," he says.
"I think there was basically a mad rush to earn as much money as possible to do unwarranted surgery."
The clinics involved in the district magistrate's investigation deny malpractice and say the hysterectomies were medically justified.
India's minister for rural development, Jairam Ramesh, says the root of the problem is the failings of the public health system.
"All the spending is in private clinics because the public system has collapsed," he told me.
"So it's rational behaviour for people to go to private clinics when the public health facilities are not there."
Find out more
- Jill McGivering was reporting for the documentary Assignment on BBC World Service
- Her programme airs on 7 February at 09:05, 13:05, 16:05 and 20:05 GMT
But in that case, I said, it was important that those private clinics had doctors who were both honest, and properly qualified.
"And that they do not fleece the consumers which they are doing right now," he said.
"That's what is leading people to spend extraordinary amounts of money for healthcare and probably getting treatments much in excess of what they need."
Legislation passed by the central government to regulate the private sector is now in the process of being implemented by India's individual states.
In the meantime, Indian women continue to have hysterectomies which many of them may not need.