Hysterectomy refers to the surgical removal of the uterus and sometimes the cervix and supporting tissues is the second common major surgical operation performed by the woman throughout the world. It is mainly done to improve the quality of life and this surgical procedure is generally associated with some complications. The different types of hysterectomies performed are partial, total, and radical. While in case of partial hysterectomy only the upper part of the uterus is removed and the cervix is left in place, in case of total hysterectomy the uterus and the cervix are removed. radial hysterectomy is suggested for the woman in case of cancer.
The LASI WAVE-1 is one of the largest longitudinal studies of India which is conducted for 45-59 (older Adult) and 60+ (Elderly) men and women. The motive of this study to design the policies and programs for older people in broad domains of social, health, and economic well-being.
In this study, we are focusing on hysterectomy which one of the serious problems in women, according to this LASI report around 11% of Indian older women undergone a hysterectomy in public and private hospitals.
Pradhan Mantri Jan Arogya Yojana (PM-JAY) or Ayushman Bharat is a pioneering initiative taken up by the Govt Of India which ensures the poor have universal access to Private health clinic along with better health care. The National Health Authority(NHA) has been entrusted with the role of designing at least 30 treatment guidelines which would ensure a minimum standard of care and would prevent fraud by the Private health clinic. Therefore, these guidelines will not only encourage a cut-off in the prices of the medicines. It will at the same time prevent the misuse of medicines. Among the 30 treatments which have been issued by The National Health Authority(NHA), 10 are about to release on August 15th which includes cataract surgery, renal failure, total knee replacement, cesarean hysterectomy, coronary artery bypass grafting, hemodialysis, and mitral valvotomy.
The National Health Authority, an implementing body for PM-JAY has rejected the claims made for hysterectomies performed in private hospitals in at least 6 states under Pradhan Mantri Jan Arogya Yojana (PMJAY). it aims to seek more caution and tighter scrutiny of such claims made under the government flagship program promising universal health care to about 10 crore beneficiaries.
Data on hysterectomy helps the researchers to find out the reasons for the increasing trend of uterus removal surgeries. In the case of developed countries, the trends of hysterectomy are studied through the analysis of population surveillance, hospital records, and various surveys while for developing countries, research on hysterectomy is very limited. In 2015-16 data on hysterectomy was collected for the first time in India through the National Family Health Survey. Data revealed Andhra Pradesh having the maximum number of hysterectomy being performed and the same result has also been shown by Longitudinal Ageing Study in India whose reports have been released recently.
Chart URL: https://www.datawrapper.de/_/gZ31i/
The women above the age of 60 living in Chandigarh, Chattisgarh, Daman and Diu, Delhi, Goa, Punjab, Lakshwadeep, Kerela, and Himachal Pradesh perform more hysterectomy than those of the age 45 to 59 living there. However, there is only a marginal difference in the number of hysterectomies performed between the women of age 45 to 59 and above 60 in the states of Assam, Haryana, and Mizoram. Very few proportions of women go for hysterectomy in the northeastern states of Assam, Arunachal Pradesh, Nagaland, Meghalaya, and Mizoram. Among the women of age group, 45 to 59 maximum hysterectomies are performed among those living in Andhra Pradesh followed by Daman and Diu. On the other hand, it is the lowest in the state of Meghalaya. The women of age above 60 living in the states of Meghalaya and Arunachal Pradesh do not perform hysterectomies. Punjab among the states and Daman and Diu among the union territories have the highest number of hysterectomies performed among the women of 60 years and above while it is the lowest for the state of Nagaland. The states of Telangana, Kerela, and Haryana also have a high proportion of women of age above 45 performing hysterectomy.
Chart URL: https://www.datawrapper.de/_/7Bl9A/
LASI has shown a higher prevalence of hysterectomy in urban areas while the previous studies including NFHS 4 have shown a higher prevalence in rural. This may be because urban women have more and better access to health care facilities.
The results of the 4th National Family Health Survey show that approximately 67% of the women prefer to opt for the private health sector for undergoing hysterectomy while only one-third prefer the public health sector. Past literature shows that hysterectomy is one of the leading reasons to use health insurance among women belonging to low-income families. This calls for revisiting the design of the insurance schemes and thus keep a check on the unnecessary hysterectomies. Alamelu has surveyed regarding the growth in the health insurance industry and has found out that for the last 10 years. There has been a rapid increase in the collection of health insurance premiums, which has raised from Rs 3,342 crore In 2006-07 to Rs 44,873 crore in 2018-2019. The National Health Authority(NHA) has commissioned a survey and has raised caution for hysterectomies conducted in Private hospitals under the Pradhan Mantri Jan Arogya Yojana. According to Gurdpeed Singh Batra, an increase in the collection of health insurance premiums is a welcome move for the lower-middle-class people of the society. This is because the health insurance premium will come with a facility of paying a premium with instalments. This on the other hand will not only be cheap for the poor people but it will also enhance coverage. That is it will be simpler for the customers to understand.
The presence of private health centres more in the urban regions may be one of the reasons for more hysterectomies being carried out in the urban regions. Although the states of Andhra Pradesh, Jammu and Kashmir, Kerela, Maharashtra, Punjab, Rajasthan, Telangana, Uttarakhand, and the union territory of Daman and Diu stand as an exception as the proportion of women living in the rural regions perform more than the urban women. Among all the rural women of the nation, the women living in the state of Andhra Pradesh and a union territory of Daman and Diu perform the highest number of hysterectomy and the lowest in the states of Meghalaya and Nagaland. On the other hand, among the urban women, those living in Karnataka and Andaman and Nicobar Islands perform the highest number of hysterectomy while those living in Meghalaya and Assam the lowest. There is not much of a difference in the proportion of women performing a hysterectomy in the states of Jammu and Kashmir and Himachal Pradesh between those living in urban and rural areas. Past literature shows that there is a difference in the reason for hysterectomy based on the place of residence, the major reason being uterine fibroids among urban women and menstrual disorders for rural.
Studies in New Zealand and rural China show that women of older women have a higher risk of hysterectomy. A study in the three villages of Panchkula district in Haryana shows that women above the age of 35 years have a higher prevalence of hysterectomy the main reason being excessive menstrual bleeding followed by uterine prolapse and fibroids. The most common reasons for women undergoing after 60 are uterine prolapse, cancer, and persistent fibroid tumours. Uterine prolapse takes place when the uterus protrudes out of the vagina due to the existence of weakened pelvic floor muscles and ligaments. Also as the risk for cancer increases with age hysterectomy is performed if a woman has uterus, cervix, ovarian, and endometrium cancer. Sometimes a surgeon may recommend a hysterectomy as a precaution to precancerous reappearing tumours.
Chart URL: https://www.datawrapper.de/_/EFCO8/
The proportion of women of age 45 and above performing hysterectomy is maximum in the state of Andhra Pradesh. Andhra Pradesh is considered a hotspot of hysterectomy. The state is a focus of debate on unnecessary and forced hysterectomies in India. This is more prevalent among the young pre-menopausal women belonging to poor socio-economic background. Research has shown the poor rural women belonging to the district of Medak in Andhra Pradesh are coerced into hysterectomy for routine gynaecological issues such as abdominal pain and white discharge. They are forced by the health care providers who do it for profit motives without offering any alternatives.
The lowest number of hysterectomy operations are carried out in the North-Eastern states of India. The strong local-level public health infrastructure and the preference for public hospitals is the main reason behind the low number of hysterectomy performed there and that too most of them in public hospitals.
The reproductive health program managers should devise strategies that will help women to seek treatment at the initial stages so that unnecessary hysterectomies can be avoided. Women should be made aware of the various physical and emotional impacts of performing hysterectomy especially on aged people so that it is performed only if it is necessary. At the policy level, there should be an improvement in terms of both quality and access to reproductive health care services in public health facilities to reduce the growing dependency on a hysterectomy to treat various health reproductive health problems.
- Long-term Effects of Hysterectomy on the Aging Patient (medscape.com)
- Shekhar C, Paswan B, Singh A. Prevalence, sociodemographic determinants and self-reported reasons for hysterectomy in India. Reprod Health. 2019 Aug 2;16(1):118. DOI: 10.1186/s12978-019-0780-z. PMID: 31375139; PMCID: PMC6679457.
- Hysterectomy tops Ayushman claims; red flags raised – The Economic Times (indiatimes.com)
- Desai S, Sinha T, Mahal A. Prevalence of hysterectomy among rural and urban women with and without health insurance in Gujarat, India. Reprod Health Matters. 2011 May;19(37):42-51. DOI: 10.1016/S0968-8080(11)37553-2. PMID: 21555085.
- Here is why hysterectomy cases in India are rising – The Hindu BusinessLine
- Singh, S. K., Sharma, S. K., &Siddhanta, A. (2020). Major Correlates and Socioeconomic Inequalities in Hysterectomy among Ever-Married Women in India. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine, 45(1), 12–17. https://doi.org/10.4103/ijcm.IJCM_12_19
- Desai S, Campbell OM, Sinha T, Mahal A, Cousens S. Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India. Health Policy Plan. 2017 Feb;32(1):68-78. DOI: 10.1093/heal/czw099. Epub 2016 Aug 6. PMID: 27497139; PMCID: PMC5886266.
- Singh, A., & Arora, A. K. (2008). Why Hysterectomy Rate is Lower in India. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine, 33(3), 196–197. https://doi.org/10.4103/0970-0218.42065
- Getting a hysterectomy after age 60:Here’s what to expect (constantcontact.com)
- pdf (csu.edu.au)
- Here is why hysterectomy cases in India are rising – The Hindu BusinessLine
Gaurav Suresh Gunnal
M.Sc. in Biostatistics and Demography, International Institute for Population Sciences, Mumbai
M.Sc. in Population Studies, International Institute for Population Sciences, Mumbai