Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India

Abstract

Hysterectomy is a leading reason for use of health insurance amongst low-income women in India, but there are limited population-level data available to inform policy. This paper reports on the findings of a mixed-methods study to estimate incidence and identify predictors of hysterectomy in a low-income setting in Gujarat, India. The estimated incidence of hysterectomy, 20.7/1000 woman- years (95% CI: 14.0, 30.8), was considerably higher than reported from other countries, at a relatively low mean age of 36 years. There was strong evidence that among women of reproductive age, those with lower income and at least two children underwent hysterectomy at higher rates. Nearly two-thirds of women undergoing hysterectomy utilized private hospitals, while the remainder used government or other non-profit facilities. Qualitative research suggested that weak sexual and reproductive health services, a widespread perception that the post-reproductive uterus is dispensable and lack of knowledge of side effects have resulted in the normalization of hysterectomy. Hysterectomy appears to be promoted as a first or second-line treatment for menstrual and gynaecological disorders that are actually amenable to less invasive procedures. Most women sought at least two medical opinions prior to hysterectomy, but both public and private providers lacked equipment, skills and motivation to offer alternatives. Profit and training benefits also appeared to play a role in some providers’ behaviour. Although women with insecure employment underwent the procedure knowing the financial and physical implications of undergoing a major surgery, the future health and work security afforded by hysterectomy appeared to them to outweigh risks. Findings suggest that sterilization may be associated with an increased risk of hysterectomy, potentially through biological or attitudinal links. Health policy interventions require improved access to sexual and reproductive health services and health education, along with surveillance and medical audits to promote high-quality choices for women through the life cycle.

Hysterectomy: still a treatment of choice for pelvic pathologies in rural India

“…6 Majority of women surveyed for study were from rural background, belong to low socioeconomic status and insured by National health insurance scheme which supports the fact that the incidence of hysterectomy is higher amongst women with relatively lower income group. 2 The rate of hysterectomy is higher i.e. 37.0% in women of 31-40 years of age group, while it is 32.0% in 41-50 years of age group in our study, which indicates that hysterectomies are still being performed on younger women, it also indicates a high level of gynaecological morbidity and unnecessary use of hysterectomy for treating gynaecological ailments similar as other studies.…”

“…A study conducted in a western state of India (Gujarat) pointed out that 7-8% of rural women and 5% of urban women had already undergone hysterectomy at an average age of 37 years, while newer study from a same state (Gujarat) states, that the only estimate of incidence in India is 20.7 per 1000 woman-years (95%) at a relatively low mean age of 36 years, which is at least four times higher than the highest global rates such as the United States (5.1 per 1000), Germany (3.6 per 1000) and Australia (3.1 per 1000) [rates in woman-years]. 1,2 However newer and lesser invasive treatment options,-are leading to fall in the trends for total abdominal hysterectomy (TAH) with or without salpingooophorectomy in developed world. 3 The condition is exactly opposite in developing countries, especially in rural population where due to lack of knowledge or social stigma, poor transport and health services, women usually present very late and desire a permanent cure for their problems with requirement of minimal follow up and free treatment in the hospital.…”

Patterns of hysterectomy in India: a national and state‐level analysis of the Fourth National Family Health Survey (2015–2016)

“…Standard treatment guidelines, including those in India, advise that heavy menstrual bleeding first be treated hormonally or with conservative surgery. 24,25,35 The correlation with higher household wealth emerges as a new finding compared with previous research, which has primarily focused on low-income women in India. 26,27 Evidence on the association of hysterectomy with age, less education, and rural residence is consistent with previous community-based research in India.…”

“…Interviews were conducted with 699 686 women, a 97% response rate. Variables were included to explore potential sources of variation across states, based on the literature 25,35 and availability of data in the NFHS. In the first stage, primary sampling units (PSUs) were selected with population proportion to size sampling.…”

“…[12][13][14][15][16][17] Population-based data from low-and middle-income countries, although limited, suggest lower prevalence compared with high-income settings. 25 Further, qualitative and facility-based research in several states has indicated the potential of medically unnecessary hysterectomy among low-income women, driven by a complex set of factors such as lack of appropriate gynaecological care, menstrual taboos, attitudes towards the post-reproductive uterus, provider or patient-induced moral hazard, and inappropriate use of health insurance. 19 In India, community-based cross-sectional studies-conducted mostly in rural settings in different age and population groups-estimate a prevalence between 1.7 and 7.8%.…”