On the hysterectomy trail: Why are some Indian women missing their uteruses?

A recent New York Times report on the hysterectomies that young women in rural Maharashtra undergo threw the international spotlight on a long-standing issue. The NYT and Fuller Project collaborated on an investigation into the working conditions of the men and women who supply sugar to the two dominant beverage companies, and found that the brands “profited from a brutal system of labour that exploits children and leads to the unnecessary sterilisation of working-age women.”

However, over the course of nearly 17 years of covering this story, I have found that there are many moving parts to this issue, the most critical being a largely unregulated healthcare systems in tier 2 and 3 towns, and villages, fuelling fear among mostly illiterate women about ailments as routine as heavy bleeding or abdominal pain resulting in many trapped in debts they can barely afford to pay. How must one tackle the impact on women’s health from what is, by several accounts, a generation practice?
I still remember the Lambada tribal women I met on a balmy August morning in Medak district’s Kowdipally mandal of then-undivided Andhra Pradesh. The year was 2007. We sat on floor mats as the women aged between 20 and 60 gathered around, sharing with me details of the surgery they had all undergone — some only just a few months ago, others many years back. The cost of the surgery had drained them of their savings, their gold and their overall well-being as they suffered aches and pains after their hysterectomy, a surgical procedure to remove a woman’s uterus and ovaries.
Grassroots nonprofit Centre for Action Research and People’s Development (CARPED) had just conducted a health survey in the village that year when it found that more than 700 women, all aged under 40, had undergone a hysterectomy.
These findings drew me to the village. To be absolutely sure that so many women had indeed undergone the same procedure, most of them at the same roadside clinic, I checked their medical reports and asked if they would undergo abdominal sonography. Four of them agreed. The test predictably showed they had no uterus or ovaries.
The clinic was a one-room structure with an operating table behind a green curtain. This is where most women were operated upon. I found a stray dog sleeping under the table when I visited it. The doctor there confirmed that hysterectomies were common in the region — young women from rural Gajwel and Narsapur also reportedly underwent hysterectomies; something that other doctors I spoke to for this story also corroborated. This particular doctor fixed surgeries for a city-based doctor, who would visit on the weekends to perform the surgeries. He said that the women “asked for it” to get rid of period pains, and vaginal infections owing to poor menstrual hygiene or heavy bleeding that often came in the way of their work, and earnings. I would hear this reasoning from many more doctors in the years to come.
Armed with quotes and evidence, I filed the story, which went as a front page flyer in the Times of India where I was working at the time. Authorities took notice and a crackdown on clinics followed. As a young reporter, I felt the job was done, having won the elusive impact on the story.
I had barely scratched the surface, as I would find out later. In the decade that followed, I would go on a hysterectomy trail, finding evidence of women losing their uterus and ovaries to the fear of cancers and tumours that doctors said were causing excessive bleeding or abdominal cramps. Poor menstrual hygiene coupled with the greed of unscrupulous doctors in small towns who suggested the surgery as a quick-fix solution to all “ladies ’problems” was robbing women, many in their 20s, of these organs, bringing on early menopause and ailments such as osteoporosis.
Gynaecologists that I spoke to said that ovaries produce oestrogen that plays a role beyond reproduction, keeping other organs including the heart and bones healthy. One doctor at a premium Mumbai hospital said she typically tried to salvage the ovaries while performing a hysterectomy.
I revisited the story in 2010, this time bringing in historical perspective to hysterectomies being a common procedure across rural Andhra Pradesh for nearly three decades. A senior doctor I interviewed for the story then told me the practice was so widespread that it was common for him to ask women during his rural visits: do you have a uterus?
Most women I met had married in their teens and borne children soon after, and accepted hysterectomies as an inevitability, almost like a post-motherhood rite of passage. “My grandmother and mother underwent the surgery. So did I,” a woman told me, again a reasoning I would hear more of in the years to come.
The women believed they were going for a life-saving procedure and would sell their family land, animals and jewellery to fund it.
I returned to the story in 2015, when I was working with The Hindu. This time, I visited Sangola taluka in Maharashtra’s Solapur district to find an entire village of women who had no wombs. I had by then spoken to health campaigners from different parts of the country to deduce that what I was finding in reporting trips to villages was at best anecdotal evidence of what was a larger problem plaguing women across rural India. I recall a local official saying that even his wife had undergone the procedure and wondered what the fuss was about since women had no real use of these organs after childbirth, again a reason I would hear multiple times from officials.
Why did the women get these hysterectomies? In most cases, their reasons ranged from painful periods that posed a deterrence to their daily wage work on farms and affected their earnings. I also found from campaigner interviews that smaller nursing homes cashed in on state health insurance policies that covered the procedure and made it appear to women that it was their best shot at good health.
Families in rural India have traditionally turned to their employers or labour contractors for money to fund life events like childbirth, marriage, deaths, and emergencies. These loans keep them on farms and wages low. In the hysterectomy cases I documented, families had taken loans from private moneylenders at high-interest rates and were now repaying the money by working for the lenders for little or no wages, in what is known as debt bondage. Some had migrated to neighbouring cities for better-paying jobs to repay these loans. Poor healthcare regulation has meant that the women had no recourse to correct, life-saving information or treatment.
In 2019, when I was working for the Thomson Reuters Foundation, I embarked on an ambitious five-month investigation covering villages across Telangana, Maharashtra and Rajasthan to build more evidence, to show the cascading impact these surgeries have on entire families, with many trapped in vicious debt cycles to repay loans they took to pay the doctors. The women battled weakness and hormonal imbalance and could barely afford to treat these conditions. They looked older than their age and were unable to work, which had shrunk family incomes, delaying loan repayments.
The investigative reports won awards and a Central health official convened a consultation in New Delhi inviting nonprofits and litigants quoted in the story and setting up six task forces to tackle the medical malpractice.
Following that, guidelines were drafted and issued to the states in 2022 to prevent unnecessary hysterectomies. A national portal was also created to record every hysterectomy performed. Last year, the Supreme Court made it binding for all states to implement the guidelines issued to them in its judgement on a public interest litigation against unnecessary hysterectomies filed by Dr Narendra Gupta of Prayas nonprofit in Rajasthan.
In its judgement, the top court observed that while hysterectomies were a common procedure globally, they stood out in India for the age group of the women undergoing it, ranging from 28 to 36 years old, many of them poor and less educated, as against the menopausal age group of women who underwent the procedure in other countries.
Continued attention to hysterectomies by researchers and journalists is important to keep the focus on this major health concern, but the needle must move. Reporting and research must acknowledge that the problem is not limited to one district but afflicts several Indian states that are now mandated to set up hysterectomy monitoring committees.
For every story, women open their lives and medical histories and share it in the hope that it would lead to a resolution, possibly even win them compensation for their losses. Making multiple players responsible for this health scandal is important but must not deflect attention from the duty of the state to not just create more awareness amongst rural women on these surgeries and strengthen public healthcare facilities in rural India, but also better regulate small-town nursing homes and clinics.
The author is an independent journalist and founder of The Migration Story. Her five-month-long investigation won the Fetisov Journalism Award in 2020 and the Laadli Media and Advertising Award in Gender Sensitivity 2020.