title: 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.
authors: Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK sapna.i.desai@gmail.com.|Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India.
authors: Sapna
authors: S
authors: Desai
authors: Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK.
authors: Oona Mr
authors: OM
authors: Campbell
authors: Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India.
authors: Tara
authors: T
authors: Sinha
authors: Nossal Institute for Global Health, University of Melbourne, Carlton VIC 3053, Australia.|Monash University, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia.
authors: Ajay
authors: A
authors: Mahal
authors: Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK.
authors: Simon
authors: S
authors: Cousens
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005191:Family Characteristics; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007044:Hysterectomy / Q000191:economics / Q000523:psychology / Q000706:statistics & numerical data*; D015994:Incidence; D007194:India; D007348:Insurance, Health / Q000706:statistics & numerical data; D008599:Menstruation Disturbances / Q000191:economics / Q000453:epidemiology; D011203:Poverty / Q000523:psychology; D013246:Sterilization, Tubal / Q000706:statistics & numerical data
keywords: Gynaecological; India; hysterectomy; menstrual; reproductive health; sterilization