India’s Hysterectomy Epidemic

There is a quiet but serious epidemic in the country – hysterectomy. It is a surgical procedure involving removal of a woman’s uterus, sometimes accompanied by removal of the ovaries, fallopian tubes and cervix. According to National Family Health Survey (NFHS 5) 2019-21, prevalence of hysterectomy among women aged 40-49 years was as high as nearly 10%. The numbers are far higher in states like Andhra Pradesh (22.5%), Telangana (21.2%), Bihar (17.2%) and Gujarat (11.7%). More worryingly, the median age of women who had undergone hysterectomy is 34 years for rural and 36 years for urban areas - more than 10 years before natural menopause.

Common reasons for getting hysterectomy include excessive menstrual bleeding/pain, fibroid/cyst, and uterine disorders. While it may be sometimes unavoidable, the surgery poses serious risk to women’s health by inducing early menopause. Research has established its links with increased risk of illnesses like cardiovascular disease, metabolic disorders, urinary tract cancer, bone density loss, mental health issues, etc. Therefore, it is not a procedure that should be taken lightly.

Despite such obvious health consequences, why is hysterectomy among young women in India on a rise? Data consistently indicate higher prevalence among lesser educated rural women despite limited access to surgical procedures in rural areas. Moreover, women agriculture workers have been hit hard by this trend as they are given to believe that it avoids loss of wages and improves endurance for demanding work hours without menstrual discomfort. This is widely documented among sugarcane workers in Beed district, Maharashtra where the prevalence was at a staggering 56% in 2024 among households where women migrated for labour work. Ironically, hysterectomy reduces the woman’s active working lifespan because of its impact on bone density and cardio vascular health among others ailments.

From global experience, we know that the structure of medical system, quality of medical advice and the extent of insurance coverage influences unnecessary surgeries. For instance, the prevalence of hysterectomy has always been much higher in the US (325 per 100000 females in 2008) compared to average European OECD nations (212 in 2010), despite similar socio-economic and health indicators. Europe’s largely public healthcare system leaves lesser incentive for private medical practitioners for invasive procedures. In contrast, the dominant private healthcare in US, covered by insurance exhibits the issue of moral hazard where health insurance coverage drives over prescription of surgeries or diagnostics.

Note that as per NFHS-5, 70% of the hysterectomies in India were done at private clinics. Mamidi & Pulla (2013) in Andhra Pradesh found that poor rural women as young as 20 years were advised by healthcare providers to have hysterectomy even for routine gynecological issues, such as abdominal pain and white discharge without offering any alternatives due to profit motive. Such nudges are common due to the lack of awareness about the importance of a womb for their overall female health and longevity.

In addition to encouragement by medical system, insurance coverage clearly plays a role. Gunnal & Roy (2024) and Singh & Govil (2021) used data from NFHS-4 to show that women covered under insurance had increased chance of undergoing hysterectomy. There are widespread media reports of unnecessary surgeries being done, particularly covered under Centre and State funded insurance schemes.

Taking cognizance of this, National Health Authority (NHA) that administers Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), brought out a 2019 working paper highlighting that hysterectomy claims under the scheme comprised almost 2 % of claims for all female packages in 24 states in first nine months (Sept. 2018 to May 2019). The paper stressed the need for monitoring claims over time. Following this, NHA in 2019 introduced pre-authorization requirements for claims. For instance, mandatory second gynecological opinion and uploading of clinical or USG findings on the portal in case of women under 40 years.

The Union Health Ministry is clearly aware of this issue and noted in an advisory that “private empanelled healthcare providers (EHCPs) are proceeding with the surgery (hysterectomy) without waiting for pre-auth approval, even after Preauth Processing Doctor (PPD) has asked a query/clarification”. In 2022, it issued guidelines on unnecessary hysterectomies, including the creation of monitoring committees at district, state and national levels to gather data on surgeries across public and private facilities.

This issue requires a multi-pronged approach. Firstly, more recent and detailed data is required on the prevalence of hysterectomy. NFHS should include questions on how women paid for the surgery to ascertain the role of public health insurance in rising cases. Secondly, greater awareness needs to be spread among women about harmful effects of early hysterectomy. For heavy menstrual bleeding which is the most cited reason, conservative treatment options like hormonal contraceptive pills, hormonal IUD, etc. need to be promoted. Lastly, there should be stricter surveillance and medical audits. It is also worth examining whether such practices are guided by the misplaced perpetuation of population control policies/mindset as it has implications not just for women’s health but on our demography, at a time when India’s fertility rate is already below replacement level.

The unnecessary hysterectomy trend highlights a deeper challenge in healthcare delivery. When private providers operate within insurance-funded systems, without transparency and accountability, there is hardly a pushback from patients as they are insured. This presents a classic case of market failure due to asymmetric information which heavily burdens the medical system with over-prescription, spirals up the health costs and strains public finances.

(Sanyal is member, Economic Advisory Council to PM, Shetty is a clinical research scientist and Chauhan is young professional, EAC-PM)