There is a quiet but serious epidemic in the country—hysterectomy. It is a surgical procedure involving the removal of a woman’s uterus, sometimes accompanied by the removal of the ovaries, fallopian tubes and cervix. According to the National Family Health Survey 2019-21 (NFHS 5), the prevalence of hysterectomy among women aged 40-49 years was as high as nearly 10 percent. The numbers are far higher in states such as Andhra Pradesh (22.5 percent), Telangana (21.2 percent), Bihar (17.2 percent) and Gujarat (11.7 percent). 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.
The common reasons for getting a hysterectomy include excessive menstrual bleeding/ pain, fibroids/ cysts, 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, ovarian failure, vasomotor symptoms, thyroid cancer, urinary tract cancer, pelvic prolapse, bone density loss, and mental health issues. 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 the rise? Data consistently indicates a higher prevalence among less educated rural women, despite the limited access to surgical procedures in rural areas. Moreover, women agricultural workers have been hit hard by this trend as they are led 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 Maharashtra’s Beed district, where the prevalence was at a staggering 56 percent in 2024, with an average age of 35 years among women who migrated for work. Similar trends were observed among women agricultural workers in Telangana and Bihar, where the prevalence was 18 percent and 10 percent, respectively, according to NFHS 4.
This grim choice, thought to be a short-term solution to avoid financial penalties, ironically reduces the woman’s active working lifespan and quality of life because of its impact on bone mineral density and cardiovascular health, among other ailments.
From global experience, we know that the structure of the medical system, the quality of medical advice and the extent of insurance coverage influence unnecessary surgeries. For instance, the prevalence of hysterectomy has always been much higher in the US (325 per 100,000 females in 2008) compared to average European OECD nations (212 in 2010), despite similar socioeconomic and health indicators.
Europe’s largely public healthcare system leaves less incentive for private medical practitioners for invasive procedures. In contrast, the dominant private healthcare in the US, covered by insurance, exhibits the issue of moral hazard where health insurance coverage drives overprescription of surgeries or diagnostics.
Note that as per NFHS 5, 70 percent of the hysterectomies in India were done at private clinics. Bharath Bhushan Mamidi and Venkat Rao Pulla’s research, published in 2013, found in Andhra Pradesh that healthcare providers advised poor rural women as young as 20 years to have a hysterectomy even for routine gynaecological issues, such as abdominal pain and white discharge, without offering any alternatives due to the profit motive. Such nudges are common due to the lack of awareness about the importance of the womb for their overall health and longevity.
In addition, insurance coverage clearly plays a role. Gaurav Gunnal and Sudeshna Roy (2024), and Angad Singh and Dipti Govil (2021) used data from NFHS 4 to show that women covered under insurance were more likely to undergo a hysterectomy. There are widespread media reports of unnecessary surgeries being done, particularly covered under Centre and state-funded insurance schemes.
Taking cognisance, the National Health Authority, that administers the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, brought out a working paper in 2019 highlighting that hysterectomy claims under the scheme comprised almost 2 percent of claims for all female packages in 24 states in the first nine months (September 2018 to May 2019). The paper stressed the need for monitoring claims over time. Following this, the NHA in 2019 introduced pre-authorisation requirements for claims. For instance, a mandatory second gynaecological opinion and uploading of clinical or USG findings on the portal is required for women under 40 years.
The Union health ministry is clearly aware of this issue and noted in an advisory that “private empanelled healthcare providers are proceeding with the surgery (hysterectomy) without waiting for pre-auth approval, even after preauth processing doctor 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 are needed 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 the harmful effects of early hysterectomy. For heavy menstrual bleeding, which is the most cited reason, conservative treatment options like hormonal contraceptive pills and hormonal IUDs 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 also for our demography at a time when India’s fertility rate is already below replacement level.
The trend of unnecessary hysterectomies highlights a deeper challenge in healthcare delivery. When private providers operate within insurance-funded systems, without transparency and accountability, there is hardly any 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 overprescription, drives up health costs, and strains public finances.
Sanjeev Sanyal | Member, Economic Advisory Council to the PM
Dr Sujata Kelkar Shetty | Clinical research scientist
(With inputs from Srishti Chauhan of EAC-PM)
(Views are personal)