Womb Robbers

  • Zehru Nissa
  • Publish Date: May 31 2016 2:52PM
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  • Updated Date: May 31 2016 7:57PM
Womb Robbers

How unscrupulous doctors are stripping unsuspecting women of their wombs - to devastating consequences

 

Shakeela’s is a stylishly decorated kitchen, and quite neat but for the gas stove on the floor. “I can’t stand and cook. My back won’t let me,” says the 43-year-old from Anantnag town. as she fries pieces of chicken.

What’s wrong with her back? Nothing as such really, she says. She had a hysterectomy – which involves the surgical removal of uterus, sometimes along with the ovaries – about 10 years ago, and somehow the procedure wrecked her back.

Not just her back either. Shakeela looks much older than her years, she of the grey hair, thick dark skin and flushed looks. “I am not the same person I used to be,” she says, eyes welling up.

One does not expect a routine hysterectomy – and we are told it is just that, by those who advertise it and those who advise it – to blight a woman’s life, yet that’s exactly what it has done to Shakeela and countless women across Kashmir.

Although reliable data on hysterectomies isn’t readily available, a survey conducted by the state’s Directorate of Health Services in 2012 provides some pointers. In Kulgam district,for instance, government hospitals had done 650 hysterectomies and private clinics 3,546 over the preceding five years. In the same period, the neighbouring district of Anantnag witnessed 394 such procedures in state hospitals while 2,441 were conducted privately;Shopian had 586 such surgeries, 491 of them by private doctors.

In north Kashmir’s Baramulla and Kupwara districts, the corresponding figures were, respectively, 876 and 1,009 in state hospitals and 2,141 and 159 in private clinics. Even in the remote Gurez, 924 women had undergone this life-altering operation, 265 at public medical facilities and 659 privately.

As the data shows, most hysterectomies in Kashmir are done privately. This may be because public hospitals here aren’t really known for providing good healthcare. Or, and anecdotal evidence corroborates this, private clinics and doctors are doing hysterectomies that aren’t really needed. In other words, medical malpractice is thriving.

Take Shakeela. After giving birth to her second child, she started having heavy menstrual periods. According to hospital records, she had a “bulky uterus” with menorrhagia, the medical term for heavy menstrual bleeding. “It used to be painful, too,” she says. She saw a doctor at a private nursing home in Srinagar who advised hysterectomy as the only “permanent solution”. Her family agreed, and Shakeela underwent Total Abdominal Hysterectomy. She was just 33.

The surgery proved nothing like a “solution”. “Since they ‘freed’ me from menstrual pain, I have been having pain in my entire body,” Shakeela says, sobbing. She is taking anti-hypertension drugs, has frequent hot flashes, and suffers from spinal disc space degeneration. “I have to take three medicines for three problems. Now I don’t even talk of my health issues in front of my family. I feel ashamed.”

Sakeena is the latest woman from her neighbourhood in Achwal, Kokernag, to have herwomb removed. She is 32. In this small cluster of 30 houses, at least 10 women have had hysterectomy in recent years.

Sakeena is still recuperating, and a few woman relatives are visiting her. They ask why she need the surgery. “I had very heavy periods for many months. The doctor said I had cysts on my ovary, many of them. He said removing the uterus was the only option.” The visiting women offer their well wishes and tell Sakeena she need not worry. “You have two children. Allah bless them. What more do you need?”

This mentality, a few doctors Ink spoke with point out, is only encouraging the unscrupulous among them. They convince the women that hysterectomy is absolutely needed when it may not be. Not knowing better, most of the women, and their families, consent without fuss. Indeed, all the women in Sakeena’ village who have had the surgery believe it was their only option. So deeply is this belief held, the doctors say, that it has resulted in “villages without wombs” in many districts of Kashmir.

Mostly, uterus are removed to check heavy periods, pelvic pain, reproductive tract infections and other “undefined conditions”, says Dr Shehnaz Taing, the head of Gynaecology and Obstetrics at Lal Ded Hospital, Srinagar. “In most cases, such problems can be managed with medicines. There are treatments, devices that can be used to handle problems for which women here undergo hysterectomy,” she says. “But once the woman has been told by a surgeon she needs a hysterectomy, it is very difficult to convince her otherwise.”

To prevent this, Dr Taing says women need to have access to gynecologists everywhere. “Or else their gynae issues will only be mismanaged,” she says.

Indeed, most of the medical records seen by Ink show the women had been diagnosed with “bulky uterus” or fibroid prior to hysterectomy. Often, there had been no further investigations to ascertain the cause of the bulky uterus or the nature of the fibroid. Senior radiologists say that “bulky uterus” is “no term”. “Bulky means enlarged. And a uterus can enlarge because of anything, even infection,” explains Dr Omar Kirmani, Consulatant Radiologist, SMHS Hospital, Srinagar. He adds that vague terms which “leave a scope for doubt” are in fashion with doctors who aren’t trained to use radio-imaging techniques but are allowed to do so nevertheless. Sometime ago, the National Consumer Disputes Redressal Commission awarded a compensation of Rs 10 lakh to a woman whose uterus had been removed by a doctor after telling her it had large fibroids, something that could not be verified from her medical records.

To safeguard against such practices, Dr Kirmani says the health authorities must be more vigilant about who is allowed to do ultrasonography and other such investigations. “Then it might be possible to have some accountability regarding the radio-imaging reports.”

And accountability is one thing that’s sorely lacking, especially in the private sector. Though private clinics are required to regularly submit details of hysterectomies done to the Chief Medical Officers of their districts, their records are usually far from accurate. In 2012, a nursing home in Srinagar had conducted 31 hysterectomies in just one month before it was closed down for malpractice. All the women were 25-35 years old.

At a small dingy nursing home in Anantnag, the manager – who demands to see this reporter’s identity card “on account of many NGOs getting into the affairs of the hospital” -- insists they don’t conduct hysterectomies. His own records, however, show that 7-9 such procedures are conducted every month. They are done by a surgeon. In 2012, concerned by a spike in hysterectomies, the J&K government had ordered that the procedure could only be performed by a gynaecologist. But as is the fate of such orders, it has remained on paper.

The problem isn’t unique to Kashmir. In many places across India, doctors have been found to have coerced women into undergoing hysterectomies for as simple a complaint as abdominal pain -- just to siphon off money from the public insurance scheme Rashtriya Swasthya Bima Yojana. Such cases have come to light in Rajasthan, Bihar, Andhra Pradesh and elsewhere. There has been talk of bringing a legislation to check this malpractice, but not much has happened.

Although lack of awareness and unscrupulous medical practices may be chiefly responsible for the upsurge in unwanted hysterectomies, there is a physiological aspect to it as well. Many psychiatrists believe that the role of depression and Post Traumatic Stress Disorder in chronic and vague pains has not been fully studied. These doctors, speaking from the experience of treating patients in Kashmir, where the ongoing conflict has often visited unspoken terrors upon the women, say there is a psychological explanation for many women going through the unending cycle of pains and aches.

“This started in the mid-90s when you had lots of women in Kashmir with PTSD, they would somatise their psychic pain, that’s convert psychological anguish into physical symptoms,” says a noted psyschiatrist. “Because there is a correlation between PTSD and menstrual disturbances, the doctors were led to believe that hysterectomy might be indicated for this triad of back pain, menstrual disturbances and incidental fibroid that might have been found by radio-imaging.”

Most such women, adds the psychiatrist Dr Arshid Hussain, suffer from depression before undergoing hysterectomy. “And with hysterectomy, it does not end,” he says. “I have seen women with severe melancholic phases of depression following hysterectomy.” His observation is supported by empirical evidence.

A study published in the Journal of Obstetrics and Gynaecology in October 2011 found that 22% of women reported symptoms of depression following hysterectomy. The chances of depression increase if the woman has had her ovaries removed, too. The case is similar to post-menopausal depression, only it’s worsened by the fact that menopause sets in very early in women who have had their reproductive systems removed at a young age, which is 35-45 in Kashmir.

Prospective Research on Ovarian Failure, a Duke University Health System study found that women who have had hysterectomy are twice more likely to develop ovarian failure than those who have their uterus intact – the ratio being 15% to 8%. Ovarian failure refers to ovaries losing the capacity to produce normal amounts of estrogen, the hormone responsible for female sex characteristics as well as many other body functions.

A Swedish population-based study conducted in 2011 and published in the European Heart Journal found that women aged 50 years or younger who had undergone hysterectomy were substantially at greater risk of getting cardiovascular diseases. “This finding corroborates the notion that hysterectomy interferes with the ovarian blood flow and may result in premature ovarian failure and hormone-related effects,” the study concludes.

Several studies have revealed that a complete hysterectomy at any age results in rapid bone loss. Even when only the uterus is removed and not the ovaries, there is usuallya significant decline in estrogen production, which results in menopause and increased bone loss in 5-8 years. The effects of bone loss are most pronounced in spine, neck and lumbar, as reported by Watson MR in the Journal of Obstetrics and Gynaecology.

These findings are enough to warrant that a women is clearly informed about the quality of life she could expect after undergoing an elective hysterectomy. But most Kashmiri women who have undergone the procedure had been led to believe that “life would be beautiful” afterward.

“Had I known I would lose my womanhood after the operation, I would have lived with menstrual pain forever,” says Shakeela, struggling to straighten her back after frying the food.

As it is, “informed consent” is a concept that’s virtually absent from the medical practice in Kashmir, as in much of the developing world. Often, patients are kept in the dark about the repercussions and outcomes of the procedures they are advised – to devastating consequences. In 2008, in Samira Kohli vs Dr Prabha Manchanda, the Supreme Court of India ruled that “the consent must be real, that is, the patient must be given sufficient information about the operation and effects in order to reach a proper decision”. Incidentally, the case related to the hysterectomy of a woman whose family had consented to the surgery while she lay unconscious.

It’s time that providing a detailed but simplified description of the side-effects of hysterectomy on the consent form is made mandatory in Kashmir. It would greatly help women make more informed decisions. But that would only be the first step.