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Singh V. Publicly funded health insurance schemes and demand for health services: evidence from an Indian state using a matching estimator approach. Health Econ Policy Law 2024:1-17. [PMID: 38433465 DOI: 10.1017/s174413312400001x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Using Demographic and Health Survey data (2015-16) from the state of Andhra Pradesh, we estimate the differential probability of hysterectomy (removal of uterus) for women (aged 15-49 years) covered under publicly funded health insurance (PFHI) schemes relative to those not covered. To reduce the extent of selection bias into treatment assignment (PFHI coverage) we use matching methods, propensity score matching, and coarsened exact matching, achieving a comparable treatment and control group. We find that PFHI coverage increases the probability of undergoing a hysterectomy by 7-11 percentage points in our study sample. Sub-sample analysis indicates that the observed increase is significant for women with lower education levels and higher order parity. Additionally, we perform a test of no-hidden bias by estimating the treatment effect on placebo outcomes (doctor's visit, health check-up). The robustness of the results is established using different matching specifications and sensitivity analysis. The study results are indicative of increased demand for surgical intervention associated with PFHI coverage in our study sample, suggesting a need for critical evaluation of the PFHI scheme design and delivery in the context of increasing reliance on PFHI schemes for delivering specialised care to poor people, neglect of preventive and primary care, and the prevailing fiscal constraints in the healthcare sector.
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Affiliation(s)
- Vanita Singh
- Economics and Public Policy, Management Development Institute, Gurgaon, India
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Singh SK, Chauhan K, Tripathi V. Key drivers of hysterectomy among women of reproductive age in three states in India: comparative evidence from NFHS-4 and NFHS-5. BMC Womens Health 2024; 24:107. [PMID: 38336664 PMCID: PMC10854047 DOI: 10.1186/s12905-024-02886-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
PURPOSE According to the 4th and 5th rounds of National Family Health Survey (NFHS), there is high prevalence of hysterectomies in the three states of Andhra Pradesh Telangana and Bihar. The three said states have more than double the number of hysterectomies taking place than the national average. Our purpose is to analyse whether these rates are increasing, decreasing or have stabilized and their reasons thereof. Such an analyses will help the policy makers in recommending good clinical practices within their states. MATERIAL AND METHODS We used data from NFHS-4 (2015-16) and NFHS-5 (2019-2021) rounds. We calculated the differences in predicted probabilities for various factors, performed a Fairlie Decomposition analyses to quantify the positive and negative contributors in the prevalence of hysterectomy across the three states over two time points, and assessed the association of various socio-demographic characteristics to hysterectomy through a multilevel logistic regression model. RESULTS AND CONCLUSION The results show that out of a total of 80,976 eligible respondents from the states under study, 5826 respondents self-reported that they had a hysterectomy done. It was found that older age, living in rural areas, belonging to other backward classes and higher wealth quintile, and higher parity positively contributed to the increased prevalence of hysterectomies in the three states. Higher educational attainment and previous use of family planning methods acted as protective factors. Characteristics at the household level had the highest intra-class correlation value in the prevalence of hysterectomy among women, followed by the Primary Sampling Unit and District levels, indicating high clustering in the prevalence of hysterectomy at the household level in all three states. Heavy menstrual bleeding/pain was the leading cause of hysterectomies in all three states, followed by fibroids/cysts in Andhra Pradesh and Telangana and Uterine disorder/ prolapse in Bihar. Over 80% of hysterectomies took place in the private hospitals. RECOMMENDATIONS The study recommends better, more efficient and accountable hysterectomy surveillance to ensure more sustainable woman's reproductive health services in India. Government should adopt and implement standard regulatory guidelines to prevent provider-driven avoidable hysterectomies. Moreover, we recommend informing primary care professionals about the long-term health effects of hysterectomy and promoting alternate therapies for treating uterine fibroids and heavy bleeding.
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Affiliation(s)
- Shri Kant Singh
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Kirti Chauhan
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, Maharashtra, India.
- Department of Biostatistics and Demography, International Institute for Population Sciences, Mumbai, Maharashtra, India.
| | - Vrijesh Tripathi
- Department of Mathematics and Statistics, The University of the West Indies, St. Augustine, Trinidad and Tobago
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Aggarwal H, Aggarwal H, Wanjari A. Unnecessary Hysterectomies Among Premenopausal Women in Developed and Developing Countries: A Critical Review of Steps Taken to Improve Women's Health. Cureus 2023; 15:e49943. [PMID: 38179386 PMCID: PMC10765271 DOI: 10.7759/cureus.49943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
Women with pelvic organ disease often require a hysterectomy for better health. Still, in countries like India, there are many challenges for them as they are subjected many a time to unnecessary hysterectomies. Through this article, we suggest many ways to address this menace, such as proper health education and sensitization of women of premenopausal age group by health workers and mass media. Many preventable hysterectomies can be avoided if we guide women about their pathology before giving consent for surgery. Role enhancement of health agencies and nongovernmental organizations for early identification of such women in the society of all segments, stopping the greed of various health institutions using government-sponsored insurance health schemes for personal gain, and law enforcement by courts and health departments should also be our main focus. This study aims to review nonsurgical procedures adopted to decrease unnecessary hysterectomies and make suitable directions by government and lawful agencies to curb this menace. All states and union territories received the "Guidelines to Prevent Unnecessary Hysterectomies" recommendations from the Ministry of Health and Family Welfare for compliance. The recommendations suggest creating hysterectomy monitoring committees at the district, state, and federal levels. The duration of hospital stays and associated expenditures can decrease by performing minimally invasive treatments as outpatient operations. Minimally invasive options may shape the future of gynecology in developed nations.
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Affiliation(s)
- Hitaishi Aggarwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Hardik Aggarwal
- Medicine, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Anil Wanjari
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Abstract
Increase in the prevalence of hysterectomy among low-and middle-income countries (LMICs) such as India has become a significant concern. Reports based on either a particular group or region show an increasing trend in hysterectomy, but there is a dearth of national-level data in this domain. Hence, there seems to be an urgent need to garner evidence on the prevalence and determinants of hysterectomy, which could pave the way for future programs and policies. We aimed to estimate the prevalence of hysterectomy and assess its determinants using a nationally representative sample. An observational analysis was conducted using data from Longitudinal Aging Study in India (LASI), 2017-2018. 38,154 women aged > 18 years were included. A multivariable logistic regression, presented as an adjusted odds ratio (AOR) with a 95% confidence interval (CI), was used to predict the association between various socio-demographic characteristics and hysterectomy. A separate multivariable logistic regression model was executed to determine the association between selected non-communicable diseases (NCDs) and hysterectomy. Survey weights compensated the complex study design. The overall prevalence of hysterectomy was around 11.35%. Excessive menstrual bleeding followed by fibroids emerged as the leading causes of hysterectomy. The various determinants of hysterectomy were urban residents [AOR: 1.54 (1.21-1.96)], other backward class [AOR: 2.19 (1.72-2.78], working women [AOR: 1.19(1-1.42)] and the most affluent (rich) group [AOR: 2.06 (1.62-2.63)]. Hysterectomy was associated with cancer [AOR: 4.83 (2.51-9.29)], diabetes [AOR: 1.79 (1.25-2.57)], hypertension [AOR: 1.48 (1.27-1.71)] and joint diseases [AOR: 1.43 (1.09-1.88)]. Hysterectomy is considerably prevalent in India, which cannot be overlooked. Health promotion regarding hysterectomy and its implications is needed especially among urban residents, affluent groups and those with a higher body mass index. Health programmes aimed at women should follow a life course approach by prioritizing health and overall well-being even after reproductive years.
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Affiliation(s)
- Dejalin Rout
- ICMR-Regional Medical Research Centre, Bhubaneswar, Bhubaneswar, 751023, Odisha, India
| | - Abhinav Sinha
- ICMR-Regional Medical Research Centre, Bhubaneswar, Bhubaneswar, 751023, Odisha, India
| | - Subrata Kumar Palo
- ICMR-Regional Medical Research Centre, Bhubaneswar, Bhubaneswar, 751023, Odisha, India
| | - Srikanta Kanungo
- ICMR-Regional Medical Research Centre, Bhubaneswar, Bhubaneswar, 751023, Odisha, India.
| | - Sanghamitra Pati
- ICMR-Regional Medical Research Centre, Bhubaneswar, Bhubaneswar, 751023, Odisha, India.
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Fiks E. Imaginaries of a laparoscope: power, convenience, and sterilization in rural India. Anthropol Med 2023; 30:64-80. [PMID: 36645045 DOI: 10.1080/13648470.2022.2152634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Laparoscopic tubal ligation is the most prevalent method of contraception amongst India's rural and urban poor. Drawing on 18 months of ethnographic fieldwork in rural Rajasthan in 2012-2013, this paper investigates how rural women's perceptions of a biomedical instrument-the laparoscope-influence their perceptions of sterilization, a procedure often entrenched in coercive, target- and incentive-driven population control programme. By investigating how a laparoscope is entangled in global exchanges, national policies, institutional arrangements, and local moral worlds, this paper demonstrates that while wider biomedical discourses perpetuate the narrative of safety and convenience, people's everyday lives inform their understandings of technology that is widely known but rarely seen.
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Affiliation(s)
- Eva Fiks
- School of Medicine, Keele University, Keele, Staffordshire, UK
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Rajkumari S, Chaudhary V, Kasaudhan S, Saraswathy KN. Incidence and determinants of hysterectomy among North Indian women: An 8-year follow-up study. Front Public Health 2022; 10:1065081. [PMID: 36589953 PMCID: PMC9800844 DOI: 10.3389/fpubh.2022.1065081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Background Despite indications of a rapid increase in the number of hysterectomies performed in India, very few studies have methodically investigated the rate and determinants of the incidence of hysterectomy. The present study aims to estimate the rate of incidence of hysterectomy and identify predictors/determinants of incident hysterectomy in a cohort of North Indian women. Methods In the present study, a cohort of 1,009 ever-married North Indian women (aged 30-75 years) was followed up after a median of 8.11 years. Those hysterectomized at the baseline (63) were excluded; and of the rest 946 participants, 702 (74.2%) could be successfully followed-up. During the baseline assessment, data about sociodemographic variables, reproductive history, menopausal status, physiological health, and selected blood biochemicals were collected. During the end-line assessment, data about sociodemographic variables, current menopausal status, and incident hysterectomy were recorded. Results The overall rate of incidence of hysterectomy was found to be 11.59 per 1,000 women-years, in the study population. Interestingly, the incidence rates were found to be similar among pre- and post-menopausal women. Further, while late age at menarche was found to be negatively associated with incident hysterectomy, folate repletion and high triglyceride (TG) at the baseline were found to be positively associated. Conclusions High rate of incident hysterectomy in the studied population points toward the huge burden of gynecological morbidity and the unavailability of non-invasive protocols. Such a situation warrants immediate policy intervention. Further, maintaining TG and folate within normal physiological ranges may be beneficial in gynecological ailments necessitating hysterectomy.
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Kumari P, Kundu J. Prevalence, socio-demographic determinants, and self-reported reasons for hysterectomy and choice of hospitalization in India. BMC Womens Health 2022; 22:514. [PMID: 36503443 PMCID: PMC9743745 DOI: 10.1186/s12905-022-02072-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is limited evidence of hysterectomy in India because of a lack of data in large-scale, nationally representative health surveys. In 2015-16, the fourth National Family Health Survey (NFHS-4)-a cross-sectional survey-collected for the first-time direct information on hysterectomy and self-reported reasons for undergoing the procedure among women in the reproductive age group. The current study evaluates the prevalence, determinants, and choice of hospitalization (Public vs. Private) for conducting hysterectomy in India among women aged 15-49 years in 29 states and seven union territories (UTs) based on the new large-scale population-based nationally representative dataset (NFHS 5). METHODS Cross-tabulations and percentage distributions were utilized to analyse the prevalence of hysterectomy and the choice of hospitalization (public vs. private) across different socioeconomic backgrounds and reasons for undergoing hysterectomy. A multivariate binary logistic regression model was also used to find statistically significant determinants of hysterectomy. RESULTS In India as a whole, 3.3% of women aged 15-49 years had undergone a hysterectomy. The percentage of women who had undergone the procedure was found to vary considerably across the states and the UTs. The southern region stands out for the considerably higher prevalence of hysterectomy; particularly in the states of Andhra Pradesh (8.7%) and Telangana (8.2%), the prevalence was very high followed by Bihar (6%) and Gujrat (4%). On the other hand, the North-eastern region had the lowest prevalence of hysterectomy (1.2%). A noticeable fact that emerged was that the majority of the hysterectomies were performed in the private sector (69.6%) in India. But the scenario was quite different in north-eastern region as in this region more hysterectomies were performed in public health facilities (73%) rather than private health facilities (26.7%). Age, place of residence, religion, caste, level of education, geographic region, wealth quintiles, parity, age at first cohabitation of women were found to be the socio-demographic determinants statistically associated with hysterectomy in India. The likelihood of hysterectomy was higher among women living in rural areas (AOR: 1.3, CI: 1.23-1.35), in the richest wealth quintile (AOR 2.6; CI 2.37-2.76) and in the southern region (AOR 1.6; CI 1.47-1.66). The reasons frequently reported for hysterectomy were excessive menstrual bleeding/pain, followed by fibroids/cysts. CONCLUSION This study has attempted to analyse hysterectomy prevalence and its socio-economic determinants using the latest fifth round of NFHS data of all the states and covering 21 states and union territories of India, which gives wider coverage of hysterectomy and more recent with accurate data. More research is needed therefore to unravel the complex dynamics of hysterectomy in India (and elsewhere) which could be used to help women make more informed choices and in turn advance their reproductive health and rights.
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Affiliation(s)
- Priyanka Kumari
- grid.419349.20000 0001 0613 2600International Institute for Population Sciences, Mumbai, 400088 India
| | - Jhumki Kundu
- grid.419349.20000 0001 0613 2600International Institute for Population Sciences, Mumbai, 400088 India
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8
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Lukšaitė E. "I Do Not Have to Hurt My Body Anymore": Reproductive Chronicity and Sterilization as Ambivalent Care in Rural North India. Med Anthropol Q 2022; 36:312-328. [PMID: 35524762 PMCID: PMC9545858 DOI: 10.1111/maq.12709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Drawing on 18 months of ethnographic fieldwork in rural Rajasthan, India, I examine women's narratives of chronic reproductive suffering and the practices they employed to relieve it. Cumulative effects of adverse and ordinary reproductive events and exhaustion from caregiving were often seen as reproductive suffering, while sterilization emerged as an act of care toward women's ever-weakening bodies. Sterilization has been an integral part of the often coercive, incentive- and target-driven population control program in India. Rural women, however, described sterilization not as a form of violence but as an act of care, despite its ambivalence. In the context of reproductive chronicity-a persistent reproductive suffering recurring alongside reproductive events, available care options, relations within which these options are located, and structural conditions that shape women's lives-care and suffering are intimately and ambiguously intertwined.
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Affiliation(s)
- Eva Lukšaitė
- School of Medicine, Keele University, Keele, United Kingdom
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Putturaj M, Krumeich A, Nuggehalli Srinivas P, Engel N, Criel B, Van Belle S. Crying baby gets the milk? The governmentality of grievance redressal for patient rights violations in Karnataka, India. BMJ Glob Health 2022; 7:bmjgh-2022-008626. [PMID: 35623644 PMCID: PMC9150157 DOI: 10.1136/bmjgh-2022-008626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Patient rights aim to protect the dignity of healthcare-seeking individuals. Realisation of these rights is predicated on effective grievance redressal for the victims of patient rights violations. Methods We used a critical case (that yields the most information) of patient rights violations reported in Karnataka state (South India) to explore the power dynamics involved in resolving grievances raised by healthcare-seeking individuals. Using interviews, media reports and other documents pertaining to the case, we explored the ‘governmentality’ of grievance redressal for patient rights violations, that is, the interaction of micropractices and techniques of power employed by actors to govern the processes and outcomes. We also examined whether existing governmentality ensured procedural and substantive justice to care-seeking individuals. Results Collective action was necessary by the aggrieved women in terms of protests, media engagement, petitions and follow-up to ensure that the State accepted a complaint against a medical professional. Each institution, and especially the medical professional council, exercised its power by problematising the grievance in its own way which was distinct from the problematisation of the grievance by the collective. The State bureaucracy enacted its power by creating a maze of organisational units and by fragmenting the grievance redressal across various bureaucratic units. Conclusion There is a need for measures guaranteeing accountability, transparency, promptness, fairness, credibility and trustworthiness in the patient grievance redressal system. Governmentality as a framework enabled to study how subjects (care-seeking individuals) are rendered governable and resist dominant forces in the grievance redressal system for patient rights violations.
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Affiliation(s)
- Meena Putturaj
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands .,Health Equity Cluster, Institute of Public Health Bangalore, Bangalore, Karnataka, India.,Centre for Local Health Traditions and Policy, The University of Trans-Disciplinary Health Sciences and Technology, Bengaluru, Karnataka, India.,Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Anja Krumeich
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Nora Engel
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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10
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Majumdar A, Qureshi A. Thinking about infertility from a mixed-methods perspective: the need to look at toxicity in rural India. Sex Reprod Health Matters 2021; 29:1999565. [PMID: 34842497 PMCID: PMC8923018 DOI: 10.1080/26410397.2021.1999565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Anindita Majumdar
- Assistant Professor, Department of Liberal Arts, Indian Institute of Technology Hyderabad, Kandi, India
| | - Asif Qureshi
- Associate Professor, Department of Civil Engineering, Indian Institute of Technology Hyderabad, Kandi, India
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Abstract
Objective: Using the unit-level data of women aged 15–49 years from National Family Health Survey-IV (2015–2016), the article maps the prevalence of hysterectomy across districts in India and examines its determinants. Methods: Descriptive statistics, multivariate techniques, Moran’s Index and Local indicators of Spatial Association were used to understand the objectives. The data were analysed in STATA 14.2, Geo-Da and Arc-GIS. Results: In India, the prevalence of hysterectomy operation was 3.2%, the highest in Andhra Pradesh (8.9%) and the lowest in Assam (0.9%). Rural India had higher a prevalence than urban India. The majority of women underwent the operation in private hospitals. Hysterectomy prevalence ranged between 3% and 5% in 126 districts, 5% and 7% in 47 districts and more than 7% in 26 districts. Moran’s Index (0.58) indicated the positive autocorrelation for the prevalence of hysterectomy among districts; a total of 202 districts had significant neighbourhood association. Variation in the prevalence of hysterectomy was attributed to the factors at the primary sampling unit, district and state level. Age, parity, wealth and insurance were positively associated with the prevalence of hysterectomy, whereas education and sterilization was negatively associated. Conclusion: Hysterectomy operation in India presented the geographical, socio-economic, demographic and medical phenomenon. The high prevalence of hysterectomy in many parts of the country suggested conducting in-depth studies, considering the life cycle approach and providing counselling and education to women about their reproductive rights and informed choice. Surveillance and medical audits and promoting the judicial use of health insurance can be of great help.
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Affiliation(s)
- Angad Singh
- International Institute for Population Sciences, Mumbai, India
| | - Dipti Govil
- International Institute for Population Sciences, Mumbai, India
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12
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Gentile L. « Pourquoi vous être mariée si vous ne
voulez pas d’enfants ? » Le travail contraceptif au Gujarat,
Inde. Enfances, Familles, Générations 2021. [DOI: 10.7202/1086956ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: a national and state-level analysis of the Fourth National Family Health Survey (2015-2016). BJOG 2019; 126 Suppl 4:72-80. [PMID: 31309706 PMCID: PMC6772015 DOI: 10.1111/1471-0528.15858] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2019] [Indexed: 11/29/2022]
Abstract
Objective The National Family Health Survey‐4 in India provided the first nationally representative estimates of hysterectomy among women aged 15–49. This paper aims to examine the national and state‐level age‐specific prevalence of hysterectomy, individual and household level factors associated with the procedure, and state‐level indicators that may explain variation across states. Design Cross‐sectional, nationally representative household survey. Setting National Family Health Survey was conducted across all Indian states and union territories between 2015 and 2016. Population The survey covered 699 686 women between the ages of 15 and 49 years. Methods Descriptive analyses and multivariate logistic regression. Main outcome measures Women who reported ever having a hysterectomy and age at hysterectomy. Results Age‐specific prevalence of hysterectomy was 0.36% (0.33,0.39) among women aged 15‐29; 3.59% (3.45,3.74) among women aged 30‐39; and 9.20% (8.94,9.46) among women 40‐49 years. There was considerable variation in prevalence by state. Four states reported age‐specific prevalence similar to high‐income settings. Approximately two‐thirds of hysterectomies were conducted in private facilities, with similar patterns across age groups. At the national level, higher age and parity (at least two children); not having had formal schooling; rural residence (adjusted odds ratio [AOR] 1.36; 95% CI 1.27,1.45; P < 0.01) and higher wealth status were associated with higher odds of hysterectomy. Previously sterilised women had lower odds (AOR 0.64; 95% CI 0.61,0,68; P < 0.01) of reporting hysterectomy. Exploratory analyses suggest state‐level factors associated with prevalence of hysterectomy include caesarean section, female illiteracy, and women's employment. Conclusions Hysterectomy patterns among women aged 15–49 in India indicate the critical need to ensure treatment options for gynaecological morbidity and to address hysterectomy among young women in particular. Funding This study was part of the RASTA initiative of the Population Council's India country office under the Evidence Project supported by USAID. Tweetable abstract Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women. Hysterectomy patterns in India highlight the need for alternatives to treat gynaecological morbidity among younger women.
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Affiliation(s)
- S Desai
- Population Council, New Delhi, India
| | - A Shukla
- Population Council, New Delhi, India
| | - D Nambiar
- The George Institute India, New Delhi, India
| | - R Ved
- National Health Systems Resource Centre, New Delhi, India
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14
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Desai S, Mahal A, Sinha T, Schellenberg J, Cousens S. The effect of community health worker-led education on women's health and treatment-seeking: A cluster randomised trial and nested process evaluation in Gujarat, India. J Glob Health 2018; 7:020404. [PMID: 28959438 PMCID: PMC5604097 DOI: 10.7189/jogh.07.020404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background A community–based health insurance scheme operated by the Self–Employed Women’s Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy – the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low–income women. Methods A cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker–led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18–month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women. Results 30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome. Conclusions We detected no evidence of an effect of this health worker–led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers’ role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy – such as water and sanitation infrastructure and access to primary gynaecological care – emerged as areas to strengthen future interventions.
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Affiliation(s)
- Sapna Desai
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Self Employed Women's Association, Ahmedabad, Gujarat, India
| | - Ajay Mahal
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Tara Sinha
- Self Employed Women's Association, Ahmedabad, Gujarat, India
| | - Joanna Schellenberg
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Simon Cousens
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
BACKGROUND In India, community based studies and media reports indicate a surge in the number of young women undergoing hysterectomy in the past few years. This has led to suspicion on the misuse of procedure, and intense debates on its potential ill health-effects on young women. However, there are no population-based studies that provide insights into hysterectomy prevalence and its determinants at the national level. DATA AND METHODS This study used data from India's District Level Household Survey that involved a sample of 3, 16,361 married women in the age group of 15-49 years spread across 21 States and Union Territories of India. Bivariate and multivariate regression analysis was performed to estimate hysterectomy prevalence and identify its predictors. RESULTS The study estimated hysterectomy prevalence of 17 per 1000 ever married women. The number of women undergoing hysterectomy ranged from 2 to 63/1000 across different states. A little more than one-third of women who had undergone hysterectomy were under the age of 40 years. The proportion of women below 40 years of age who had had hysterectomy was much higher in southern states of Andhra Pradesh (42%) and Telangana (47%). The likelihood of hysterectomy was higher among women belonging to households with health insurance (OR: 1.88, CI: 1.77-2.00) and women who were sterilized (OR 1.55; CI 1.45-1.67) than uninsured and unsterilized women, and lower among women with education level of matriculation and above (OR 0.47; CI 0.42-0.50) than those with no and/or low education. CONCLUSIONS A sizable proportion of young women undergoing hysterectomy in India may have severe ill-health effects on their physical, reproductive and socio-psycho health. As women with low or no education are also more prone to hysterectomy, providing more information and education to them on the possible after-effects of hysterectomy and alternative options will enable them to make more informed choices.
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Affiliation(s)
- Ranjan Kumar Prusty
- IIHMR University, 1, Prabhu Dayal Marg, Sanganer Airport, Jaipur, 302 029 India
| | - Chetan Choithani
- IIHMR University, 1, Prabhu Dayal Marg, Sanganer Airport, Jaipur, 302 029 India
| | - Shiv Dutt Gupta
- IIHMR University, 1, Prabhu Dayal Marg, Sanganer Airport, Jaipur, 302 029 India
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16
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Desai S, Campbell OM, Sinha T, Mahal A, Cousens S. Incidence and determinants of hysterectomy in a low-income setting in Gujarat, India. Health Policy Plan 2016; 32:68-78. [PMID: 27497139 PMCID: PMC5886266 DOI: 10.1093/heapol/czw099] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 11/29/2022] Open
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.
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Affiliation(s)
- Sapna Desai
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK .,Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India
| | - Oona Mr Campbell
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK
| | - Tara Sinha
- Self Employed Women's Association (SEWA) Health; Chanda Niwas, Nr Ellis Bridge, Ahmedabad 380006, Gujarat India
| | - Ajay Mahal
- 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
| | - Simon Cousens
- Dept of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine. Keppel St, London WC1E 7HT, UK
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