Manual-V2

Preventing Hysterectomies A Systemic Manual for Action

Mitul, Luke, Siddhi

Index I Preface Problem overview Manual introduction

1 3

II Understanding the System Stakeholders & Power The Migrant Journey Getting a Hysterectomy

2

7 9 11

III

V

Problems & Opportunities

Process Examples

Living and Working Conditions Healthcare Accessibility Economic Equity Knowledge and Autonomy Gender Norms and Social Control Rights and Regulations

14 20 25 28 35 39

IV

Maasik Period Tracking Bangle Bagasse Water Purification Swasth Saathi Fellowship

60 64 68

V References

Designing Better Responses Why Traditional Interventions Fail What Systemic Design Requires How to Intervene

42 48 51

3

Part I Preface

Overview of problem and manual 4

5

Problem

In rural India, women working as migrant agricultural labor suffer from chronic pain and gynecological issues leading to preventable hysterectomies and a loss of bodily autonomy.

6

7

What is a Hysterectomy and its impact?

Hysterectomy, the surgical removal of the uterus, is the most common non-obstetric gynecological surgery for women of reproductive age. It is primarily performed for conditions like fibroids, abnormal bleeding, prolapse, chronic pelvic pain, and uterine or cervical tumors.

Hysterectomy with oophorectomy (removal of ovaries) causes surgical menopause, which can lead to symptoms such as hot flashes, vaginal dryness, urinary issues, sexual dysfunction, and long-term effects like osteoporosis and cardiovascular diseases. Oophorectomy can exacerbate early menopause symptoms.

What is an “unnecessary” hysterectomy?

In developed countries, hysterectomy is typically conducted amongst premenopausal women above age 45 years. In India, there is increasing concern about patterns rising hysterectomy rates amongst young women, ranging from 28 to 36 years. These surgeries are often performed without clear medical necessity, informed consent, or adequate exploration of alternatives, underscoring a broader narrative of structural vulnerabilities rather than clinical imperatives.

Evidence suggests that many gynaecological conditions can be managed conservatively without the need for surgical intervention and hysterectomy should always be reserved as the last option.

Who is impacted in this crisis?

The majority of women affected by this trend belong to migrant labor communities, rural agricultural families, and informal worker populations. Field data from several Indian states consistently show that these women are typically aged 25 to 40 years, predominantly from marginalized caste and tribal communities with low levels of formal education and limited access to information about reproductive health.

8

What is the scale of the problem?

India has over 28 million migrant agricultural workers.

Data from the National Family Health Survey-4 (2015-16) estimates hysterectomy prevalence to be 3.6% amongst women 30-39 years and 9.2% amongst women 40-49 years, with 37 being the median age at hysterectomy.

Data also show variation across states indicating uneven availability of treatment for women for common gynaecological disorders at primary health care level1.

Why is this happening?

What seems like a health decision is actually the endpoint of many overlapping pressures — physical, social, structural, and systemic — all converging on the uterus. Far from isolated medical events, these unnecessary hysterectomies are woven into a complex web of systemic issues.

• Exploitative labor conditions where menstruation or pregnancy becomes economically penalizing, coerced to view hysterectomy as a survival strategy.

• Incentives for private providers making quick profits while public systems falter under inadequate regulation and accountability.

• Economic precarity exacerbated by debt bondage and lack of social protection leaving few alternatives.

• Societal norms of gender and caste-based violence, where bodily autonomy of poor women is often disregarded.

• Fragmented policy responses lacking strategic coordination and an integrated approach to these systemic challenges.

9

This manual is a strategic companion for systemic action designed to enable ethical, coordinated, and grounded interventions.

How was this manual created?

This book represents the culmination of intensive research, fieldwork, and community-driven interventions aimed at addressing these gaps. Developed from comprehensive system mapping, problem identification, and collaboration with affected communities, this manual offers a strategic, context-specific guide designed to empower a diverse range of stakeholders— from policymakers and NGO leaders to frontline health workers and community organizers. It is not a conventional toolkit or a one-size-fits-all solution but a framework to translate complex analyses into actionable strategies.

Why does it exist?

As we mapped the system, we identified over 200 distinct problems — points of friction, failure, or harm that would need to be addressed to meaningfully improve this situation. And even that list only scratches the surface.

But more striking than the number is the way these problems are interconnected. These problems don’t exist in isolation. They reinforce each other. There is no silver bullet to a problem this complex.

10

11

We believe that materially changing this system requires collective action. We began asking a new question: How might we equip someone already inside the system – a public health worker, an activist, a policy maker – to intervene in ways that are grounded, responsive, and rooted in human-centric principles? This manual was designed to be a practical, working document that can inform real, systemic action across sectors and scales. By equipping stakeholders with the tools to frame problems and ideate interventions, this book seeks to inspire coordinated, ethical, and effective action.

What it is and isn’t

This manual is like a compass, not a map – it won’t tell you where to go, but it can help you get oriented.

Each section is designed to move you from systemic understanding to practical ability. It’s designed to help people see systems clearly, and then find ways to intervene. While the broader structural conditions that shape women’s health including caste, class, labor exploitation, and gendered violence are acknowledged, this manual remains tightly scoped to the systemic factors driving unnecessary hysterectomies.

Who is it for and how should they use it?

This manual was not written only for academic analysis or institutional archives. It is intended to be used by a range of actors, each positioned differently within the system. Each of these actors have a distinct, critical role in disrupting systemic harm and enabling sustainable change.

For NGOs and Grassroots

•

Illustration

• •

12

Use the intervention templates (Part IV) in community workshops to design localized responses.

Train community health workers, labor leaders, and activists using the manual’s tools and frameworks.

Use the case studies (Part III) as models to develop

•

For Community Groups and Labor Collectives

Illustration

•

• • •

For Educators, Researchers, and Design Schools

•

Illustration

•

•

•

For Policymakers and Government Officials

•

Illustration

•

context-specific, co-created interventions.

Use the ethical design principles (Part IV) to evaluate existing programs and mitigate unintended harm.

Use the stakeholder maps, and intervention templates to facilitate collective reflection and action planning.

Adapt intervention ideas to local needs and conditions.

Demand accountability from local health systems and labor contractors using the responsibility framework.

Use the manual as an advocacy tool to engage with Panchayat bodies, labor boards, and health committees.

Integrate the systemic analysis and design frameworks into curricula on public health, labor studies, gender studies, and design for social impact.

Organize design hackathons, fellowship programs, or workshops using the intervention template and ethical design principles.

Encourage students and researchers to develop context-specific, systemic interventions informed by this manual.

Use the manual’s approach as a model for how design and systems thinking can be applied to structural problems.

Develop multi-sectoral action plans that connect labor, health, and social protection policies.

Identify potential down-stream problems to consider when designing policy memos.

13

Part II Understanding the Problem Systemically 14

15

Chapter 1

Stakeholders and Power How the System Sustains Harm

16

The crisis of unnecessary hysterectomies is sustained not by the actions of any one individual or institution, but by the interaction of multiple actors and systems. Each plays a specific role, but together, their relationships, incentives, and blind spots create conditions in which harm becomes normalized, responsibility is diffused, and prevention becomes difficult.

This section outlines how power operates within this system — not in isolation, but through interconnected dynamics of control, dependency, and invisibility.

Economic Dependency and Labor Control

At the foundation of this system is the economic dependency of migrant women workers. Their livelihoods are shaped by: • Labor contractors who recruit them seasonally, offer advance loans, and control the terms of employment.

• Factory owners and employers who demand uninterrupted labor and penalize absenteeism.

• Debt arrangements that tie workers to contractors, creating cycles of obligation.

These actors control not only wages but also women’s ability to negotiate time off, seek healthcare, or refuse harmful interventions. The decision to undergo hysterectomy is often shaped by this economic dependency — presented as a way to secure stable work and avoid penalties for missing labor days due to menstruation or illness.

Medical Authority and Healthcare Incentives

Once health issues emerge — whether due to menstrual pain, heavy bleeding, or infections — women encounter a healthcare system that offers limited choices: • Private healthcare providers dominate rural health landscapes, particularly where public systems are 17

• •

Family, Community, and Social Norms

weak.

Doctors and clinics often operate in informal partnership with contractors or local employers.

Insurance providers with fee-for-service models create financial incentives to recommend surgery over preventive care.

Inside the home and community, further dynamics reinforce the decision-making process: • Husbands, in-laws, and family elders often influence or make health decisions for women.

• Peer networks normalize hysterectomy; women who have already undergone the surgery encourage others to follow, framing it as a responsible or practical choice.

• Social stigma around menstruation and reproductive health limits open discussion about pain, consent, or regret.

This layer of social power ensures that decisions are rarely challenged. Even when women experience harm, the community framing positions surgery as necessary, routine, or inevitable.

Policy Makers and Government Institutions

18

Above these everyday relationships, state institutions and policies shape the broader environment in which these decisions occur: • Public health systems set clinical guidelines for safe, consent-based hysterectomies but have limited presence in migratory labor contexts.

• Labor policies do not formally recognize the reproductive health needs of informal workers.

• Data collection and monitoring systems overlook

migrant, informal, and marginalized populations.

As a result, no single institution holds full responsibility for the cumulative harm. The public health system regulates doctors but does not regulate labor coercion.

Labor policies protect formal workers but exclude migrants. No cross-sectoral mechanisms exist to monitor how these systems interact.

Photographs or Q prompts

19

Chapter 2

The Migrant Journey

20

The daily realities of migrant agricultural labor shape how and why women’s health becomes vulnerable, and why surgical interventions like hysterectomy come to be seen as inevitable.

This section maps the typical journey of migrant agricultural labor communities, highlighting how risks and pressures build at each stage.

1 • Leaving Home Illustration for each phase

The Conditions That Push Migration For many rural families across India, seasonal migration for agricultural labor is not a choice but a necessity driven by: • Agrarian distress and lack of year-round employment in home villages.

• Debt cycles tied to landlessness, crop failure, informal loans, or droughts.

• Caste- and class-based exclusion from stable employment opportunities.

Women are often part of entire family units that migrate together. Their labor is essential not only for household income but also to repay advances taken from labor contractors before migration. At this stage, reproductive health is already shaped by systemic neglect: • Limited or no access to preventive healthcare in villages.

• Early childbearing, poor maternal health services, and untreated gynecological issues.

• Nutritional deficits, anemia, and physical weakness.

These pre-existing conditions increase vulnerability before migration begins.

21

2 • Setting Up Camp Illustration for each phase

Living Conditions and Health Risks Upon migrating, families typically settle in temporary labor camps near agricultural worksites. These camps are characterized by: • Lack of sanitation facilities, clean water, or basic healthcare services.

• Overcrowded living conditions and exposure to environmental risks such as pesticides, heavy metals, and poor air and water quality.

• No formal entitlements to health or labor protections.

For women, these living conditions further compromise reproductive health: • Poor menstrual hygiene due to lack of toilets and safe spaces.

• Exposure to infections and gynecological conditions.

• Limited ability to seek medical care while living in remote or temporary settlements.

At this stage, health vulnerabilities deepen, while access to diagnosis, information, or preventive care remains absent.

3 • Working in the Fields Illustration for each phase

Economic Pressures and Control The conditions of agricultural work place additional pressures on women’s bodies: • Long work hours under harsh physical conditions.

• Strict labor arrangements with penalties for absenteeism.

• Advance loans tied to daily wage deductions.

For women, menstruation, illness, or pregnancy are seen as disruptions to productivity. Contractors and employers prioritize uninterrupted labor, and social norms around

22

menstruation further marginalize women's health needs.

Field research shows that during this stage, the idea of hysterectomy often enters the conversation. Contractors, family members, or even peers may suggest surgery as a practical way to avoid wage cuts and maintain employability.

The conditions of work limit women’s ability to negotiate healthcare decisions or take time off to seek care.

4 • Seeking Healthcare Illustration for each phase

Navigating an Inaccessible System When women in these contexts experience reproductive health issues like such as heavy bleeding, pelvic pain, or infections, their options for healthcare are severely constrained: • Public healthcare services are often distant, overburdened, or unavailable to migratory populations.

• Private healthcare providers, operating without strict regulation, become the primary point of care.

• Medical costs are unaffordable, leading families to borrow further from contractors or informal lenders.

Within this context: • Diagnostic protocols are bypassed.

• Non-surgical treatment options are rarely offered.

• Consent processes are weak or absent.

• Surgery is positioned as a quick, one-time solution.

Women often undergo hysterectomy without full information, meaningful consent, or understanding of long-term consequences.

23

5 • Returning Home Illustration for each phase

Living with the Consequences For many migrant agricultural workers, the period of seasonal migration ends after several months of labor.

They return to their villages carrying not only wages but also debt, physical exhaustion, and, in many cases, the lasting consequences of hysterectomy.

The surgery does not resolve the structural conditions that made it seem necessary. Instead, it adds new layers of vulnerability to women’s lives after migration.

What emerges from this journey is a clear pattern of how each stage of migration, labor, and healthcare systematically increases women’s vulnerability, rather than protecting or supporting their health.

Health Impacts After Return

• •

•

Economic Consequences

24

•

Many women experience persistent weakness, chronic pain, and fatigue long after surgery.

The onset of early menopause often occurs without explanation or support, leading to hormonal changes, emotional distress, and increased risk of bone loss and cardiovascular conditions.

Women rarely receive any follow-up care or monitoring after surgery. Their health complaints are normalized or dismissed, both within families and in healthcare settings.

Reduced physical strength impacts women’s ability to participate in local wage labor or agricultural work in their home villages.

•

•

Social and Relational Impacts

•

•

•

Families often return home in debt, having borrowed to pay for surgical costs or to offset income lost during recovery.

There is no compensation, support scheme, or social protection available for women who experience long-term health impacts from hysterectomy.

Family dynamics shift post-surgery. Some women report feeling isolated or unsupported in dealing with physical and emotional after-effects.

Social stigma around menstruation and reproductive health means that women’s experiences of pain or regret are not openly discussed.

In some cases, women face pressure to continue migrating and working despite ongoing health challenges, as their labor remains essential to household survival.

Field research includes testimonies of women who continued to migrate and perform agricultural labor despite persistent pain, with no recognition of the health impacts of surgery​.

Photo of women and migrant camps or Q prompt

25

Chapter 3

Getting the Hysterectomy

Illustration of chapter summary

26

When is a hysterectomy advised?

A hysterectomy is a surgical procedure that involves the removal of a woman's uterus, and it can have significant and lasting effects on her body and health.

After a hysterectomy, a woman will no longer have menstrual periods and cannot become pregnant.

Medically, hysterectomies are necessary when dealing with conditions like uterine fibroids, cancer, severe bleeding, or prolapse, but they are not recommended for non-specific complaints such as back pain or menstrual discomfort without a thorough diagnosis. The surgery is life-altering because it can lead to hormonal changes, early menopause if the ovaries are removed, and impacts on sexual function, making it a major and not a minor procedure.

What leads a migrant woman to get a hysterectomy?

The decision to undergo hysterectomy is rarely based on medical need alone. Instead, it is shaped by multiple, interrelated structural conditions that influence women’s health decisions.

Insecure and Exploitative Work Conditions In this context, menstruation is treated not as a health need but as a disruption to work. Women are frequently advised — sometimes by contractors, sometimes by family members — to consider hysterectomy as a practical way to avoid wage losses and secure continuous employment​.

Menstrual Conditions and Limited Access to Treatment Many women in these settings experience menstrual discomfort, heavy bleeding, infections, and gynecological pain from infections and other contributing factors. In the absence of accessible treatment options, surgery is often positioned as the only solution to manage these conditions​.

Lack of Knowledge and Misinformation Many women do not fully understand what the uterus 27

is or what its removal entails. Information about alternatives to surgery is often not provided. Informed consent is weak or absent; decisions are frequently made by husbands, contractors, or family elders Several women report being told that hysterectomy will "remove all problems," prevent future illnesses, or improve their ability to work​​.

Gaps in Healthcare Systems and Medical Incentives Most surgeries occur in private clinics or hospitals where regulatory oversight is weak. Often skipping standard protocols and operating under a fee-for-service model. In some cases, healthcare providers and labor contractors maintain informal partnerships, making it easier to refer women for surgery without external accountability​.

Public healthcare systems, where stricter guidelines exist, often do not reach migratory labor populations. These structural gaps leave women dependent on private healthcare, where economic incentives outweigh patient welfare.

Societal Norms and Gendered Beliefs Menstruation is considered taboo or inconvenient. Once a woman has completed childbearing, the uterus is seen as unnecessary. Decisions about reproductive health are often made by male family members or community elders. Discussions about pain, menstrual health, or longterm side effects are limited. These beliefs reinforce the idea that surgery is a routine, acceptable response to reproductive health complaints​.

Environmental and Material Conditions Environmental factors also play a role. Studies and field data suggest that exposure to heavy metals, which likely come from pesticides, industrial runoff, etc. may 28

contribute to increased rates of gynecological conditions such as fibroids and infections, which in turn lead to higher rates of hysterectomy. These environmental risks remain unaddressed, and medical responses focus only on treating symptoms through surgery​.

What happens to a woman’s body after the surgery?

For many women in rural, migrant labor communities, hysterectomy is presented as a solution—a way to end health complaints, stop menstrual pain, and enable uninterrupted work. However, research shows that the surgery rarely marks an end. Instead, it becomes the beginning of a set of structural, physical, emotional, and economic consequences that extend far beyond the operating table: The body: Fatigue, pain, early menopause, and long-term health risks.

The mind: Confusion, regret, emotional distress, and loss of autonomy.

The economy: Debt, reduced capacity to work, lack of healthcare access.

The social fabric: Normalization of harm, silence, and structural invisibility.

The Body

•

•

Sudden, premature menopause: Removal of the ovaries with the uterus, leads to abrupt hormonal changes. Women report symptoms such as hot flashes, sleep disturbances, body pain, and mood shifts — without having been informed that this would happen.

Persistent weakness and fatigue: Despite the perception that surgery "solves" health problems, women describe long-term exhaustion, joint pain, 29

•

•

and reduced physical strength. Many note that tasks they could easily perform earlier — carrying water, lifting loads, walking long distances — become difficult after surgery.

Chronic pain: Contrary to the belief that surgery ends abdominal discomfort, many women continue to experience pain in their back, lower abdomen, and legs.

Loss of reproductive capacity: Although most women have completed childbearing, the sudden removal of the uterus without proper counseling or consent leads to confusion, regret, or distress in some cases.

“After surgery, I was back in the field in three days.

My back has hurt every day since then.”

Rekha, Beed district​

The Mind

30

Beyond physical symptoms, women describe emotional and mental health effects that are rarely acknowledged: • Feelings of confusion and betrayal: Many women only realize the full extent of the surgery after it is done. Some recount being told, "It’s a small operation," only to discover later that their uterus was removed.

• Loss of control over their own bodies: Several testimonies reflect how decisions about surgery were made by husbands, contractors, or doctors, with little or no involvement from the women themselves.

• Sense of incompleteness: Some women articulated a sense of loss, of something missing, without being able to fully explain it.

•

Internalized silence: Even when experiencing regret, pain, or distress, women often do not talk about it — reflecting a broader culture of not speaking about reproductive health.

These emotional impacts are compounded by the lack of any space — in health systems, family structures, or labor camps — to process the experience.

The Economy

•

•

•

•

Women return to labor almost immediately after surgery, often within 3–7 days, without adequate recovery. This increases the risk of long-term physical weakness and injury.

Post-surgical health impacts reduce women’s work capacity. Many women report difficulty meeting labor demands after surgery, leading to further wage cuts or loss of employment.

Medical costs increase household debt. In most cases, women’s families borrow money from contractors or informal lenders to pay for the surgery. These debts tie them further into exploitative labor contracts.

No formal compensation or support exists. There is no mechanism within labor policies or healthcare schemes to support women facing long-term health impacts of unnecessary surgery.

“We took a Rs.20,000 loan from the contractor for my surgery. I am still paying it back.”

Field interview, Horpal district​

31

The Social Fabric

The effects of hysterectomy extend into women’s relationships, caregiving responsibilities, and social participation: • Reduced capacity for care work: Fatigue and weakness after surgery limit women’s ability to care for children, elderly family members, or household tasks.

• Strained family dynamics: Some women reported tension with spouses or in-laws over the decision to undergo surgery, particularly when debts were involved.

• Silence and normalization within communities: Hysterectomy is so common in some labor camps that women describe it as a routine fact of life. This normalization silences discussion about pain, regret, or harm.

These impacts reveal why addressing unnecessary hysterectomy requires more than clinical guidelines.

The consequences of unnecessary hysterectomy are not limited to individual health outcomes. It requires acknowledging the broader economic, social, and political structures that shape how and why women undergo this surgery — and how they live with its aftermath.

32

Photographs or Q prompts

33

34

Part III Problems & Opportunities

The systemic drivers outlined in this section do not exist in silos.

They operate as an interconnected web — reinforcing each other in ways that make harm predictable, normalized, and difficult to interrupt.

Chapter 1 Living and Working Conditions Chapter 2 Economic Equity Chapter 3 Healthcare Accessibility Chapter 4 Knowledge and Autonomy Chapter 5 Gender Norms and Social Control Chapter 6 Labor Rights

35

Chapter 1

Living and Working Conditions

36

The physical environments in which migrant agricultural workers live and work are marked by multiple, layered health risks.

Social

The social structures within labor camps deeply impact women’s access to healthcare. Social norms often treat menstruation and pregnancy as liabilities, perpetuating stigma around natural biological processes.

This social pressure can lead to the normalization of surgical interventions like hysterectomy as a means of conforming to rigid labor demands.

Technological

Technological infrastructure in these labor camps is grossly inadequate, especially concerning healthcare.

The absence of diagnostic tools and essential facilities like sanitation systems exacerbates health challenges.

This lack of technological support drives women toward invasive medical procedures, such as hysterectomy, due to the absence of less severe treatment options and medical guidance.

Economic

Economic constraints play a significant role in coercing women into surgery. Missing even a single day of work due to health issues can lead to significant loss of income, around Rs.500 to Rs.1,000. This economic vulnerability, coupled with debt pressures, often forces women to opt for hysterectomy as a means to remain continually productive, thus perpetuating a cycle of economic dependency and exploitation.

Environmental

The environmental conditions of labor camps are unfit for healthy living. Overcrowded spaces and insufficient sanitation exacerbate the health risks, 37

making natural biological processes cumbersome. The poor environmental conditions significantly leads to compromised health. The water and soil is likely to be significantly contaminated by heavy metals from industrial runoff and pesticides.

Political

Politically, there is a significant gap in governance and policy enforcement regarding labor rights and healthcare in these camps. The lack of official oversight and data collection on hysterectomies highlights a systemic failure to address and regulate private healthcare practices in rural areas. Policy neglect contributes to an environment where exploitative practices can persist unchecked.

Values

The prevailing values within these communities prioritize labor productivity over individual well-being, reflecting a broader societal inclination toward economic output above humane conditions. This results in systemic practices where invasive procedures like hysterectomies are seen as routine solutions.

38

Design Principles

Need to rewrite, feels too generic / fluffy

Visual

Design for Rest, Not Just Labor

Visual

Design Within Informality

Visual

Design for Embodiment

Visual

Design Without Extraction

Visual

Make the Camps Visible

Rest is health. Without it, survival becomes sacrifice.

These systems aren’t broken they were never meant to protect. Build for that truth.

Bleeding, pain, exhaustion these are normal. Build around the body, not against it.

If surviving work requires losing a uterus, that’s not design, that’s violence.

If camps remain invisible to the state, harm will remain visible on women’s bodies.

39

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

40

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

41

Do ASHA workers have the gynecological expertise needed for early intervention?

ASHA workers are trained for maternal health outreach but not for identifying or addressing menstrual and gynecological issues.

Why is there such low access to menstrual products in rural areas?

Supply chains for menstrual products do not reach labor camps, and welfare schemes exclude menstrual health provisions.

Why is there no access to first-aid or basic medicines for minor health issues?

Camps lack primary healthcare services, forcing women to neglect or normalize reproductive discomfort.

Why is there no secure space in camps to store aid, supplies, or medical materials?

Temporary and exploitative labor camp conditions offer no infrastructure for women’s health and hygiene needs.

Why don’t women have time to seek medical care before problems become severe?

Labor systems penalize women for missing work, leaving them unable to prioritize preventive healthcare.

Why don’t children in camps have access to toys or books?

Migrant families lack access to educational or recreational resources, perpetuating knowledge deprivation for the next generation.

Why do children have to start from scratch every time 42

they migrate?

Lack of continuity in education for migrant children leads to repeated disruptions and loss of learning.

Why can’t children continue school when they migrate?

There are no policies or programs that ensure educational continuity for children of migrant workers.

Why are girls married off so early?

Economic precarity, social norms, and lack of schooling opportunities lead to early marriage, cutting girls off from formal education about health and rights.

Agency

Why do women have no control over their earnings?

Household and labor camp structures centralize financial control with male relatives and contractors, limiting women’s autonomy.

How are women influenced or pressured into hysterectomies?

Contractors, doctors, and family members promote surgery as a solution to menstruation, leveraging misinformation and economic pressure.

Why are nearly all mukadams men, and what power dynamics does this create?

Male dominance in labor contracting reinforces gendered power imbalances over information, wages, and health decisions.

Why do mukadams have to recruit entire families every season?

Labor systems depend on family units’ mobility, reducing individual autonomy and binding women’s health choices 43

to economic survival.

Why is there such a lack of health awareness and education among workers?

Responsibility for reproductive literacy is abdicated by institutions, leaving workers dependent on informal, inaccurate information.

How does advance money lead to coercion around surgeries?

Debt cycles and wage advances create financial dependency that limits women’s ability to question or refuse medical decisions.

Why are women asked to pay for missed days of work?

Labor systems economically penalize menstruation and illness, coercing women to eliminate these “disruptions” through surgery.

Why do some women seek hysterectomies for social protection?

Women internalize societal messaging that their worth and safety are tied to reproductive control, making surgery appear protective.

44

Reflection

What are some scenarios that come to mind related to the migrant journey?

45

Chapter 2

Healthcare Accessibility

46

The healthcare landscape available to migrant agricultural workers is marked by absence, inaccessibility, and opportunism.

Social

Social dynamics in rural India contribute significantly to the normalization of unethical medical practices. The lack of informed consent and the dominance of surgical interventions reflect social attitudes that prioritize labor productivity over women’s health. Within these communities, healthcare transactions replace genuine care, leading women to view potentially harmful medical practices as standard. This societal norm is perpetuated by narratives like “It’s not their responsibility,” which highlight the neglect in preventive healthcare.

Technological

The technological infrastructure in these healthcare systems is insufficient and largely underdeveloped. The absence of diagnostic tools and preventive healthcare measures results in surgery being the first and often only response to health concerns like heavy bleeding or fatigue. Technological gaps in healthcare delivery mean non-surgical alternatives are often overlooked, pushing women toward unnecessary surgeries due to a lack of visible, accessible treatment options.

Economic

Economically, the profit-driven nature of healthcare in these informal settings creates a system where surgical interventions are incentivized. Private doctors and clinics operate in an unregulated environment, making surgeries such as hysterectomy a transactional endeavor rather than a health necessity. Efficiency and profit become paramount, sidelining ethical considerations, and healthcare is commodified, with surgeries performed not for health outcomes but for economic gain.

47

Environmental

The healthcare environment is characterized by a focus on emergency response rather than preventive care. The lack of outreach from health workers, like ASHAs, and the minimal presence of PHCs during migration contribute to an environment where health is only addressed when it disrupts labor. This reactive approach to healthcare neglects the broader environmental need for consistent, preventive care that could mitigate the need for invasive procedures.

Political

Politically, there is a glaring lack of regulation and oversight within the healthcare system. The absence of public health data on rural or labor-linked hysterectomies indicates a systemic failure to monitor medical practices effectively. Without data, there is no regulation; without regulation, there is no accountability, allowing unethical practices to persist unchecked. This political void permits systemic coercion, where women’s health needs are subordinated to labor demands.

Values

The prevailing values in these healthcare systems prioritize efficiency and compliance over patient wellbeing. Surgical interventions are normalized as they align with contractors’ timelines rather than addressing women’s health needs. This value system deems surgeries as a means to maintain productivity, making harm invisible and perpetuating structural violence against women’s health. The need for ethical and accessible healthcare systems demands a recalibration of values to prioritize women’s health rights and dignity over economic efficiency.

48

Design Principles

Visual

Design for Consent, Not Just Information A woman agreeing under pressure, fear, or silence is not giving consent.

Visual

Design Beyond the Clinic

Visual

Design for Non-Surgical Options as Default

Health doesn’t start in hospitals. Design outreach, mobile care, and systems that travel with migration.

Surgery must be the last resort, not the only one.

Design systems that make other options visible and accessible.

Visual

Design to Track Harm What isn’t counted can’t be regulated. If a hysterectomy isn’t in the data, the violence isn’t in the policy.

Visual

Design Systems That Acknowledge Exhaustion Design with the assumption that women are tired — physically, emotionally, systemically. Care must meet them where they are.

49

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

50

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

51

Chapter 3

Economic Inequity

52

Economic inequity in migrant labor camps is driven by a combination of factors that prioritize productivity over the well-being of workers.

Social

The social structure within labor camps reflects economic inequities that prioritize labor productivity at the cost of women’s health and autonomy. Societal norms reinforce expectations that women should continue working despite health concerns, perpetuating cycles of exploitation. The widespread acceptance of surgical procedures like hysterectomy as “normal” highlights how deeply these inequities shape women’s roles and identities, treating their bodies as mere instruments for economic output rather than valuing them as individuals with rights and dignity.

Technological

The lack of technological advancement in healthcare in these settings limits women’s access to quality medical care. The absence of advanced diagnostic tools and accessible medical facilities forces women into costly, invasive treatments like hysterectomy, which are seen as quicker solutions that suit labor demands. This gap denies women equitable options, marginalizing nonsurgical and preventive treatments that could promote long-term health and economic stability.

Economic

The economic system entrenches women in cycles of debt and financial instability, limiting their economic equity. Advance loans taken before migration tie women into dependency, redirecting wages toward debt repayment instead of health investments. Wage penalties for health-related absences force women to prioritize maintaining “problem-free” bodies over their well-being.

This economic coercion commodifies women’s health, 53

transforming it into an asset for productivity rather than a facet of personal choice and agency.

Environmental

The harsh environmental conditions of labor camps reflect economic inequities that place the burden of poor living standards on women. The lack of amenities and protective measures undermines their ability to manage reproductive health naturally, pushing them toward economically driven surgical solutions. This environmental neglect disproportionately affects women’s health outcomes and economic opportunities, warranting investment in safer conditions.

Political

Political inaction perpetuates economic inequity by failing to safeguard women against exploitation and health abuses in labor systems. The absence of regulatory frameworks and enforceable labor rights creates an environment where economic disparities thrive, with unregulated exploitation of workers who remain legally invisible. Meaningful political intervention is necessary to establish statutory protections prioritizing the economic rights and health of these workers.

Values

Prevailing values within these labor systems emphasize economic output over health equity, viewing rest as a luxury rather than a necessity. This value system contributes to structural inequities by endorsing surgical interventions that favor short-term economic gains at the expense of women’s health. Internalized beliefs that compromise human dignity and bodily integrity necessitate a reevaluation of values towards more equitable, humane labor practices that prioritize health and well-being over mere productivity.

54

Design Principles

Visual

Visual

Visual

Visual

Design Against Coercion If a choice is made under debt, pressure, or silence — it’s not a choice. Design with that truth.

Design for Informal Realities These are not broken versions of formal labor.

They are full systems. Design for them.

Design to Shift Power, Not Just Offer Services Without accountability, “awareness” does nothing.

Interventions must pressure contractors, regulate mukadams, and recognize women as workers with rights.

Design for Rest as an Economic Right Rest is not leisure. It’s survival. If a design penalizes menstruation or pain, it’s a system of violence.

Visual

Design With Structural Memory Every intervention must remember: the system rewarded a surgery over a sick day.

55

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

56

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

57

Chapter 4

Knowledge and Autonomy

58

The decision to undergo hysterectomy is rarely made with full information or free consent. It is shaped by structural misinformation and lack of knowledge.

Social

Social factors play a significant role in perpetuating the lack of bodily knowledge and health literacy among women in rural labor settings. Cultural norms often silence discussions about reproductive health, labeling such topics as shameful or disrespectful when questioned. These norms lead to an internalized belief system where ignorance is normalized, and coercion becomes an accepted part of social interactions. Phrases like “Everyone in the camp has done it” highlight how peer normalization leads to a societal acceptance of potentially harmful medical practices.

Technological

The technological aspects, particularly in information dissemination, are critically lacking. There are no robust systems for providing accessible reproductive health education or financial literacy. The technological void contributes to misinformation and the inability to access non-surgical options. By decentralizing knowledge from hierarchical structures like doctors, communities could leverage technology to educate and empower women, fostering greater autonomy and informed decisionmaking.

Economic

Economic illiteracy compounds the coercive practices, as many women lack understanding of how wages and debts impact their choices. This financial dependency keeps women in a cycle of economic vulnerability, making them susceptible to accepting surgeries like 59

hysterectomy without comprehending their full impact.

The economic power held by mukadams and contractors underscores a system designed to extract value from laborers without providing knowledge that could foster independence.

Environmental

The environmental conditions within labor camps are indicative of systemic neglect, with little to no outreach from health organizations. This environment of silence and lack of interaction not only isolates these women but also perpetuates a cycle of unawareness. The absence of systems that travel with migratory populations exacerbates this issue, making it difficult for women to maintain continuity in their education and health literacy.

Political

Politically, there is a significant gap in the establishment of policies that promote educational outreach and awareness in rural and migratory labor settings. The lack of regulatory frameworks that mandate informed consent and educational programs allows the systematic deprivation of knowledge to persist unchecked. Without political intervention, healthcare systems will continue to operate in a manner that prioritizes extraction over education.

Values

The prevailing values within these systems prioritize obedience and productivity over autonomy and education. There’s a cultural undervaluation of inquiry, with questioning regarded as disrespectful or unnecessary. This values system must shift to recognize knowledge and autonomy as fundamental human rights.

By fostering environments that prioritize learning and empowerment, women can be supported in making informed choices about their health and economic futures.

60

Design Principles

Visual

Design for Reproductive Literacy as Survival Understanding the body is not education — it’s protection.

Visual

Design to Decenter the Doctor

Visual

Design for Dialogues, Not Just Messages

Visual

Design Knowledge Systems That Travel

Visual

Design for Decision-Making, Not Just Awareness

Information should come from peers, frontline workers, and community — not only from hierarchical gatekeepers.

Campaigns don’t work if people can’t ask questions. Build formats for listening, not just telling.

Migration should not mean starting from zero.

Build tools, networks, and materials that move with the workers.

It’s not enough to know. Design systems that give women the power and support to act on what they know.

61

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

62

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

63

Chapter 5

Gender Norms and Social Control

64

Social norms and taboos sustain this crisis by normalizing hysterectomies as routine and silencing discussions about pain and individual rights.

Social

Social factors play a significant role in perpetuating the lack of bodily knowledge and health literacy among women in rural labor settings. Cultural norms often silence discussions about reproductive health, labeling such topics as shameful or disrespectful when questioned. These norms lead to an internalized belief system where ignorance is normalized, and coercion becomes an accepted part of social interactions. Phrases like “Everyone in the camp has done it” highlight how peer normalization leads to a societal acceptance of potentially harmful medical practices.

Technological

The technological aspects, particularly in information dissemination, are critically lacking. There are no robust systems for providing accessible reproductive health education or financial literacy. The technological void contributes to misinformation and the inability to access non-surgical options. By decentralizing knowledge from hierarchical structures like doctors, communities could leverage technology to educate and empower women, fostering greater autonomy and informed decisionmaking.

Economic

Economic illiteracy compounds the coercive practices, as many women lack understanding of how wages and debts impact their choices. This financial dependency keeps women in a cycle of economic vulnerability, making them susceptible to accepting surgeries like hysterectomy without comprehending their full impact.

65

The economic power held by mukadams and contractors underscores a system designed to extract value from laborers without providing knowledge that could foster independence.

Environmental

The environmental conditions within labor camps are indicative of systemic neglect, with little to no outreach from health organizations. This environment of silence and lack of interaction not only isolates these women but also perpetuates a cycle of unawareness. The absence of systems that travel with migratory populations exacerbates this issue, making it difficult for women to maintain continuity in their education and health literacy.

Political

Politically, there is a significant gap in the establishment of policies that promote educational outreach and awareness in rural and migratory labor settings. The lack of regulatory frameworks that mandate informed consent and educational programs allows the systematic deprivation of knowledge to persist unchecked. Without political intervention, healthcare systems will continue to operate in a manner that prioritizes extraction over education.

Values

The prevailing values within these systems prioritize obedience and productivity over autonomy and education. There’s a cultural undervaluation of inquiry, with questioning regarded as disrespectful or unnecessary. This values system must shift to recognize knowledge and autonomy as fundamental human rights.

By fostering environments that prioritize learning and empowerment, women can be supported in making informed choices about their health and economic futures.

66

Design Principles Design to Make Silence Impossible Visual

If a woman can’t speak her pain, the system will always erase her. Create spaces that invite storytelling and community testimony.

Visual

Design for Dignity, Not Discipline

Visual

Design Against Normalization

Visual

Design for Collective, Not Just Individual Change

Women are not tools for labor or cleanliness.

Design systems that honor complexity and humanity, not “efficiency.”

If “everyone has done it,” it’s a signal of mass harm — not a justification. Make the normalized visible as violence.

Gendered systems are upheld communally. Shift must be communal too — involve men, elders, mukadams, families.

Visual

Design With Feminist Solidarity Don’t “empower” women by giving them messages. Stand with them by challenging the systems that hold power over them.

67

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

68

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

69

Chapter 6

Rights and Regulations

70

A lack of rights and regulations leave workers vulnerable to exploitation, but offer opportunities to improve conditions and empower workers through better legal frameworks.

Social

The social dimension reflects how the invisibility of migrant laborers, particularly women, is both a product and perpetuator of the neglect they face. The lack of institutional recognition keeps their contributions hidden and unvalued. Social norms often prioritize economic survival over rights, as demonstrated by statements like “If we don’t cut cane, who will feed our family?” This social invisibility reinforces the systemic oppression and denial of basic rights, making it difficult for these individuals to be acknowledged as rights-bearing members of the workforce.

Technological

Technologically, the absence of robust systems for data collection and monitoring significantly hampers institutional recognition and protection. The lack of ID tracking, health cards, and labor registries means that workers remain uncounted and untraceable. This technological void prevents the development of informed policies and regulations that could better protect these workers’ rights and health outcomes. Improved data systems could support more proactive and protective interventions.

Economic

The economic aspect underscores the systemic exploitation resulting from informal labor arrangements.

Without formal recognition and legal rights, workers are trapped in a cycle where their labor value is extracted without appropriate compensation or protection.

71

Economic survival often trumps legal and health rights, with wage structures and debt cycles enforcing dependency. The absence of formal contracts and labor protections leaves workers vulnerable to exploitation, with economic insecurity as a constant threat.

Environmental

The environment within labor camps is characterized by inadequate living conditions and a lack of oversight.

These conditions contribute to the overall invisibility of the workers and their experiences. The absence of formal recognition or registration of camps results in a lack of accountability for living and working conditions, perpetuating a cycle of neglect that exacerbates health and safety risks for workers.

Political

Politically, there is a glaring absence of regulatory frameworks that recognize and protect migrant workers’ rights. The lack of formal acknowledgment in policy and law facilitates ongoing cycles of exploitation, with labor violations flourishing in legal gray zones. This political neglect underscores the need for intentional intervention and policy reform to establish statutory protections that prioritize workers’ health and economic rights.

Values

The prevailing values within these systems underscore a prioritization of economic productivity over individual rights and well-being. The systemic invisibility and engineered neglect of workers reflect a value system that deems their contribution as less worthy of acknowledgment and protection. There is an urgent need to recalibrate these values toward greater emphasis on human rights, dignity, and institutional accountability, ensuring that protection frameworks are inclusive and equitable.

72

Design Principles

Visual

Design for Legibility Without Surveillance

Visual

Design to Make Harm Traceable

Visual

Design for Cross-Sector Coordination

Recognize workers and camps formally — without criminalizing or over-policing them.

Track hysterectomy rates. Create reporting protocols. Demand transparency from private providers.

Bridge labor, health, and migration policy. No single ministry can protect what all of them ignore.

Design with Enforcement in Mind Visual

Rights mean nothing without enforcement.

Design with penalties, protections, and grievance mechanisms.

Design for Flexibility Within Mobility Visual

Migratory labor isn’t going away. Design institutions that move with people — not ones that exclude them.

73

Opportunities

Awareness

Visual about 3As

Why do women have no access to safe, hygienic menstrual products or drying spaces?

Taboos around menstruation and poor living conditions in labor camps prevent women from accessing or safely storing menstrual materials.

How can menstrual hygiene be maintained when women must wash the same cloth daily until it becomes unusable?

Lack of access to disposable products and inadequate hygiene infrastructure forces women to reuse cloth unsafely.

How can menstrual cloth be stored and dried with dignity and privacy?

Living arrangements in labor camps offer no private, hygienic spaces, reinforcing shame and health risks.

Why is there no consistent health education to build awareness about menstrual and reproductive health?

Health systems focus only on maternal health and sterilization, neglecting menstrual literacy in public health programs.

Why do women visit doctors only when symptoms become urgent?

Lack of preventive health education and normalized silence around reproductive health delays early careseeking.

74

Why is health education absent even at the school or camp level?

Migrant and informal worker communities are excluded from formal education and public health outreach.

Why is there no sexual or reproductive health education for girls?

Early school dropout, early marriage, and gendered education gaps leave girls with no formal knowledge about their bodies.

How can we increase awareness of hygiene and general health among adolescent girls?

Adolescent girls, particularly from migratory and rural contexts, are structurally excluded from reproductive health learning spaces.

How can women be better informed about the effects and consequences of hysterectomy?

Medical consent procedures focus on signatures, not meaningful explanation; women undergo surgery without knowledge of long-term risks.

How can we break taboos around menstruation and hysterectomy in communities?

Deep-rooted social norms treat menstruation as shameful, preventing open discussion and collective awareness.

Access

Why do rural doctors lack the gynecological expertise needed to address women’s reproductive health?

Rural healthcare systems lack trained gynecologists and prioritize sterilization over menstrual or reproductive care.

75

Part IV Designing Better Responses 76

77

Chapter 1

Why Traditional Interventions Fail This section explains why many conventional approaches to intervention have failed to prevent this systemic crisis. It highlights the limits of medical, data-driven, and awareness-only solutions and underscores the need for a systemic, ethical, and context-sensitive approach to intervention design.

Illustration about chapter

78

Over the years, many efforts have been made to address the issue of unnecessary hysterectomies — through clinical guidelines, awareness campaigns, policy advisories, and data collection. However, these well-intentioned interventions have had limited impact. The structural patterns outlined in Part I remain largely intact, and unnecessary hysterectomies continue to occur at scale, particularly among migrant agricultural labor communities.

What Exists Today

In 2022, India’s Ministry of Health and Family Welfare introduced guidelines to regulate hysterectomy procedures in response to reports and studies highlighting their unnecessary prevalence. It focused on adherence to diagnostic protocols, mandatory second opinions, informed consent, state- and national-level data collection, and post-surgical audits. While these guidelines provide a critical clinical protocol, they do not encompass the downstream socio-economic conditions like labor coercion and misinformation that influence surgical decisions.

The current landscape offers an opportunity to expand guidelines and embrace a more holistic approach to healthcare. By recognizing and incorporating broader influences such as labor contractors and informal healthcare providers, we can foster a more integrated system. This includes aligning health, labor, and social policies to acknowledge and address economic insecurity, labor conditions, and power dynamics. Such an approach not only promotes ethical clinical practices but also works proactively to alter systemic conditions, empowering women with more informed choices regarding their health.

79

Why Traditional Interventions Fail

Designing interventions in contexts like this is not only a technical or managerial task — it is an ethical responsibility. Every action taken to “help,” regulate, or improve this system interacts with existing structures of inequality, coercion, and institutional neglect. If these dynamics are ignored, even well-intentioned interventions can cause further harm. There are three ethical risks that any intervention must acknowledge: Breaking Existing Power Asymmetries When interventions are designed without analyzing who holds power and who is excluded, they often reproduce the very hierarchies they seek to change. For instance: • Healthcare policies may tighten clinical consent protocols but continue to ignore labor exploitation.

• Awareness campaigns may target women without addressing the structural conditions that constrain their choices.

• Regulatory efforts may criminalize individual doctors without reforming systemic incentives for surgery.

In each case, responsibility is pushed downward — onto women, frontline workers, or individual clinics — without shifting the deeper structures of control.

Shifting the Burden Away from Those Already Disempowered When interventions focus on informing women or training ASHAs without changing economic, social, or institutional conditions, they place the responsibility for systemic change on those who are least equipped to carry it.

Producing Unintended Consequences Frontline health workers, community activists, and women themselves are already stretched thin —

80

navigating debt, labor demands, social stigma, and health risks. Interventions that expect them to fix systemic problems without providing structural support are ethically irresponsible.

Interventions that fail to engage with complexity can generate new forms of harm. Examples include: • Surveillance programs that monitor women’s reproductive health without providing services.

• Awareness campaigns that raise alarm without offering alternatives or care.

• Data collection exercises that extract information without accountability.

How This Manual Is Different

•

• •

•

Highlight the limitations of clinical oversight alone, and make visible the socio-economic, gendered, and labor-related forces shaping the crisis.

Expand the frame of analysis beyond individual clinical practice to systemic patterns of harm.

Provide tools for actors outside the formal health system — including NGOs, labor organizers, policymakers, and community leaders — to understand the structural drivers of unnecessary hysterectomies.

Offer strategic, systemic guidance to design interventions that go beyond compliance and address the root conditions leading to these surgeries.

81

Chapter 2

What Systemic Design Requires Systemic design proposes a different approach. It is not a matter of scale or complexity alone — it is about the mindset, principles, and methods used to intervene in a problem that is structural, multilayered, and deeply embedded in economic, social, and institutional systems.

82

This section lays out what systemic design requires in the specific context of unnecessary hysterectomies among migrant agricultural labor communities. It is not a general theory of systemic design but a grounded articulation of what it means to design responsibly, ethically, and effectively in this space.

These consequences are often unintended — but predictable when systemic conditions and power dynamics are overlooked. Ethics, in this context, is not about individual intent. It is about how interventions are designed, who they serve, who they burden, and how they reshape power.

Proposing a different approach

This manual is not a clinical protocol, an awareness campaign, or a legal handbook. It is a systemic manual — designed to help you see the full picture, understand the root conditions, and act strategically to change them. The purpose of this analysis is threefold: To Change the Framing Most public health policies and clinical guidelines treat hysterectomy as a technical or medical issue. This manual reframes it as a structural, systemic issue — one shaped by labor arrangements, gendered norms, knowledge systems, environmental harm, and healthcare inequities.

To Identify Points of Intervention By mapping the structural drivers of harm, this analysis helps identify: • Where in the system power operates • Where responsibility is diffused • Where the conditions for harm accumulate over time It is intended to help activists, policymakers, practitioners, and community leaders recognize which parts of the system can and must be changed — and how their roles connect to that process.

83

To Lay the Groundwork for Systemic Action The analysis in Part I is not an endpoint. It is a starting point for systemic action. The following parts of this manual will: • Translate this systemic diagnosis into clear strategies, tools, and practical guidance.

• Provide specific recommendations for different actors — whether working in healthcare, labor rights, community organizing, or policy.

• Emphasize the importance of working across sectors rather than addressing the issue in isolation.

This analysis is what makes this manual different.

This section builds on this foundation — moving from understanding the problem to identifying how we can intervene, prevent, and transform the system that sustains unnecessary hysterectomy.

Design Principles Based on the systemic analysis in Part I, designing in this context requires adhering to a set of clear, grounded principles: Redistribute Responsibility

Design interventions that shift responsibility away from women, frontline workers, or marginalized communities — and toward institutions, policymakers, employers, and healthcare providers who hold systemic power.

Center Lived Experience

Ensure that the voices, knowledge, and agency of affected communities shape the design process.WSystemic change cannot be imposed; it must be co-created with those who live within these systems.

Acknowledge Structural Inequalities

Design with explicit recognition of how caste, gender,

84

labor exploitation, and rural marginalization shape vulnerability.hAvoid interventions that ignore or flatten these power dynamics.

Design for Long-Term, Systemic Impact

Prioritize interventions that build capacity, shift structures, and redistribute power over those that deliver short-term results.yThis means investing in systemic change even when it is slower, harder to measure, and less visible.

Minimize Unintended Harm

Design with caution, humility, and accountability. Ensure that interventions do not reproduce existing inequalities, shift harm to others, or create new forms of burden.

Build a System of Care

At the heart of systemic design in this context is the principle of care — not just as an emotional value but as a structural commitment.

This means designing systems, policies, and services that: • Prioritize dignity, well-being, and safety over efficiency or control.

• Recognize the unpaid, invisible labor of care performed by women, frontline workers, and community networks.

• Create institutional structures that support, rather than extract from, marginalized communities.

A system of care is not a soft addition — it is the structural opposite of exploitation, coercion, and neglect.

Building such a system requires embedding care in every aspect of intervention design.

85

Chapter 3

How to Intervene Designing an intervention involves a strategic and phased approach to ensure effectiveness and sustainability. Each phase builds on the previous one, creating a comprehensive roadmap for successful intervention design and execution.

86

A design framework is a structured approach that guides the planning, development, and execution of creative solutions to achieve specific objectives or solve problems effectively.

Visual explaning how to use the frameworks?

Phase 1 Understand the Problem

The focus is on comprehensively analyzing the issue at hand, utilizing various frameworks to capture insights into its root causes and context. This foundational understanding informs the ideation in the next phase.

1.

2.

3.

4.

Research Guide – What is happening and why?

Deeper Research – What is the system at play?

Map Yourself – Where do I stand in this system?

System Understanding – What structural factors shape and affect this problem?

5. Problem Definition – What is the problem and what is my role in the system?

Phase 2 Design Pathways

In this phase, potential solutions are developed, drawing on creative and evidence-based approaches to craft 87

pathways that address the identified challenges.

1. Map Constraints – Where can I intervene meaningfully?

2. Ideate Interventions – What can I design to change conditions?

3. Past Interventions – What has been done before?

4. Define Interventions – How will it work in this context and what will it look loke?

5. Evaluate Ethically – Is this intervention effective?

Phase 3 Implementation

This phase involves putting these pathways into action, ensuring that intervention strategies are executed effectively and adaptively in real-world settings.

1. Preparation & Adaptation – How will I put this into practice, considering local conditions?

2. Long Term Planning – Who will sustain this work?

3. Monitoring & Measuring – How do we monitor and measure the impact?

Phase 4 Sustain Change

The emphasis in this phase is on the importance of long-term impact by embedding the intervention within existing systems, continuously evaluating outcomes, and making necessary adjustments to sustain positive changes over time.

1. Defining Success – What does success mean beyond numbers?

2. Scale Strategically – How can I scale a successful intervention?

3. Accountability – How do I embed systemic care and accountability?

4. Building Alliances – Who can help sustain change?

88

89

90

How to Use This isn’t a tool you fill out once and move on. It’s a way to keep orienting yourself as you move through complexity.

Step 1

Step 2 Step 3

Step 4 Step 5

Start with a real situation. Pick something concrete. It could be a story you heard, a moment you witnessed, or a troubling pattern you’ve noticed like women being sent for surgery without understanding why. Don’t start with theory. Start with lived experience.

Choose one row to explore. Pick one layer of the system to begin with. What is happening? What keeps repeating?

What is enabling it? What beliefs or norms make this seem acceptable?

Look across different kinds of knowledge. For that row, gather insights from four angles. Published research (reports, articles, data), Field insights (interviews, observations, conversations), Tacit knowledge (what people know but don’t always say out loud), Missing data (what feels unclear, avoided, or erased) Pause and reflect. Step back and ask: What am I seeing more clearly now? What still feels blurry? Where might I be making assumptions?

Repeat and revisit. As you learn more, return to the framework. What you thought was an event might reveal a deeper structure. Let this tool evolve with your understanding. It’s not a map. It’s a compass.

91

92

How to Use This isn’t a tool you fill out once and move on. It’s a way to keep orienting yourself as you move through complexity.

Step 1

Start with a real situation. Pick something concrete. It could be a story you heard, a moment you witnessed, or a troubling pattern you’ve noticed like women being sent for surgery without understanding why. Don’t start with theory. Start with lived experience.

Step 2

Choose one row to explore. Pick one layer of the system to begin with.

What is happening? What keeps repeating? What is enabling it? What beliefs or norms make this seem acceptable?

Step 3

Look across different kinds of knowledge. For that row, gather insights from four angles. Published research (reports, articles, data), Field insights (interviews, observations, conversations), Tacit knowledge (what people know but don’t always say out loud), Missing data (what feels unclear, avoided, or erased)

Step 4

Pause and reflect. Step back and ask: What am I seeing more clearly now? What still feels blurry? Where might I be making assumptions?

Step 5

Repeat and revisit. As you learn more, return to the framework. What you thought was an event might reveal a deeper structure. Let this tool evolve with your understanding. It’s not a map. It’s a compass.

93

94

How to Use This isn’t a tool you fill out once and move on. It’s a way to keep orienting yourself as you move through complexity.

Step 1

Start with a real situation. Pick something concrete. It could be a story you heard, a moment you witnessed, or a troubling pattern you’ve noticed like women being sent for surgery without understanding why. Don’t start with theory. Start with lived experience.

Step 2

Choose one row to explore. Pick one layer of the system to begin with.

What is happening? What keeps repeating? What is enabling it? What beliefs or norms make this seem acceptable?

Step 3

Look across different kinds of knowledge. For that row, gather insights from four angles. Published research (reports, articles, data), Field insights (interviews, observations, conversations), Tacit knowledge (what people know but don’t always say out loud), Missing data (what feels unclear, avoided, or erased)

Step 4

Pause and reflect. Step back and ask: What am I seeing more clearly now? What still feels blurry? Where might I be making assumptions?

Step 5

Repeat and revisit. As you learn more, return to the framework. What you thought was an event might reveal a deeper structure. Let this tool evolve with your understanding. It’s not a map. It’s a compass.

95

96

How to Use This isn’t a tool you fill out once and move on. It’s a way to keep orienting yourself as you move through complexity.

Step 1

Start with a real situation. Pick something concrete. It could be a story you heard, a moment you witnessed, or a troubling pattern you’ve noticed like women being sent for surgery without understanding why. Don’t start with theory. Start with lived experience.

Step 2

Choose one row to explore. Pick one layer of the system to begin with.

What is happening? What keeps repeating? What is enabling it? What beliefs or norms make this seem acceptable?

Step 3

Look across different kinds of knowledge. For that row, gather insights from four angles. Published research (reports, articles, data), Field insights (interviews, observations, conversations), Tacit knowledge (what people know but don’t always say out loud), Missing data (what feels unclear, avoided, or erased)

Step 4

Pause and reflect. Step back and ask: What am I seeing more clearly now? What still feels blurry? Where might I be making assumptions?

Step 5

Repeat and revisit. As you learn more, return to the framework. What you thought was an event might reveal a deeper structure. Let this tool evolve with your understanding. It’s not a map. It’s a compass.

97

98

Part V Process Examples

These interventions are not hypothetical proposals; they emerged through an intensive, iterative design process embedded in the real conditions of migrant agricultural workers’ lives, and leveraging the frameworks we proposed in Part II. 1. The Bangle 2. Bagasse 3. Fellowship

Illustration of section summary

99

Case Study 1

Maasik Bangle What is it?

A bangle with 31 beads helps women track their menstrual cycles by marking the start of their period with a safety pin, allowing them to predict and prepare.

Why is it needed?

Women in Maharashtra may be unprepared when their period starts while working in the fields, leading to unsanitary solutions, embarrassment, or even domestic violence.

How does it work?

The solution will be shared through community education, teaching women about the menstrual cycle and how to use the bangle as a simple tracking tool.

100

How we used the frameworks to come up with this intervention...

101

Case Study 2

Bagasse Purification What is it?

A technique for improving water quality by boiling contaminated water with sugarcane bagasse to adsorb heavy metals, then filtering it through a sari cloth.

Why is it needed?

Sugarcane cutters drink water contaminated with heavy metals, leading to adverse health effects like fibroids and cancer, which lead to hysterectomy.

How does it work?

The solution will be spread through peer educator training, live demonstrations within migrant communities, and easy-to-understand verbal and pictorial instructions.

102

103

Case Study 3

The Fellowship What is it?

The Swasth Saathi Fellowship trains and pays migrant women to serve as in-camp health companions, providing menstrual and hygiene support, translating medical language, and ensuring access to dignified care.

Why is it needed?

Traditional health systems rarely reach sugarcane labor camps, and when they do, they lack trust, continuity, and relevance, leaving women with little access to care in high-risk conditions.

How does it work?

One to two women per camp are selected, trained in basic health care, and equipped with tools to support their peers, with funding sourced from government schemes and NGO partnerships.

104

105

Part VI References

106

107

This manual is not an endpoint.

It is a bridge — from knowledge to action, from harm to care, and from structural neglect to collective stewardship.

This document would not have been possible without the incredible research, activism, and reporting done in the field. We are deeply grateful to the following individuals for their time, insights, and care in co-creating this artefact.

Researchers

108

Name Role

Name Role

Name Role

Name Role

Name Role

Name Role

Activists

Name Role

Name Role

Name Role

Name Role

Name Role

Name Role

Name Role

Name Role

Name Role

Journalists

Educators

109

Acknowledgements

• • • • • • • • • • • • • • • • • •

Academic Research

1. Research paper citation 2. Research paper citation 3. Research paper citation 4. Research paper citation 5. Research paper citation 6. Research paper citation 7. Research paper citation 8. Research paper citation 9. Research paper citation 10. Research paper citation 11. Research paper citation 12. Research paper citation 13. Research paper citation 14. Research paper citation 15. Research paper citation 16. Research paper citation

110

Sapna Desai Manisha Tokale Seema Kulkarni Nick Melissa Ronnie Megha Quazi ... ... ... ... ... ... ... ... ... ...

17. Research paper citation 18. Research paper citation 19. Research paper citation 20. Research paper citation 21. Research paper citation 22. Research paper citation 23. Research paper citation 24. Research paper citation 25. Research paper citation

Reporting and coverage

1. News/media article 2. News/media article 3. News/media article 4. News/media article 5. News/media article 6. News/media article 7. News/media article 8. News/media article 9. News/media article 10. News/media article 11. News/media article 12. News/media article 13. News/media article

111