The authorities in Uzbekistan have a robust policy on birth control, but evidence is emerging that in pursuit of a smaller population they are abusing women's rights by conducting hysterectomies and implanting contraceptive devices against their will.

The authorities want women to give birth to fewer babies, less often. They argue that a reduced birth rate is for the good of the national economy as well as the welfare of mothers themselves.

IWPR has interviewed healthcare experts and mothers who accuse the authorities of using coercive family planning measures that are often brutal in their implementation, and that allow for neither consultation nor alternative options.

Although the methods are shrouded in secrecy, there is mounting evidence that this is a coherent state policy rather than misguided imposition of voluntary methods.

According to one doctor, there is a secret order from the health ministry dating from 2000 to reduce the birth rate among women in rural areas. One of the methods recommended for achieving this goal is to perform hysterectomies on young women who have already given birth.

As well as hysterectomies, the other main practice is the implanting of intrauterine devices, IUD (commonly known as "the coil") immediately after a mother has given birth. Again, both mothers and health professionals say this is often done without consent.

The way both types of intervention are carried out leads to heightened health risks, medical experts say.

In a further indication that there is a coherent state policy, doctors have been dismissed for failing to hit birth control targets for their region.

All these measures taken by the government, which were discovered by IWPR journalists during their investigation, are portrayed by officials as benign concern for the health of women and children.

LEGAL SYSTEM UPHOLDS WOMEN'S RIGHTS

Human rights activists say that the government's covert policy and the practices it dictates are in direct contravention of national legislation and also international conventions.

Uzbekistan is a signatory to an array of United Nations conventions which ban physical mistreatment of and discrimination against women.

The country's constitution also guarantees that "everyone has the right to non-interference in his or her private life". The family code states that "the family, motherhood, fatherhood and childhood are under the protection of the state".

The chair of the government women's committee, Deputy Prime Minister Svetlana Inamova, delivered a glowing report on Uzbekistan's performance on women's rights when she addressed the United Nations Commission on the Status of Women at the beginning of March.

The government places high value on family planning both for health and demographic reasons. Current policies are based on a government decree from 2002 on how to "increase medical standards within the family, to improve women's health and to bear and raise a healthy generation", which recommends inter alia that women should wait three or four years between children.

An additional decree, from the health ministry, contains instructions that all women of childbearing age should be given IUDs immediately after they give birth. The wording appears to be a strong recommendation rather than an instruction to consciously act against the woman's will.

Finally, and most controversially, another decree, also from the health ministry, demands that the birth rate in rural areas should be brought down, and permits hysterectomies on women who have already given birth.

ARGUMENTS FOR BIRTH CONTROL

For the authorities, one of the basic problems for the future is how to match a growing population against economic performance that has to date proved disappointing, and objective constraints such the limited nature of the country's water supply.

Uzbekistan has the largest population of any Central Asian republic. Official statistics indicated that there were around 26.5 million people living in Uzbekistan last year. That year and the year before saw the numbers rising by half a million, or close to two per cent, annually.

While growth figures for Uzbekistan's economy differ between optimistic official data and the more cautious estimates of international financial institutions, rapid population growth clearly puts a damper on the all-important calculation of gross domestic product measured per head of the population.

Perhaps just as important in the government's calculations is a recognition of the constraints within which it has to operate. Although a big country, Uzbekistan has limited amounts of usable land, and much of that requires irrigation – placing demands on already strained water resources. So without some change in this basically rural, agriculture-based economic structure, there will come a point where the available resources cannot support the people who live there, say water and agriculture experts.

By 2010, the population of Uzbekistan will be fast approaching 30 million, and it is far from certain that food production can be improved enough to feed that many people. The United Nations Population Fund, UNPF, places Uzbekistan among the three poorest countries in the former Soviet Union in terms of per capita income. One in five of the population live in rural areas and are classed by UNPF as very poor. PUBLIC RESISTANCE, BACKDOOR POLICIES

For all these reasons, the government sees curbing the growth rate as a priority.

It also says it is dedicated to healthcare for women, particularly in rural areas, to improve overall healthcare provision, and in particular to encourage them to space out births for their own well-being and so that they – and the state – do not have to support so many children.

But even for this powerful government, birth control is not an easy to discuss let alone promote in a society where conservative family values are enduring. The Muslim Uzbek majority population may put up with a lot of instructions from their government, but they resent intrusions into areas of life they regard as private, and get prickly when the government tries to tell them what they can and cannot do in their own families.

Uzbek families tend to be large, with an average of four or five children and sometimes up to ten. Women marry at 18 and men at 22 on average. There is strong pressure to produce children early in the marriage – one of the factors being the desire to have sons.

Public information campaigns are transmitted via the state healthcare system and For a Healthy Generation (Soghlom Avlod Uchun) Foundation, a government agency.

Rather than stir up public anger by launching media campaigns, the policy is to work on a one-to-one basis to give women information about family planning at clinics and maternity hospitals.

But the strategy consists of a lot more than public information.

There are indications that healthcare officials are forced to act on written instructions to bring the birth rate down, including through non-voluntary medical interventions.

DISMISSED FOR BAD DEMOGRAPHICS

So mathematical is the thinking on demographics that officials penalise medics who fail to deliver on the "plan".

In March, the head doctors of two emergency medical centres in Andijan region, Soibjon Bozorov from the Oltinkul district and Atkhamjon Davlatov from Ulugnor district, were dismissed after the statistics showed that too many babies had been born in the areas where they worked.

Government officials in Tashkent were displeased by figures showing that in Oltinkul, 404 more babies were born last year than in 2003.

The head of the health ministry department for Andijan region, Rano Shermatova, also lost her job because of statistics showing excessive amounts of births, according to local doctors.

One of the sacked doctors, who wished to remain anonymous, told IWPR how he was sacked after being summoned to Tashkent for a high-level healthcare meeting. Significantly, the February 3 meeting was hosted by the economic ministry, with the health ministry officials clearly in a subordinate position.

As Economy Minister Rustam Azimov presided, the head doctors of emergency health centres in Andijan region had to report on progress in implementing a 2002 government decree on female healthcare and motherhood.

"Then Azimov told health minister Feruz Nazirov to stand up, pointed at us and said 'fire them'," said the doctor.

According to the doctor, the officials wanted to sack five senior doctors from Andijan, but only two were dismissed because the others had not been in their jobs long enough to be held accountable for what happened last year.

Deputy Health Minister Assomidin Ismoilov told a recent press conference that doctors in Uzbekistan were indeed being held responsible for increased birth rates.

But he added that they would not be sacked for failure to meet targets.

In an interview with IWPR, Ismoilov appeared to contradict this latter point, saying the two dismissed doctors, Davlatov and Bozorov, were indeed culpable for "poor organisation".

"We are aware of cases where they failed to offer women IUDs or other forms of protection from unwanted pregnancy," said Ismoilov.

The result was, he said, that they failed to meet the targets set out in decree which set three or four years as the prescribed interval between births for women.

HYSTERECTOMY AS POLICY

IWPR has uncovered cases where women who are in hospital after the birth of a child have undergone a hysterectomy – removal of the uterus
(womb) – without their consent, and with no medical need.

While IWPR's enquiries focused on Andijan, the women's rights organisation Ozod Ayol (Free Woman) says it has recorded cases of involuntary hysterectomies in other parts of Uzbekistan.

Furthermore, there is evidence that this is not a question of a lapse in medical ethics as a deliberate tactic to reduce the birth rate.

A doctor in Andijan region, who spoke on condition of anonymity, says a secret decree from the health ministry exists, dating from 2000, which sets the task of reducing the birth rate in rural regions. The decree even allows removal of the uterus among women of childbearing age who have already given birth.

IWPR correspondents were not able to find a copy of this decree, but the increase in cases of uterus removal among young healthy women indirectly confirms that this document may exist.

IWPR talked to several women from the Oltinkul, Bulokboshin and Balikchi district, all in Andijan region, who have undergone post-natal hysterectomies. None was informed about the procedure beforehand.

The women interviewed all said there were complications with their births, which fits with the justification that officials cite for conducting emergency operations. However, what stands out in these stories is the immediate resort to hysterectomy rather than less traumatic interventions for woman who are otherwise healthy.

Khulkaroi Abdullaeva, 31, from Oltinkul, checked into the maternity hospital on February 17 this year as her third pregnancy came to term. Her contractions stopped, and "they tied a sheet around my stomach and started pulling on it until it tore. They tormented me and I lost consciousness", she said.

The baby was stillborn, and afterwards doctors performed a hysterectomy,

When she left hospital, Abdullaeva was still unaware this had been done. It was only when she got home and told her mother that she had not been fitted with an IUD, as is standard practice, that she learned she no longer had a womb.

"Why did they make me an invalid?" she said. "I wanted to have more children."

Her mother Sharofat Isaeva said that while her daughter was in hospital, another three women had hysterectomies.

Now Abdullaeva is confined to bed, she suffers back pain and cannot walk on her own.

"Because of a doctor's error, my daughter has become an invalid," said her father Turdibay Isaev. "She cannot give birth any more - who will answer for that?"

A second interviewee, mother of two Feruza Ashurova, also from Oltinkul, underwent a hysterectomy when she lost a child after heavy bleeding.

Ashurova does not understand why she needed a hysterectomy simply because of the bleeding. "My family gave blood for me and my uterus was healthy – I'm only 25," she said.

Nodira Samatova, also 25, had her uterus removed after a successful birth. She was discharged from hospital but readmitted after developing a high temperature, and given the operation.

"I don't feel like a woman anymore, I have become an invalid, and I suffer from back pains," she said.

OFFICIALS SAY THEY OPERATE ONLY WHEN NECESSARY,

Uzbek health officials say such operations are carried out for strictly medical reasons and only when there is no other option.

"Removing the uterus is a decision taken in the course of an operation," said Valikhon Hakimov, head of Andijan regional health department, if during the birth the woman experiences heavy bleeding, then to save the mother the uterus may be removed."

At a press conference in Tashkent, Deputy Health Minister Assomidin Ismoilov also refuted reports of illegal removal of uteri and that a decree existed on removing uterus from women. "Removal takes place when a choice needs to be taken between life and death, there are no unjustified cases of removal," said Ismoilov.

IWPR approached the government agency responsible for the mother-and-child health campaign, Soghlom Avlod Uchun. Jumabek Nurov of the mother-and-child health department was non-committal, saying it was not his remit to work with women who have undergone hysterectomies.

Another representative of the agency, Fiara Zhonbekova, who heads its social medicine centre in Tashkent, did at least admit the existence of the problem, saying that on visits to rural areas, Soghlom Avlod Uchun officials were often approached with requests for help from women of childbearing age who had had hysterectomies.

Apart from its medical consequences, hysterectomy often bears immediate risks for the women involved in Uzbekistan.

The head of the pathology department for Andijan region, Gulbahor Turaeva, said women often became effectively disabled after the operations, falling into the official category of "invalid, second class".

"They cannot work. What sort of work is there in the villages? Field work, and with their health like that, it will be impossible for them," said Turaeva.

A gynaecologist in Tashkent, who wished to remain anonymous, explained the consequences of hysterectomy and why the method should only be used when there is no medical alternative. If the operation is conducted and involves a subtotal (or upper) hysterectomy, then this operation, said the expert, should not seriously affect the woman's health, "She simply won't have children."

But if it is a total (also termed lower) hysterectomy or the operation is performed incorrectly, there are inevitable consequence to blood pressure and other areas. "The aging process may be accelerated, and the woman may become irritable and suffer diseases of the nervous system," said the gynaecologist.

"The psychological significance of this operation is also important, when a woman knows that she has no uterus and that she will never have children again."

AN ATTEMPTED COVER-UP?

Turaeva is given many uteri to examine in her work as a pathologist, ranging from three to ten a day. Her examination show that in many cases removal was unjustified, and she concludes that the number of healthy women given hysterectomies is rising.

She cites 207 cases involving the removal of a healthy uterus in September-December 2004 in Andijan region, and says there may have been more cases of which she was unaware. Many cases are not recorded, and the medical evidence simply discarded with the rubbish.

"I don't believe that there were serious reasons to remove uterus from these young women," she said. "It is an extreme measure: cancer patients have their uterus removed, and in the past the cases were isolated, usually among older women."

The pathologist says she cannot say for definite whether these hysterectomies were carried out as a result of secret government orders to cut birth rates. But she says that as well as lacking professional skills, doctors may also be motivated by the requirement to reduce the birth rate.

"If they see that head doctors are dismissed because of a rise in the birth rate, then they will ask themselves, 'Why should I stand on ceremony with these women? I'll kill two birds with one stone – save the woman and improve the demographic situation'," said Turaeva.

One of the cases she has seen involved Gulchekhra Okhunova, a 32-year-old mother of four, who underwent an abortion but suffered complications as the operation was not carried out well.

Okhunova went back into hospital where she was given a hysterectomy. She is still ill as she developed an infection afterwards.

According to Turaeva, when Okhunova learned of the operation and made a fuss, she was told by hospital staff that she already had four children, so had no need for a uterus.

Turaeva was given Okhunova's uterus to examine, and she concluded that the organ was healthy and there was n0 medical need to remove it. Oddly, Okhunova's case history says that he has not had a hysterectomy.

On the basis of this and other cases, Turaeva wrote to the health department of the Andijan regional health department. The response from its then head was, in Turaeva's words, that "Rano Shermatova, to put it bluntly, told me to shut up".

Soon after this, the doctor who performed the hysterectomy on Okhunova offered 200 US dollars to return the uterus.

In response, Turaeva wrote a letter to the health ministry in Tashkent, but received no response.

Over time, the bribe offered to Turaeva to take part in a cover-up increased to 1,000 dollars and a job with the health ministry.

Questioned about Turaeva's accusations, regional health chief Hakimov replied that the pathologist spends her time writing to the authorities, yet she is unwilling to cooperate with an expert who has been appointed to deal with her complaint.

Turaeva counters that she does not trust the expert, and specifically is reluctant to hand over Okhunova's healthy uterus as this is a key piece of evidence.

Hakimov refused to provide data about the number of hysterectomies removed.

INVOLUNTARY IUD IMPLANTION

In the low key consultation system favoured by the government, every young woman of child-bearing age is supposed to be assigned to the nearest clinic, which should call her in now and then for consultations during which she will be advised on family planning.

Women who have just given birth or who already have several children are a priority.

The recommended method of contraception in Uzbekistan is the IUD, which the health ministry distributes free of charge to health centre as part of an intensive but, officials insist, entirely voluntary birth control programme.

Even in Oltinkul district, where doctors were blamed for failing to cut the birth rate, 16,000 young women were given IUDs last year, and another 10,000 have been ordered for 2005.

Doctors in Uzbekistan have told IWPR of a health ministry decree which requires that all women of childbearing age be fitted with IUDs immediately after given birth. A maternity hospital doctor in Tashkent confirmed the existence of this instruction, adding that if for health reasons it was not possible to carry out the intervention while the women was still in hospital, her local clinic would be instructed to see that it was done.

None of this by itself suggests a coercive character to the IUD campaign. But there is evidence that that is exactly what it is. As well as Andijan, IWPR has seen evidence of coercion in Tashkent and Kashkadarya regions.

"Some women have IUDs inserted two hours after given birth, which constitutes a coercive measure," said Sahiba Hasanova, a gynaecologist from Andijan region.

Common medical practice in other countries is to wait about four weeks after birth before inserting an IUD.

Dr Bozorov says that in the drive to impose IUD use, the authorities ignore essential preliminary checks to make sure the method will not cause health problems. As a result, he said, there has recently been an increase in women coming into hospital with complications such as bleeding and inflammation.

"Spirals can not only cause bleeding, they can cause complications such as myoma uterus and even cancer," said Bozorov.

In some cases, incorrect application of IUDs forces doctors to carry out a hysterectomy for medical reasons.

OFFICIALS SAY NO HIDDEN AGENDA ON IUDS

Klara Yadgarova, head of the maternity and children's department at the Uzbek health ministry, insists that IUD provision is always consensual.

She says the voluntary IUD policy does not imply that women are forbidden to have children. All the authorities want is for women to observe the recommended gap between births, as too frequent births have a negative impact on the health of both mother and child.

PUBLIC REACTION

As birth control is not discussed in the media, still less the coercive interventions apparently carried out at the government's behest, public debate on the subject is limited. Rural women will rarely discuss medical problems with their husbands.

Those men who become aware of the campaign are often as outraged as the women.

"I won't allow my wife to have her uterus removed, or someone to tell us how many children to have," said one young man from Tashkent.

The man voiced concern that if the population is allowed to grow older on average, there will be fewer young people to care for the old.

Atanazar Arifov, who heads Erk, one of the two main opposition parties in Uzbekistan, said forced sterilisation was "amoral" and "criminal".

Arifov rejected the official argument that unhealthy children are the result of too-frequent births, and says the government is at fault for creating the kind of poverty that leaves people – including would-be mothers – in poor health.

Most doctors agree with Arifov, saying that diseases and the poor health of women is the consequence of social problems, but it is not a reason to prohibit them from giving birth and becoming mothers.

Non-government organisations, NGOs, specialising in women's rights find themselves in a particularly awkward position on the issue. Some are forced to toe the official line since they belong to that curious category known as GONGOs – "government-organised non-government organisations".

But even the independent NGOs have trouble as they seek to balance the individual's right not to be subjected to medical treatment against her will, and the right of governments to pursue measures to improve women's health.

For example, Zulfia Tokhtakhujaeva, who heads the Mehr Association of Women's NGOs, steered a cautious line when questioned about the policy of cutting the birth rate, saying it made sense because too many women were giving birth to unhealthy babies.

Another NGO, Ozod Ayol, was more forthright, saying the state's birth control policy was taking on monstrous forms.

"People are simply being destroyed, it is a humiliation for women and the entire people," said Ozod Ayol's head Gauhar Oripova.

Oripova says birth control measures may well be necessary, but these need to be implemented by raising awareness among women, not abusing their rights. In any case, the way to resolve the current problems are through economic and political development, which will enable people to decide for themselves how many children to have.

As things stand, she claims, "The authorities are breaking the law. They should stop the forced sterilisation of women."

Malik Boboev and Yusuf Rasulov are IWPR contributors in Tashkent. Galima Bukharbaeva is IWPR project director in Uzbekistan.