SAHELI: Study and Action on Hysterectomy: Evidence on women's health through the life course in India. Protocol for a mixed-methods study.

Hysterectomy, removal of the uterus, is a commonly performed surgery for gynaecological morbidities. Emerging evidence indicates that hysterectomy performed before age 45 (early hysterectomy), is associated with considerable risks to women's health. While most evidence on hysterectomy is from high-income settings, national surveys from India report high prevalence of early hysterectomy in specific regions, as well as higher prevalence amongst women in rural areas and with less education. The median age at hysterectomy in India is close to ten years before the onset of natural menopause. India has recently introduced national guidelines to address early hysterectomy, but large evidence gaps on the causes and consequences remain - which in turn limits the potential effectiveness of interventions at the clinical, health system and community level.

Methods: SAHELI is a Team Science study that will examine: (i) individual, social and health system determinants of early hysterectomy; (ii) women's treatment pathways to hysterectomy and for gynaecological morbidity in general; and (iii) the consequences of undergoing hysterectomy on women's physical, mental, economic and social well-being across the life course. This mixed-methods study includes population surveys amongst women in ages 25-49 in three high-prevalence states; qualitative health systems research to trace treatment journeys with women, health care providers and other stakeholders; evidence syntheses; and knowledge translation activities to ensure findings inform co-produced strategies and interventions. The study is grounded in a feminist epidemiology approach, aiming to examine individual and structural causes of vulnerability and prioritising the views of women, particularly in knowledge translation.

Conclusions: SAHELI, implemented by an all-women, multi-disciplinary team, is the first study in India to examine the causes and consequences of hysterectomy in a life course approach. We aim to influence interventions, policy and future research on women's health, particularly access to quality gynaecological care and comprehensive health services through the life course.