Saodat Rakhimbayeva says she wishes she had died with her newborn baby. The 24-year-old housewife had a cesarean section in March and gave birth to Ibrohim, a premature boy who died three days later.
Then came a further devastating blow: She learned that the surgeon had removed part of her uterus during the operation, making her sterile. The doctor told her the hysterectomy was necessary to remove a potentially cancerous cyst, while she believes he sterilized her as part of a state campaign to reduce birthrates.
"He never asked for my approval, never ran any checks, just mutilated me as if I were a mute animal," the pale and fragile Rakhimbayeva said through tears while sitting at a fly-infested cafe in this central Uzbek city. "I should have just died with Ibrohim."
According to rights groups, victims and health officials, Rakhimbayeva is one of hundreds of Uzbek women who have been surgically sterilized without their knowledge or consent in a program designed to prevent overpopulation from fueling unrest.
Human rights advocates and doctors say autocratic President Islam Karimov this year ramped up a sterilization campaign he initiated in the late 1990s. In a decree issued in February, the Health Ministry ordered all medical facilities to "strengthen control over the medical examination of women of childbearing age."
The decree also said that "surgical contraception should be provided free of charge" to women who volunteer for the procedure.
It did not specifically mandate sterilizations, but critics allege that doctors have come under direct pressure from the government to perform them: "The order comes from the very top," said Khaitboy Yakubov, head of the Najot human rights group in Uzbekistan.
Uzbek authorities ignored numerous requests by The Associated Press to comment on the issue. Most Western media organizations have been driven from the country, and government officials face serious reprisals for contacts with foreign journalists. However, the AP was able to interview several doctors, sterilized women and a former health official, some on condition of anonymity.
This Central Asian nation of 27 million is the size of California or Iraq, and population density in areas such as the fertile Ferghana Valley is among the world's highest.
Rights groups say the government is dealing with poverty, unemployment and severe economic and environmental problems that have triggered an exodus of Uzbek labor migrants to Russia and other countries.
Heightening the government's fears is the specter of legions of jobless men in predominantly Muslim Uzbekistan succumbing to the lure of Islamic radical groups with ties to Afghan Taliban and al-Qaida.
Uzbekistan is not alone in coming under allegations of using sterilizations to fight population growth: Authorities in China's Guangdong Province were accused by Amnesty International in April of carrying out coerced sterilizations to meet family planning goals. But no other country is known to use that method as a government policy.
Uzbekistan once had one of the Soviet Union's highest birthrates, four to five children per woman, and Communist authorities even handed out medals to "heroine" mothers of six or more. Young army conscripts from Uzbekistan and the four other Central Asian republics made up for a declining ethnic Russian population.
Now, as authorities try to unravel that legacy, the birthrate has dropped to about 2.3 children per woman — still higher than the rate of 2.1 that demographers consider sufficient to replenish a falling population.
The sterilization campaign involves thousands of government-employed medical doctors and nurses who urge women of childbearing age, especially those with two or more children, to have hysterectomies or fallopian tube ligations, said Sukhrobjon Ismoilov of the Expert Working Group, an independent think tank based in the capital, Tashkent.
The surgeon in Rakhimbayeva's case, a burly man in his 40s named Kakhramon Fuzailov, refused to comment on her claims and threatened to turn an AP reporter over to the police for "asking inappropriate questions."
In 2007, the UN Committee Against Torture reported a "large number" of cases of forced sterilization and removal of reproductive organs in Uzbek women, often after cesarean sections. Some women were abandoned by their husbands as a result, it said.
After the 1991 Soviet collapse, Karimov, a former Communist functionary, remained at the helm and retained many Soviet features, such as strict government control of public health. Government-paid doctors and nurses are assigned to each district or village.
Family planning is far different from Western norms.
Instead of focusing on raising awareness of widely available condoms or birth-control pills, the Health Ministry has chosen to promote uteral resections nationwide as the most reliable method of contraception.
Some women do volunteer. Khalida Alimova, 31, a plump, vivacious sales manager from Tashkent, agreed to a resection in March, almost a year after her third child was born.
She said her husband, Alisher Alimov, 32, an occasional cab driver who spends days playing backgammon with his friends, refused to use condoms or allow her to take birth-control pills.
"Now I feel relieved," Alimova said over a cup of green tea in the kitchen of their shabbily furnished Tashkent apartment. She added, though, that she never told her husband about the operation.
Many other women, especially from poor rural areas, say they face coercion from health workers or even potential employers to agree to sterilization.
A 31-year-old mother of two from the eastern Uzbek city of Ferghana said the director of a kindergarten where she sought a job told her to show a certificate confirming she had been sterilized.
After consulting her disabled husband, who receives a government pension of $40 a month, she said she agreed to the procedure, produced the certificate and got the job.
"We just had no choice," the woman, who gave only her first name Matluba, said by telephone from the eastern city of Ferghana. She refused to provide her last name or identify the kindergarten for fear of being fired.
Several health workers, who spoke on condition of anonymity also because they feared dismissal or persecution, said the authorities are especially eager to sterilize women with HIV, tuberculosis or a drug addiction. Instruments often are not sterilized properly and can infect other women, they said.
Inexperienced medical workers can also cause serious health complications. "Any negligence can do a lot of damage," said Shakhlo Tursunova, a gynecologist from Tashkent.
Health workers involved in the campaign are threatened with salary cuts, demotion or dismissal if they do not persuade at least two women a month to be sterilized, a former high-ranking Health Ministry official told the AP on condition of anonymity.
Veronika Tretyakova, a 32-year-old doctor from Tashkent, said she came under pressure from health workers to be sterilized.
"The nurse said, 'They would hang me if I let you have another child,"' Tretyakova said. "I told her to think about her soul."
Tradition plays a strong role in this male-dominated society, where a large family is seen as a blessing from God, and women are often blamed for childless marriages.
After checking out of the maternity hospital in Gulistan where she lost her son, Rakhimbayeva said she shared her anguish with her husband, Ulmas, a 29-year-old bus driver who refused to be interviewed for this story. Their marriage was arranged by their parents in 2008.
Instead of consoling her, she said, he told her to move back to her parents' house and wait for divorce papers as he did not want to live with a barren wife.
"He never even questioned why the doctors maimed me, just blamed everything on me," Rakhimbayeva said wringing her hands. "Now I have no hope of having children, no job, no future."