Uterine Prolapse in Nepal

“I gave birth to my first daughter and after six days, I went to bring millet from the farm. I was carrying the load of millet and I felt that something was coming out [of my vagina]… My husband treated me indifferently. He used to say: ‘I am not satisfied with you, I will bring another wife’.”

-Kesar Kalla Malla (see Amnesty International’s 2014 report)

What is Uterine Prolapse?

Uterine prolapse is a debilitating form of pelvic organ prolapse that occurs when the muscles and ligaments that support a woman’s uterus are weakened, resulting in the descent of the uterus from its original position within the body. Uterine prolapse (UP) is recognized as a form of maternal morbidity, and can be classified in terms of severity. While first and second stage prolapse may be treated with specific exercises which strengthen the pelvic floor or by the insertion a small low cost medical device called a ring pessary, severe prolapse requires surgical intervention in the form of a vaginal hysterectomy or pelvic floor repair surgery.

obgyn-uterine-prolapseUterine prolapse is both a global health problem and human rights issue which has yet to be sufficiently addressed by the international community. While typically thought of as a condition which mainly effects women beyond reproductive age, in Nepal there is a multitude of sociocultural and economic factors that exasperate the prevalence of UP amongst women both young and old. To illustrate, in the United States, the average age that women seek medical treatment for uterine prolapse is 61 (Amnesty International, 2014). In Nepal, according to a study carried out by the UNFPA in 2013, the median age at which Nepali Women first experience uterine prolapse is 26. While it is difficult to say exactly how many women in Nepal experience UP, a 2007 study carried out by the Center for Agro-Ecology and Development found that over 1 million women in Nepal suffer from the condition, many of whom require surgery and 40% of whom are of reproductive age. Moreover, the prevalence of UP within different districts varies significantly, with rates having been documented as reaching over 40% in some districts.

Uterine Prolapse in Nepal: Causes and Consequences

The causes of the high prevalence of uterine prolapse in Nepal are complex and manifold. Within Nepal, there are various sociocultural norms that expose women to multiple risk factors that decrease the age at which prolapse occurs, and increase the prevalence of the condition within the country. Nepal is a patriarchal society, within which gender has immediate implications for health and wellbeing throughout one’s life course. UP in Nepal is also exasperated by poverty and limited access to adequate health care services. While many women in Nepal experience uterine prolapse after having given birth, women who have never been pregnant may also experience the condition at all degrees of severity.

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Nepali women’s work burden is 12%-22% greater than that of men’s

According to the World Bank, only 55.6% of births in Nepal are attended by skilled health staff (2014). This lack of access is particularly evident in rural regions where 81% of the Nepali population lives (WB, 2015). A lack of access to skilled health workers means that many Nepali women are exposed to harmful birthing practices that heighten their chances of experiencing UP later in life. Moreover, women in Nepal make up the backbone of familial structures; their work burden is between 12%-22% greater than that of men’s (Earth & Sthapit, 2002). Nepali women are expected to work both throughout and shortly after their pregnancy. Reproductive organs require at least 6 months to heal post-delivery, but within many ethnic communities it is expected that women return to extremely arduous tasks as soon as a week following delivery. Moreover, cultural norms mean that many women are nutritionally deprived post-delivery. Finally, a lack of access to healthcare also means that it is difficult for women experiencing UP to seek treatment.

The development of UP, if left untreated, leads to severe pain and discomfort. In many instances these symptoms may manifest as painful intercourse, an inability to sit, walk, and/or stand, difficulties urinating and defecating, odorous discharge and an inability perform daily tasks. Women in Nepal who suffer from UP often experience emotional and physical abuse from their family and or community because of the stigmatization surrounding the condition. In a 2013 UNFPA study which interview 357 women who underwent surgery in Nepal to treat UP, 80% of women said that after having developed the condition they lost hope in life. Depending on the district, between 5% and 23% of women said that “their mother-in-law and family members started hating them” (UNFPA, 2013). Owing to the ostracization and stigmatization that women with UP in Nepal experience, many choose to conceal the condition, living in severe pain and discomfort, sometimes for decades. Care Women Nepal has spoken with women who have been living with uterine prolapse for over 10 years, inserting cloth into their vaginal canals to hold their reproductive organs in place and prevent the secretion of bodily fluids (see Morgan Moses’ 2016 Blog).

Care Women Nepal: Addressing and Preventing Uterine Prolapse

The lived experiences of women in Nepal have long gone largely unacknowledged by the Government of Nepal and the international community alike. Although there are many community based organization in Nepal such as Care Women Nepal and The Women’s Reproductive Rights Program that work tirelessly to advocate for the reproductive and sexual health rights of women in Nepal, efforts to prevent and treat uterine prolapse remain dismal. Despite a groundbreaking Supreme Court case in 2008 in which uterine prolapse was formally declared for the first time, nationally or internationally, to be a human rights issue, the government of Nepal has yet to put in place a “strong, effective and comprehensive plan for uterine prolapse that addresses the underlying gender discrimination [that perpetuates the condition]” (AI, 2014).

In response to the 2008 case, the government of Nepal pledged to provide hysterectomies free of charge. Today, while the government does issue quotas for a certain number of subsidized surgeries per year, these quotas are not sufficient for all women in need of surgery to receive it, and do not cover the cost of transport to and from surgery (approx. 100 USD in the case of women from Dhankuta who must travel to Biratnagar), counselling, medication (approx. 30 USD) or food (approx. 40 USD) for women who must travel long distances to access a medical facility with a gynaecologist.

Mother and Daughter
Dhanmaya Limbu and her daughter Manusha the day after Dhanmaya’s hysterectomy. She had 5 children after the onset of her uterine prolapse due to pressure from her husband

Care Women Nepal covers the cost of as many surgeries as possible, as well as the costs of transportation, medication, and food for a woman undergoing surgery and her loved one.

Care Women Nepal acknowledges the need for a broad coordinated response on the part of government ministries, INGO/NGO’s and community based organizations to ensure that women and men alike are aware of women’s reproductive health rights, the risk factors for uterine prolapse (and how to reduce exposure to said factors), and the harmful impact of gender discrimination on all facets of women’s lives. Care Women Nepal hopes to play an increasingly large role in the process of raising awareness, preventing UP and supporting the treatment of women suffering from the condition.