Prolapse Is Leading Cause of Poor Health in Women

By Kalpana Bhusal

KATHMANDU, NEPAL -- Lokmaya Maharjan, 83, is small, fragile. Her hands and legs are thin. Her body is stooped and her face is wrinkled with age. She looks breakable. She says she incessantly suffers acute back pain, can't walk properly and is plagued by problems with her reproductive system.

In 1955, three weeks after the delivery of her fourth child, Maharjan says she had to prepare wine for an upcoming Hindu festival. She carried heavy vessels of wine and performed other hard labor tasks. "I felt my stomach fall down. When I checked, a ball of muscle had come out. I was really scared to see it and then I just pushed it inside with my fingers," Maharjan says. Unknowingly, she, like many Nepali women, suffered uterine prolapse. More than fifty years later, she still feels the effects of the condition.

Uterine prolapse is a condition that occurs when the tissues and ligaments that support the uterus weaken, causing the uterus to descend into the vaginal canal. Tissues are weakened during childbirth, difficult labor and delivery, and multiple births over a short period of time.

Over the years Maharjan has spent many sleepless nights because of the pain in her lower back and abdomen. She recounts, "It [my uterus] used to come out while I was carrying loads, working at the farm and sometimes while I just walked. I always pushed it back."

Maharjan is one of many Nepalese women suffering from uterine prolapse, which remains the leading cause of ill-health among women of reproductive and post-menopausal age in Nepal today. A survey jointly conducted by World Health Organization (WHO) and the United Nation's Population Fund (UNFPA) in 2006, revealed that more than 600,000 women are suffering from uterine prolapse in Nepal. Though due to limited access to health care, ignorance of the condition, and poverty, the number is likely even higher. Nearly a third of the affected women, researchers say, need immediate surgery.

In Nepal, girls are married and give birth at an early age, which makes the prevalence of prolapse more widespread here. According to a survey conducted by UNICEF in 2004, about 40 percent of the women in Nepal get married before they reach 15 years of age while 60 percent get married between the age of 15 and 19. The reproductive rate of Nepali women is 4.1 per person and 21 percent women have children between the ages of 15 and 19.

Like many Nepalese women, Maharjan was married at age 17, in 1942. She delivered her first child in 1945 at the age of 20. Among the seven children that she bore, only five, three daughters and two sons survived. The other two died soon after their birth. She says she resumed her household work, like working on the farm, carrying heavy loads, fetching wood and grasses from the forest, and preparing wine, soon after the delivery of all her children.

Dr. Rajendra Gurung , a reproductive health officer with UNFPA, says, women with uterine prolapse often suffer from lower back pain, urinary disturbance, pain when defecating, incontinence, and foul-smelling discharge. "Uterine prolapse is curable, however, patients continue to suffer because of social stigma and shame," he says.

Despite the acute pain and discomfort Maharjan suffered, she remained ignorant of her condition for more than five decades. She says she learned the medical term and details of her illness only seven years ago when a volunteer from a community based reproductive health care and counseling center, PHECT, a local non governmental organization that works for to increase reproductive health care, visited her village to give counseling about uterine prolapse. She says a volunteer informed her of her condition and told her that her pain could be cured. Maharjan says she was thrilled to learn that there were treatment options available to her.

In 1999 she went to PHECT to explore treatment options, but her happiness was short lived. Doctors advised her to undergo an operation, which would cost 13,000 rupees, about $200 USD. She says she had no choice but to ignore the suggestion because she could not afford the operation. Instead she took her doctor's secondary recommendation, a ring pessery -- -a rubber-coated ring pushed up to the vagina to prevent the uterus from descending. This ring costs only about 10 rupees, about $0.70 USD. Since the ring needs to be changed every three months, experts say that women in Nepal do not often follow that reccomenation. "This might lead to infection and in extreme cases cause uterine cancer," Dr. Nafisha Malla, Reproductive Health Consultant at PHECT said.

While the ring prevents the uterus from descending, it does not prevent the pain that is associated with uterine prolapse. So a year ago Maharjan says the pain in her lower abdomen became so acute that she decided to take a loan of 13,000 rupees from her neighbor and admitted herself to the Nepal Medical College Kathmandu. But doctors refused to operate on her because of her age and fragile physical condition. Maharjan, disappointed, still uses the rubber ring. She says she regrets not taking the loan for the operation in 1999. "If I had operated on time, I would not have to live with this pain," she said.

Women with uterine prolapse wait to be seen by a doctor in Kathmandu.

Despite the physical discomfort, many prolapse sufferers do not seek help due to the social stigma and fear of being ostracized. According to an on-site survey conducted by WOREC, Women's Rehabilitation Center, a non-governmental organization working for women's rights in the eastern districts of Nepal, about 30 percent women suffering from the uterine prolapse do not share their problems with anyone.

Babita Basnet, a women's rights activist and president of Sancharika Samuha, a local NGO, says that the problem is aggravated because of the social structure and traditional beliefs of Nepal. "This is an unseen pain faced by many Nepali women," Basnet says. "Society views women with prolapsed uterus as inauspicious and impious and also because the illness is related to private parts, women do not talk about their problem." Basnet stressed that the government should provide proper facilities for treatment and should initiate new public awareness programs.

Arjun Bahadur Singh , a spokesperson for the Nepali government's Health Ministry, says that UNFPA and the government are working together to develop a three-fold national strategy to tackle uterine prolapse. It includes improved access to health care facilities for women of low-income, lower caste and women living in conflict areas. The program also aims increase mobile reproductive health camps. "We are very serious on this issue and we are trying to raise the awareness of people about uterine prolapse," says Singh.

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