KATHMANDU, NEPAL – After eight years of living with a prolapsed uterus, Pritimaya Shrestha, 66, is finally receiving medical treatment. She lives in the remote hills of Nepal some 600 kilometers (370 miles) from Kathmandu. Now, Shrestha has traveled to the capital to seek the care she has waited nearly a decade for.
Her face is wrinkled and adorned with a nose ring, and her body is starting to stoop with age. Shrestha says that she has been suffering from back and lower abdominal pain for years, and when she started bleeding, she asked her daughter Tika to accompany her on the journey to the capital.
“I fear that I would be looked down upon due to my problem,” Shrestha says with a sigh. “Therefore, came only when my daughter promised that she would not tell anyone about my problem.”
Shrestha, who spent most of her life farming and rearing cattle, says she began to suffer from mild prolapse nearly a decade ago. Still, she worked with a lump protruding from her vagina.
“I had to push that lump of muscles 20 times a day inside the vagina,” Shrestha says.
Then a buffalo hit her three years ago, worsening her condition. She says that she fell to the ground, leading to the complete prolapse of her uterus. She was terrified at first but didn’t seek help because of the stigma attached to uterine prolapse, Shrestha says.
Dedicating her life to tending to the needs of her family after getting married at age 15, Shrestha says she used to think that she would have a better life in her old age. She had no idea that her toils would lead to her current condition.
She says that the doctor she consulted at Kathmandu’s Prasuti Griha Government Maternity Hospital also attributed her condition to lack of prenatal and postnatal care surrounding her seven pregnancies. She says she knew about this care but never obtained it.
“I gave birth to seven children with two years’ birth gap in each case,” she says, further wrinkling her face in distress. “I used to easily carry load of 50 kilograms (110 pounds) even in my post-pregnancy period. And now I cannot even sit properly.”
Many women in Nepal, especially in rural areas, suffer from uterine prolapse. Doctors attribute this condition to various causes, including poverty, heavy labor, lack of prenatal and postnatal care, inadequate birth spacing and a social stigma that prevents them from obtaining medical care. But health professionals say that this is changing, noting an increase in the number of women seeking treatment for uterine prolapse. The government, nongovernmental organizations and hospitals have been collaborating to offer free treatment at medical camps, with doctors stressing nutrition and ring pessaries over surgery.
Uterine prolapse is the condition in which the uterus falls from its normal position and, in more severe cases, protrudes out of the vagina, says Dr. Aruna Shakya from Kathmandu Model Hospital, a private hospital in the capital.
More than 600,000 women in Nepal suffer from uterine prolapse, and nearly 200,000 are in need of immediate surgery, according to 2006 research by the United Nations Population Fund, the World Health Organization and Tribhuvan University’s Institute of Medicine.
Like Shrestha, Kishori Rana, 45, also suffers from uterine prolapse.
Married when she was 18, Rana says she gave birth to two children before age 24. Rana says she hardly had time to recuperate after the deliveries before she had to resume her household chores. For example, she had to walk six kilometers (3.7 miles) every day to fetch water for the household and to collect wood from the jungle for fuel. She says that it was during one of these ventures that she felt a lump of organ coming out of her vagina.
“The lump comes out while I sit, and I have to push it back with my hands while standing,” she says. “Sometime[s] it comes out while walking and gets wrapped in my clothes. It is really frustrating.”
Rana says that her husband did not show any interest in her condition. Rather, he demanded regular sexual intercourse with her, which she says aggravated it.
“Men only want sexual satisfaction – nothing else,” she says vehemently.
But she says that she didn’t take her condition seriously either, thinking it was natural.
Like Shrestha, she also waited 10 years before she sought medical help because of the stigma attached to the condition.
“What would people say if they find out?” Rana asks. “I may be an outcast.”
She was forced to acknowledge her problem when she started having back and abdominal pain and it began to hurt while urinating. Rana says that it also made her feel physically weak.
Rana tried to visit free medical camps in her village in Lamjung, a district in Nepal’s Western region.
“I walked to the place where the medical camp was happening twice but couldn’t get a chance to consult the doctor,” she says.
Luckily, a friend who had obtained a checkup and had learned what to look for examined Rana and informed her that she had a prolapsed uterus.
When she started having difficulty sitting and standing, Rana decided to travel to Kathmandu for proper treatment. She initially wanted to have surgery but then opted for a ring pessary, a less invasive measure.
Dr. Nilima Bajracharya, Shrestha’s doctor at Prasuti Griha Government Maternity Hospital, says that a specialist needs to change the ring every three months.
Rana says she believes that her situation will now improve.
Shrestha and Rana are representatives of a wider population who suffer from prolapsed uteri in Nepal. Shakya cites various causes, including poverty, lack of awareness, uterine infection, early pregnancy, lack of postpartum care and lack of spacing between births.
She says that the lack of timely medical intervention because of the social stigma attached to the condition also exacerbates it. In rural areas, women especially delay seeking medical intervention because they consider uterine prolapse a natural process in a woman’s life.
In rural areas, it is a daily routine for women to be involved in taxing domestic work, says Samita Pradhan, director of Women’s Reproductive Rights Program, a nongovernmental organization that takes a preventative and treatment-based approach to addressing the high incidence of uterine prolapse in Nepal. She attributes this burden to the traditional patriarchal concept that women are solely responsible for all household work.
She adds that the society gives more preference to male children, leaving girls without the proper care that they need.
“When women do not get proper medical treatment in their villages, they use pieces of bangles and slippers to hold their uterus inside their bodies,” she says.
But this is beginning to change, as health professionals note an increase in women seeking care for uterine prolapse.
Nearly 170 females received treatment for the condition at Prasuti Griha Government Maternity Hospital during the past year. Rudra Prasad Dhungana, a health assistant at the hospital, says that more women are overcoming the stigma attached to the condition in order to seek treatment.
“The number of patients has increased,” Dhungana says.
Nearly two dozen women now come to the hospital every month to seek treatment for uterine prolapse.
Medical experts attribute the increase in women seeking help for uterine prolapse to the gradual change in attitudes toward this condition, says Om Khanal, health assistant at the Ministry of Health and Population’s Family Health Division.
The government, nongovernmental organizations, and public and private hospitals have also been collaborating in recent years to address this issue. Their main initiative is free treatment camps throughout Nepal.
The Safe Motherhood Network Federation, a Nepal-based federation of nongovernmental organizations, has organized several national conferences on safe motherhood. Special workshops and discussions at these conferences led in 2007 to the Uterine Prolapse Alliance, which helps to conduct the treatment camps.
But Dr. Aruna Upreti, a gynecologist, voices concern that nongovernmental organizations don’t follow up with patients after surgery, which can lead to infections. Some gynecologists say the organizations focus more on quantity than quality, using women’s conditions as a medium to acquire foreign donations.
Pradhan acknowledges difficulties in follow-ups but denies the latter allegations.
“There are some complication regarding follow-up,” Pradhan says. “But it’s not like in the way people are blaming. We are getting proper support from the government in every cas[e] we handle. It’s not the earning business, so we do not compromise with the health of the people.”
The government of Nepal has also been collaborating on the free medical camps to treat uterine prlapse, Khanal says.
Khanal says that the government carries out district-level surveys to find out the number of women suffering from the condition in order to organize the medical camps. The Regional Health Service Directorates manage the finances for the treatment, and 13 private hospitals provide the services. The government provides incentives to these hospitals to participate: The hospitals working in the mountainous region receive 5,000 rupees ($57) per patient treated, 3,000 rupees ($34) per patient in the hilly region and 1,500 rupees ($17) per person in the flat region.
Kathmandu Model Hospital is one of the private hospitals that provide medical assistance in these camps. First, the hospital staff checks the level of the dislocated womb. According to the level of dislocation, they diagnose the severity of the condition and do the surgery on site if needed.
Shakya of Kathmandu Model Hospital says that the women who come to the camps range in age from 18 to 80, though the majority are in their mid-40s and come from rural areas.
The government has been surpassing its targets in recent years, Khanal says. Whereas only 2,307 received free operations of the target population of 12,000 in 2008 to 2009, 9,728 received operations the following year, and 14,044 received operations last year. In the current year, 6,618 have received treatment so far.
The government also provides travel allowances to patients who have to travel long distances to obtain treatment at the camps, Khanal says. The patients receive 1,500 rupees ($17) if they come from the mountainous region, 1,000 rupees ($11) in the hilly region and 500 rupees ($6) in the flat region.
Still, many women like Shrestha say they are not aware of these camps.
“I live in a very remote village,” Shrestha says. “I have never heard about such camps. Therefore, I came to Kathmandu for treatment.”
Pradhan also criticizes the government’s focus on surgery as the medical treatment for uterine prolapse in these camps instead of alternatives such as the ring pessary method.
Shrestha says that the doctors in the government maternity hospital advised her to obtain surgery in one of the private hospitals, but she decided to obtain a second opinion. Because of her age, Bajracharya has advised her to instead use a ring pessary. Shrestha says she just began to use it and is looking forward to the results.
