Uterine Prolapse in Nepal: The Rural Health Development Project's Response

Messerschmidt£l

Abstract.

This paper describes Rural Health Development Project (RHDP)'s experience with women'shealth and uterine prolapse (UP) in three districts in Nepal. Gynecological and UP surgicalcamps are discussed and data analyzed in light of increasing interest in UP from a socialdevelopmentperspective. The findings indicate that non-medical contexts and factors play amuchmore significant role in UP than current literature suggests, both as causation as well assignificantlyinfluencing prevention and treatment success. The author links these findings tothegreater issues of women's empowerment andpoverty alleviation. Promising lessous fromthe RHDP experience are shared as an important component towards engaging in a moreholisticdialogue, and response, to preventing and treating UP.

.Key Words: genital prolapse, uterine prolapse, reproductive morbidity, gynecologicalmorbidity,maternal health, Nepal

I

Introduction

Reducing maternal morbidity, however,which causes untold suffering to milliousof women, is not accorded comparablepriorityl.Oneof the most common,but oftenhidden,gynecologicalmorbidities is uterineprolapse (UP). A progressive and chronicpublichealth concern, UP occurs when themusclesof the pelvis no longer support thepositioningof the uterus and it drops intothe pelvic cavity, and eventually descendsout of the vagina. Globally, 30% of allwomen who have delivered a child areaffected'.

Nepalhas a maternal mortality ratio of281per 100,000live births3.While this numberhasdecreased(from531 in 2001), it remainsoneof the highest in South Asia4.For everymaternal death, an estimated six to 15women face debilitating morbidity'.Population-based studies reveal thatbetween 9-35% of NepaIi women aresuffering from UP - some as young as 15,

and some for as long as 45 yearsl,6.7,8.Up to40% of affected women are of reproductiveage with only one child, and at least 200,000are in need of immediate surgicaltreatmentl.3,6,9,IO.

This paper focuses on the Rural HealthDevelopment Project's (RHDP) ExtensionPeriod and Phase VI (2006-2009) responseto UP in three districts of Nepal: Dolkha,Ramechhap, and Okhaldhunga. RHDP wasdesigned by the Swiss Agency forDevelopment and Cooperation (SDC) inNepal in 1991, as part of their ongoingbilateral agreement with the GovernmentofNepal.Methods

RHDP's Response to Uterine Prolapse inNepal

TheRuralHealth DevelopmentProjectaimsto improve the overall health status of ruralpeople of Dolakha, Ramechhap andOkhaldhungadistricts. Theproject doesthis

'Correspondingauthor:UeslMesserschmidl,Email:lies/.messerschmidlliiJamai/.com

by strengthening the linkages betweendemand and supply through positivelychanging health seeking behavior ofcommunitypeople, especially women, andcapacitating local health service providersto respond to priority health needs. RHDPutilizes participatory and inclusivemethodologies, working with localcommunitymembersandgroups,health careproviders and promoters, and systems andbodiesthatbringcommunitiesandproviderscloser together".

One urgenthealth priority identified by localcommunitymembers in RHDP districts wasUP mitigation. According to most medicaltextbooks, UP occurs in post-menopausalwomen who have had multiple vaginalbirths and large babies. Evidence fromdeveloping countries including Nepal,however, suggcsts that prolapse occurs inmuch younger womenl.2.5,7.9.IO.12.Contributing medical factors include earlypregnancy, multiparity, inadequate birthspacing, prolonged labor, large babies, andintercoursetoo soon after delivery,maternalmalnutrition, excess intra-abdominalpressure, and forced abortion 1.2.'.7.9.10. Aprogressive condition, first degree UP iscontrollablewith diet and exercises; secondand third degree managed by ring pessariesinserted into the vagina; and advanced thirddegree and procedentia cases treated byhysterectomy.

RHDPfieldstaffbecame increasinglyawareof the problem of UP due to the frequencysymptoms and side effects were raised inmother's gtoup discussions, and duringcommunity outreach activities. UP cancompromise basic daily activities such asstanding, sitting, lifting, and walking. It can

Journal of NetJalPublic Health Association :34.cause backache, difficulty urinating anddefecating,hemorrhoids,abdominalhernias,abdominal pain, unpleasant discharge,ulcers, and infection. It also increases theincidence of reproductive and urinary tractinfections fourfoldl'. RHDP's response toUP included organizing mobilegynecological 'camps' for rural women.Campswere collaborative efforts, involvinginput and resources from the project, theDistrict Health Office, other local andinternational organizations working in thearea, community leaders, local healthworkersand volunteers, andmother's groupmembers.

Results

During thirteen camps organized by theproject between July 2005 and December2008, 3675 female clients receivedgynecological services. In total, 1006women were diagnosed with UP, aprevalence of 27.4% (see Figure 1). Thisfigure includes a number of women whoattended camps, advertised as for allgynecological concerns, and were surprisedto leam that their prolapse wasnot 'normal'.Nearly 40% of UP cases diagnosed wereadvanced (third degree and procedentia),and nearly 53% of these required surgery,an indication of the rapid progression fromfirst degree to advanced prolapse amongstpOG:,rural women (see Figure 2 and Figure4). Concurrent diagnosis included urinaryand reproductive tract infections, cystocele,rectocele, infertility, abdomen pain,backache, decubitus, ulcers, andkeratinization'4.

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3). Of UP cases diagnosed, 60% areBrahmins, Chhetris and Newars, 28.7%Janajatis, and II % Dalits, a reflection ofattendance patterns. Sixty-four percent ofthird degree and procedentia cases wereBrahmins, Chhetris and Newars, 27%Janajatis, and 9% Dalits. However, of the42% of cases referred for surgery thatdropped out, only 38.2% were Brahmins,Chhetris or Newars, while 52.1% wereJanaj~~isand 39.6%Dalits.This underscoresthe fact that poor and disadvantagedwomenhave greater difficulty accessing andbenefiting from services. It also hints at thepossibility that, unintentionally, Janajatismay have been overlooked in the quest toimprove data on Dalits participation.

Figure 3: Attendance by District and Caste/Ethnicity at RHDP Camps

.I RHDPworks to ensure that all social groups

in catchment areas had equal access toproject activities, including UP Carl1.pSIl.Knowledge about upcoming camps wasconveyed to rural women and women'sgroups through village health workers,pampWets, FM radio spots, and RHDP'sown community health workers, whotargeted poor and disadvantagedcommunities. Despite these efforts, camputilization by poor Dalits (occupationalcastes, typically suffering socialdiscrimination and exclusion) and ethnicJanajati minorities, was overshadowed byhigh participation from privilegedBrahmins,Chhetris, andNewars (see Figure

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Journal of NetJalPublic Health Association :36Figure 4: UP Cases by Specification at RHDP Camps

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At RHDP camps, UP ranged in women from 18to 74 years of age (see Figure 5), with half ofcases occurring in women between the ages of 31-50, the peak of their productive andreproductive years (see Figure 6). In Okhaldhunga, the mean UP client age was 49.85, butwhen broken down by ethnic distribution, the mean age for Dalits was 40. This is muchyounger than for Janajatis, whose mean age was 46.7, or Bralunins, Chhetris and Newars,whose mean age was 52.4. Dalit women, suffering greater hardship at the hands of poverty,are clearly engaging in activities that aggravate their UP more than other, less discriminated,groups.

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JournalofNert/PublicHealth Association :37MostUPclientshad sufferedfor 11-20years fiv~ chi .en, at h~me, and mostly WithOutbeforeseekingcare, with 3% sufferingover skilled buth assistance. This was not41 years (see Figure 7). Of those dropping ~aseb?ok,howeve~,for severalwomel!wereout of surgery, most (55%) were between IIIthelf earlytwenties, having deliveredonly21 and 50 years of age. In Okhaldhunga, one child. Only 6% had received antenatalmostUPclientshaddeliveredtheirfirst child care checkups. Many described the use ofinearlymarriage, between 14 and 18years foreignobjectsto 'force' deliveryof thebabyof age.The majority of women aged 21-30 andplacenta. Mostclaimed to have resumedpresentedwith first degree UP, while those regular domestic chores within the first few41-50 presented with third degree UP. On days after delivery. All these activitiesaverage,thirddegree UP caseshaddelivered aggravate UP.

Figure 7: Number of Years Suffering UP at RHDP Ramechhap andOkhaldhunga Camps

Whilethese examples come directly ITORHDPexperience and literature review 0otherstudies conducted in rural Nepal, th,broadercategories are true for women, an(especiallypoorwomen,well beyondNepal'

jborders.

. Early marriage. According to th2006 Nepal Demographic andHealth Surveys, 60% of women aremarried by the age of 183. Fortypercent of Nepalese women havegiven birth to at least one childbeforethe ageof19!5.Earlymarriageleads to early childbearing age anda greater number of lifetimepregnancies.

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Discussion

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pregnancy,and resumeswithin a fewdays of childbirth. The struggle fordaily survival means that ,mosthouseholds cannot subsist without awoman's laborcontributionformore

than a few days!o.

Gender devaluation. Nepal has oneof the highest son preferences in theworld'.. This results in womenhavingmultiple birthsand shortbirthintervals, in the repeated attempt fora boy.The low social valueaccordedgirls and women influences gender-based violence. Genderdiscrimination also leads to alifetime of inadequate nutrition inboth quantity and quality of food,and high maternal malnutrition".

. Female labor burden. Women inNepal work 11-16hoursa day,muchhigher than the global average, and3.1 hours more than menI6.17.18.Thisincludes demanding agriculturalwork in addition to physicalhousehold chores. Heavy work andmanuallabor often continues during

--- - -- Journal of NepalPublicHealth Association .'i8. Improper pregnancy and birthing Socio-Economic Lessons and Solutions

practices. Only 53.4% of ruralwomen receive prenatal care, and18.8% postpartwn services. Withmore than 81% of births stilloccurring at home, very fewdeliveries are assisted by a skilledbirth attendant'.15.Some untrainedassistants apply significant pressureto the lower abdomen during laborto 'force' the birth and expel theplacenta. Following delivery, it iscommon for the new mother toreceive massage, but a masseusecanunknowingly apply too muchpressure to the pelvic region.

. Poor health-seekingbehavior.Nepallacks sufficient, appropriate, andaccessible prenatal, delivery, andpostpartum care. Inaccessibilityrefers to the types of practitionersand services provided, facilitylocations, financial and opportunitycosts, perceptions of quality andreliability, degree of outreach andfollow-up, etc.Additionally, there isa lack of promotion and awarenessraising around 'women's' issues.Subsequently,girls andwomen havepoor health seeking behavior.Eighty-three percent of ~omensuffering UP did not seek treatmentuntil it was advanced, and mostsuffered 21-30 years7.8.

Causative Contexts

These cultural practices play out to varyingdegrees within a socio-economic contextinvolving a (i)patriarchal and caste-basedsocial structureguidinglocal belief systems,nonns, values, behaviors, androles; and, (ii)widespreadpoverty.

Development workers in the field of publichealth know what medical practitioners arebeginning to appreciate - that the onlysustainable way to reduce the incidence ofUP requires going beyond the medicalcauses, to the 'sources' of the issue. For areal andsustained impact, development andmedical responses need to work in tandem,taking into consideration the socio-economic practices and contexts that affectwomen's reproductive health13.

Learningsfor Prevention

MostNepalese women are aware of UP riskfactors, including early child bearing age,heavywork duringandfollowing pregnancy,pressure on the lower abdomen duringchildbirth,lack ofpostpartwn care, improperdiet, and multiple birthsI3.Women are alsoaware of preventive practices, includingpostponing marriage, using family planningto space andreduce pregnancies, restduringpregnancy and postpartum, eating .anutritious diet, and having skilled birthattendance8.I3. This is largely due toawareness raising and outreach programsconducted by community health promoters,female health volunteers, and mother'sgroup.

Sustained attention to prevention demandsaction at all levels, including at the healthpolicy level. In 2006, RHDPjoined with 32organizations (donors, non-govennnentalorganizations, networks) to form the UPAlliance (UPA), with a national advocacyagenda. The UPA plays an wnbrella role,working on:

. UP policy

Journal of NepalPublicHealth Association 39. Providing programmers--- 'with RHDP camp medical personnel began to

informational and educational teach women how to regularly remove,materials for community awareness clean, and replace the rings themselves,raising rather than expect them to make frequent

. Training health care providers to trips to health facilities. Through the UPA,detect cases early before surgery is RHDP is campaigning to list UP as anrequired Essential Health Care Service, and ring

. Incorporating UP messages into pessaries as an 'essential' medical supply,relevant higher secondary school ensuringthey arestockedat allhealth facilitycurriculum. pharmacies.

. Advocating for the inclusion of UP S . It I.h I h I.. d .. OCIO-CU ura

In ea t po ICles an strategies,where it currently is only mentionedas a reproductive health problem ofpost-menopausal women13.19

In 2007,they drafted a National StrategyonUterineProlapse.Unfortunately,internalandpolitical conflict seems to have reducedUPA's initial momentum, stalematingactivities.

Learningsfor Treatment

Unlike prevention, very few NepalesewomenknewaboutUP treatments, and 83%did not seek treatment until they hadadvancedprolapsed'. In the absence of anational prevention and awareness-raisingagenda,myths and rumors blaming womenfor UP are rampant. Unchecked, theserumors discourage women from seekingtreatment.

RHDP'sapproachwas prevention first, butwheretreatmentwas mandatory,the projectpreferredto counselwomen about exercisesanddiet,and insertringpessaries,rather thanconduct hysterectomies. Ring pessaries,while simple and ingenious at managingmoderateUP,require frequent cleaning andreplacement to prevent infection. Afterdocumentingcases of women wearing ringpessariesfor ten or more years because theywere unable to obtain maintenance care,

. Time and location: Initial RHDP

gynecological camp lengths wereone day, which resulted in theturning away of many would-beparticipants due to lack of time.Additionally, referral clients faceddifficultiesattending surgicalcampsbecause of seasonallabor demands.Early on, RHDP increasedgynecological camp length to threedays, and planned camps in centrallocations, to increase accessibilityand participation, and follow-upsurgicalcamps were scheduledinthewinterto avoidpeak agriculturalandrainy seasons. In Dolakha, RHDPimplemented a voucher syst~mforreferrals after finding that one-offcamp-based surgeries were notconvenient for many clients.

Social stigma: UP is associatedwithwidespread stigma anddiscrimination against womensufferingfromUP.Toovercomethis,RHDP stopped calling camps 'UP'camps, and instead advertised themas 'gynecological' camps, whilequietly maintaining the UP focus.This additionally encouraged morewomen to attend, andresulted in the

.

. Journalof NevalPublicHealthAssocia'!;ion40camps capturing a larger number of aavocatcs, much of the fear andUP cases. misinformation was countered, andu Ith d I' d h Ith k ' women were more apt to complete£lea e lvery an ea -see mgb h

. St d' t' .

h treatment.e aVlor: rong coor ma IOnWit

political parties and local medialhelped to overcome the negativeinfluence a decade of internalviolenceand political instability,andpoor health delivery, had on health-seekingbehavior.Collaboration withother organizations working in thedistricts tapped additional resourcesand audiences.

Gender, ethnicity, and language:Most surgeons are male, speakNepali, andare fromprivilegedcaste/ethnic groups. These factors arepotentially intimidating for manyrural women who hesitate to havemale practitioners address their'female' problems, may have faceddiscrimination by 'elite', and mightspeak Nepalese poorly as a secondlanguage.RHDP,therefore, made aneffort to have female gynecologistsandsurgeonswhenever possible, andlocal interpreters (such as femalecommunityhealth volunteers), to actas an interface with providers -answering questions, and explainingthe risks of incomplete treatment.

.

.

. Terminology: For many women andfamilies, the term 'operation' inNepal is feared as synonymous withdeath. Women reported seekingsurgicaltreatmentonlyas a lastresortafter trying many traditional, andsometimes dangerous, remedies.RHDP found that engaging localwomen who had successfullyundergone surgical interventions asspokespersons and surgery

Financial

While RHDP and partners underwrote thecost of each surgery, they were unable tounderwrite the many other secondary costsincluding transportation, food, time awayfrom work, and reduced agriculturalproduction. The importance of thesesecondary costs were particularly telling inOkhaldhunga, where surgical cases wererequiredto travel to Manthali inneighboringRamechhap District for the actual surgeries.An astounding 50% of Dalits, 72.5% ofJanajatis, and 75.4% of Brahmins, Chhetrisand Newars never appeared for surgery,Tofind a solution, RHDP explored ways ofmobilizing mother's groups and linkinggroup revolving funds to UP activities,allowingpoor and discriminated womentheopportunityto take lowinterest loans tohelpcover secondary costs. RHDP also lookedat ways to reduce transportation expenses.At a higher level, RHDP's efforts throughthe UPAresulted in the Ministry of Healthand Population allocating funds for 12,000women to obtain free hysterectomies foradvanced UP during the fiscal year mid-2008 to mid-2009. .

Uterine prolapse is a ch ronic andprogressive condition affectingup to a thirdof Nepalesewomen. 'Hidden' due to shame,fear, and a belief that prolapse is 'normal',studies of UP were rare until a few yearsago. Most studies of UP are from a clinicalperspective, attempting to flush out theprevalence, etiology, and risk factors. Veryfew studies look at the socio-culturalpractices and contexts affecting and/or

Journalof NepalPublicHealthAssociation 41mf]uencmg UP. RHDP's experience m thedistricts of Dolakha, Ramechhap andOkhaldhunga, Nepal, demonstrates theimpactthese factorshave on preventionandtreatment-seeking behavior, a messagereinforcedby their data from UPcamps.Thelack of non-medical information on thecontributi!lgpractices and contexts of UP,in Nepal and elsewhere, encourageswidespread misinformation and adherenceto damaging socio-cultural practice's.Comprehension of the role of socio-economicfactors and gender discriminationon UP is needed to reduce stigmatization,advocatepro-women policies, and improvehealthcare delivery and behavior.

There is no argument that UP has anoverarching and negative effect on allaspectsof a woman's life. "In that there willalwaysbe women, and there will always bepoorwomen,and at least for the foreseeablefuture in Nepal, there will be poorundernourished women engaged in hardlaborwithscant access to health care, whichthey cannot at any rate afford in terms oftime... or money..., (UP's) impact is akinto that of an infectious disease"lO. Only aholisticapproachthat considerseducational,socio-cultural, religious, and economicaspects of health care; that focuses onprevention,earlymanagement,andresearch;and that includes collaboration between

public, private, and non-profit bodies andinstitutions,will succeedin reducingUPandotherfemale morbidities2°.

-

Acknowledgements

The authorthanks SDC/RHDP for supportinpreparingthis article. She also thanks toHarka Thapa, Srijana Rai, Dambar SinghGurung,Santi Shrish, Kedar Nath Bhatta,SunilGurung,Renuka Rai,Apsara Khadka,

Khyam Bahadur Bishwokarma, andDandiram Bishwakarma.

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