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Published by Unheeded Agonies Women's Reproductive Rights Program (WRRP)
A Study of Uterine Prolapse Prevalence and it's Causes in Centre for Agro-Ecology and Development (CAED) Siraha and Saptari Districts, Nepal Post Box 4555, Kathmandu, Nepal Phone: 0977 1 6632942 Email: [email protected]
September, 2007
Citation: Pradhan, S. 2007. Unheeded Agonies - A Study on Uterine Prolapse Prevalence and it's Causes in Siraha and Saptari Districts. Women's Reproductive Rights Program (WRRP), Centre for Agro-Ecology and Development (CAED), Kathmandu, Nepal.
Supported by Fastenopfer-The Swiss Catholic Lenten Fund Luzern, Switzerland. www.fastenopfer.ch
Photoes by Women's Reproductive Rights Program (WRRP) WRRP/CAED Center for Agro-Ecology and Development (CAED)
Kathmandu Cover Design by 2007 Pramod Dahal with friends
Cover Sketch by Anonymous
Layout Design by Bimal Bogati
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Acknowledgement Executive Summary
On behalf of WRRP/CAED, I would like to thank the respondents, who, despite their busy time, provided hours of their valuable time to Reproductive morbidity is one of the major problems faced by Nepali tell us about their problem to make us understand their situation women. Uterine Prolapse (falling of womb) is one of the poignant issues better. This research is dedicated to them. Special thanks go to the of reproductive health. It is a consequence of multiple pregnancies intertwined with abject poverty and discriminatory practices against enumerators Ambika Devi Chaudhary, Bhikni Devi Chaudhary, women in the society. Based on two districts of eastern terai, this Sapeta Urau, Eklas Mahara, Devanti Devi Bhagat, Amkula Yadav, research seeks to understand the relationship and its intensity amongst Asha Kumari Chaudhary, Sabita Kumari Singh, Bina Devi these components. Chaudhary, Chanita Chaudhary, Meenadevi Koirala, Gita Devi Ram, Ranjita Chaudhary, Nirmala Chaudhary, Shanti Devi Ram, Arhul With a total population of some 53,000 and 60,000 in Siraha and Saptari Devi Mandal, Tirtha Maya Mandal, Safala Neupane, Beli Devi Ram districts respectively, a total of 24 VDCs in Siraha and Saptari districts and Bhola Bishwakarma, who went door to door collecting were selected for the study area. It is inhabited by Dalits, Tharus, information facing a variety of situations - not always pleasant, using Muslims, Brahmins and Chhetris. Survery areas were chosen based on local languages, knowledge and contacts. the density of dalits and indigenous peoples. A little more than 60% of Tharus and 40% of dalits of their total population were incorporated in I appreciate the contribution of my colleagues at WRRP - Moti Rai, the study. Enumerators could speak Maithili and Tharu that are the Ram Kumari Chaudhary and Chhatra Tembe without whom the most widely spoken languages of the area. The economy is whole idea would not have gone into action. Special thanks go to predominantly agricultural with significant number of agricultural the partner organizations from Siraha and Saptari districts for their laborers. The districts score low in human development and gender every efforts including logistical support during the survey period indices. (names in Annex III for lack of space here). The survey covered a total of some 2,300 households, (that is just We are very much thankful to Tej Adhikari, who helped in under 10% of districts total population), where married women were processing and analyzing the data using SPSS package and Teeka respondent from the age group of 16 to 60 years representing different Bhattarai, who constantly encouraged and supported us by social groups, including dalits, indigenous groups (janajati), Brahmins providing his comments and suggestions during research and report and Chettris. The c lustered stratified sampling method was used to writing. ensure representation of different ethnic groups.
We wish to thank Cherry Bird and Nicole Farkouh for editing English Uterus (or uterine) Prolapse (UP) is widespread chronic problem as well as for their comments and suggestions on the report. amongst women - an ignored major public health issue in Nepal. UP is defined as falling of the womb, when the muscles of the pelvis are We like to thank the all the audience who took interest and gave strained to a point where they can no longer support the positioning of input on the report during the presentations of findings of the the uterus. The uterus drops from its normal position in the pelvic cavity, research at various occasions. descending into and eventually, in extreme stages, out of the vagina. It
Finally, we would like to thank Rene Wuest of Fastenopfer - The is a progressive condition that typically occurs in post menopausal women in most countries. However, it can also occur in younger women Swiss Catholic Lenten Fund, who helped making this research (SMNF, 2005) which happen frequently in Nepal. possible and gave WRRP/CAED an opportunity to bring out the findings on uterine prolapse on the discourse of gender issues and For women living with uterus prolapse, life’s basic activities are a the public health. challenge. Urinating, defecating, walking, standing and sitting are
Samita Pradhan difficult and painful. Despite the occurrences being alarmingly common, Principal Investigator the women who suffer are awfully (kept) silent. Many women believe (Member-Secretary of the Board) (or made to believe) that reproductive health problems are women’s fate September 2007 and falling of uterus is part of being a woman.
It is not known what portion of country's women exactly is suffering from what level of uterus prolapse in what geographical settings. Literature
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indicates in the range of 9% to 35% at varying degrees are suffering from it. It used to be believed that women in the western hills of Nepal Apparently, the role of education has been found to be quite strong in suffer from prolapsed uterus more than the women in other parts of the the study: almost all the women who were illiterate were suffering from country. One of the objectives of this study was to enumerate the UP. Women who do not have access to education are more prone to intensity and map the distribution of prevalence of uterine prolapse in prolapsed uterus. the study area. The specific objectives of the study were: 95% of the women gave birth without trained assistance. Although some To find out the prevalence, characteristics and factors causing of the women reported being subjected to pressure for expelling uterine prolapse in Siraha and Saptari districts. placenta and being affected by UP afterwards, no clear conclusion if this To test the following assumptions regarding UP, for a better is an important cause of UP could be drawn. Available national and understanding: international studies albeit limited state one major cause of uterus • Prevalence of UP is lower in more accessible areas. prolapse is intra-abdominal pressure during child delivery. • Patriarchy is a root cause of UP. • Poverty and ethnic background affect UP prevalence Just over 75% of the women with UP reported occurrence while lifting or • Frequent child bearing is an important factor of UP. carrying heavy loads, collecting water, chopping firewood, husking and pounding rice. They also mentioned its occurrence immediately after The nature of the research is exploratory and descriptive. The study childbirth. Heavy workload appears to be the most direct cause of UP, was carried out through mainly qualitative and few quantitative which points to a need for information and gender education within questions. Since uterine prolapse is a socially sensitive issue, local families. This indicates that lack of attention to women’s health needs, bilingual women were mobilized in support of local organizations. aggravated by discriminatory practices is a root cause of UP.
Findings Over a half of the women first discovered (realized to have come out) An average prevalence of uterine prolapse in Siraha and Saptari was UP when squatting although there is no enough evidence that squatting found to be 37%, Saptari with an astonishing figure of 42%, higher than attributes to UP. It does nonetheless suggest that working in squatting any other district studied by CAED. The findings of this study therefore position is not good for women. challenge the widely held 'belief' that UP is not highly prevalent in the terai, compared to western hills. It strongly indicates a high prevalence It is not that women do not speak out about their problem. Over half of of UP in all parts of Nepal whether it is hills or terai, or the west or the the women said they did tell their husbands about their prolapsed east. The study shows that women from all social groups suffer from uterus. A 57% of their husbands did not show any reaction to this prolapsed uterus, with those from dalit communities having the highest information. This strongly suggests the lack of concern for a “women’s prevalence in comparison to the terai indigenous groups (mostly Tharu) problem” and the need for a rights based approach to UP, enabling and other terai groups such as Brahmin, Chhetris, Thakurs, Telis and more women to speak and obliging men to listen and support. Halwais etc. Women of all ages including relatively young were found to be affected. Recommendations Uterine prolapse should be considered an important public health issue The hypothesis of multiple and frequent child birth as the major cause of and dealt accordingly. It must be taken as a part of Safe Motherhood UP is not supported by the findings of this study, as a large number of and Reproductive Health. There is no provision for UP affected women women with UP (nearly 60%) suffered first onset after giving birth to to receive services from local health posts. UP must be included in the their first or second child. Rather it suggests early child bearing among list of Essential Health Care Services, so that the women can obtain the most important causes. In some cases the first delivery was found basic clinical and counseling services at health posts. Health workers to have been at a very young age - as young as 14. Just over 60% of should be provided with orientation and training on both preventive and women with UP had their first child under 19 years. This points to the curative aspects of UP. In the medium term, the government should fact that most women suffer from UP for a long period if they do not allocate funds for hysterectomy camps and prepare a strategy for receive timely treatment. providing hysterectomy (surgery) services in district or regional hospitals for women needing urgent attention. The survey shows as one can expect, a relatively strong relationship between UP and economic condition. Women from the families with Awareness on the prevalence and causes of uterine prolapse is very land and adequate food for the whole year are less affected in important, targeting different groups, such as adolescents in and out of comparison to the women from landless and wage-laborer-families. schools, newly married couples, husbands and mothers-in-law, health
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workers, volunteers and traditional birth attendants, UP sufferers. The above target groups need to be made aware of both the social and Abbreviations medical causes of uterine prolapse. Since the most of the causes are related to gender issues, awareness should be focused on gender ADB Asian Development Bank discrimination, patriarchy, reproductive health and rights of women. The government and concerned civil society and the development ANM Auxiliary Nurse Midwife organizations should work with the mass media to raise awareness on CAED Center for Agro-Ecology and Development UP issues, through electronic and print media. More sustained and CBS Central Bureau of Statistics explicit messages are necessary to draw attention to this. CMA Certified Medical Assistant Close and immediate coordination of the Ministry of Health at least with GDI Gender Development Index two other Ministries is necessary: Ministry of Education and Sports and the Ministry of Women Children and Social Welfare. UP issues should GoN Government of Nepal be incorporated in the relevant curricula in appropriate grades in school GTZ German Technical Cooperation education, and for Health Assistants, Community Medical Assistants HA Health Assistant and Auxiliary Nurse Midwives under reproductive health topics. HSSP Health Sector Support Programme (of GTZ) The government should allocate tasks for different sectors, such as HDI Human Development Index curative service providers, social service sectors, human resource development and media for effective delivery of services. This is an INF International Nepal Fellowship opportunity and moral responsibility of the donor community to realize IoM Institute of Medicine (Tribhuvan University) their gender sensitivity. There should be a forum to exchange MMR Maternal Mortality Rate information and build synergy amongst the concerned stakeholders. MoHP Ministry of Health and Population Researchers need to be introduced to the UP problem to study it further NESOG Nepal society of Obstetricians and Gynecologists from different medical and sociological perspectives to provide a basis for understanding it better and popularize the issue. phect-NEPAL Public Health Concern Trust Nepal RHEST Rural Health and Education Service Trust SLC School Leaving Certificate
*** SMNF Safe Motherhood Network Federation TBA Traditional Birth Attendant UNDP Untied Nations Development Programme UNICEF United Nations Children and Education Fund UNFPA United Nations Fund of Population Activities UP Uterus (Uterine) Prolapse VAW Violence Against Women VDC Village Development Committee WHO World Health Organisation WOREC Women's Rehabilitation Center
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The Cases 49
Contents References 50
Acknowledgement i Annexes 53 Executive Summary ii Annex I 53 Abbreviations vi Reports of UP Prevalence in Nepal Annex II 55 1. Background 2 List of Agencies Working on UP
1.1. The Situation of Nepali Women 2 Annex III 58 List of VDCs and Number of Respondents 1.2. The Reproductive Health Situation of Nepali Women. 4 1.3. Uterus Prolapse 5 Annex IV 59 Uterine Prolapse Prevalence by VDCs 1.4. Study Area 6 Annex V 60 2. Purposes and Objectives of the Study 7 Frequency Tables F. Table 1 -- Age Group of Respondents 60 3. Conceptual Framework 8 F. Table 2 -- Study Population by Social Group 60 F. Table 3 -- Education Level of the Respondents 60 4. Research Methods and Study Design 11 F. Table 4 -- Uterine Prolapse Prevalence by District 61
4.1. Rationale for Selection of the Study Area 11 F. Table 5 -- Prevalence of Uterus Prolapse by Social Group 61 4.2. Research Design 11 F. Table 6 -- Age of Women at First Uterine Prolapse 61 4.3. Sampling 11 F. Table 7 -- Uterine Prolapse after Which Child Birth 62 4.4. Data Collection Techniques 11 F. Table 8 -- UP Occurrence Years 62 4.5. Reliability and Validity of the Data 12 F. Table 9 -- Number of Post UP Pregnanc(y)ies 62 4.6. Definitions, Selected Concepts and Variables 12 F. Table 10-- UP Prevalence & Economic Condition 63 4.6.1. Working Definitions 12 F. Table 11-- Women with UP Shared Problem With 63 4.6.2. Social Groups 13 F. Table 12-- Reasons for Sharing UP Problem 63 4.7. Data Processing and Analysis 13 F. Table 13-- Reaction of family Members on UP Problem 63 4.8. Limitations of the Study 13 F. Table 14-- Symptoms of RH Problems 64 F. Table 15-- Immediate Cause of Falling of UP 64 5. Review of Literature 14 F. Table 16-- UP Prevalence and Education Level 64 F. Table 17-- Age of Marriage of Women with UP 65 5.1. Uterine Prolapse as a Medical Problem 14 F. Table 18-- What can be the Solution for UP Problem? 65 5.2. Uterine Prolapse as a Social Issue 16 F. Table 19-- What was done for Treatment? 65 5.3. Review or Previous Study 18 F. Table 20-- Where was the Treatment Received? 65 5.4. A Review of Institutions Working On Uterine Prolapse 21 Annex VI Survey Questionnaire on Uterine Prolapse Issues 67 6. Finding and Analysis 23
6.1. Respondent Characteristics 23 6.2. Prevalence 25 6.3. Characteristics of Women with Uterus Prolapse 28 6.4. Factors Affecting UP 33 6.5. Perceptions of Women on Reproductive Health Related Issues 40
7. Summary, Conclusion and Recommendations 44
7.1. Prevalence 44 7.2. Causes 44 7.3. Characteristics of Uterus Prolapse 45 7.4. Gender Relations and Self-Awareness 46 7.5. Recommendations 47 7.5.1. Policy Interventions 47 7.5.2. Social Aspects 48 7.5.3. Medical Aspects 48
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1. Background
1.1. The Situation of Nepali Women
Women comprise slightly over 50% of total population of Nepal (CBS, 2001), but the country has one of highest indices of son preference in the world (UNDP, 2004). As a predominantly patriarchal society, institutions such as education, the legal system and even health services are heavily influenced by these norms and values. The consequences of this system can be seen in social indicators such as literacy, child mortality, maternal mortality and morbidity amongst and women.
Generally, women in Nepal have three levels of responsibility: 1) Reproduction and child rearing, 2) Household maintenance and 3) Income earning. Under traditional gender divisions of labour women tend to concentrate more on their reproductive roles and household responsibilities, while men focus on income-earning. Women's jobs are generally not regarded as "work" or considered productive in economic terms, although they contribute considerable time in productive activities. Yet the, often non-formal, work burden of women in Nepal, which averages 16 hours per day, is much higher than the global average (UNDP, 2004). This also has the effect of reducing their access to self-improvement opportunities and paid employment. Even when they do have access to paid employment, women suffer from discriminatory practices in all the sectors. Women’s mobility is also highly restricted, which is significant as mobility plays important role in increasing self-confidence, self-reliance, skill development and decision making power.
At least the last three Constitutions of Nepal, including the current interim one, have non-discrimination and equality as fundamental rights. The National Penal Code (Muluki Ain, 2022), in its Eleventh Amendment, sets out women’s right to property and a conditional right to abortion, an increase in the minimum age of marriage (from 16 to 18 years) and equality in grounds for divorce. However, these policies have not been fully implemented, particularly at grassroots level. They are overwhelmingly influenced by the strong traditional beliefs and social norms leading to continuing widespread discrimination.
Gender parity in terms of opportunity is poor in Nepal. The Gender Development Index (GDI) is 0.452, against the Human Development Index (HDI) of 0.471. In rural areas it is even lower. The sex ratio, as an indicator of women’s status, has shown some improvement, form 105:100 in 1981 to 99. 8:100 in 2001 (UNDP, 2004). However, women
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Table 2: show an increment in the influence of women’s decision making at Status of Women in Nepal (B) household level, although there is still a long way to go.
Parameters Women Men Both The Government of Table 1: Life expectancy 61.46 yrs 60.52 yrs Nepal has made an Status of Women in Nepal (A) Percentage of women of 15-19 international Parameters Women Men years currently married 43.3% commitment to Literacy 42.5 65.1 General fertility rate (per 1000 follow the ICPD Primary school attainment 45.9 39.3 women) 167 Programme Action, S.L.C level 8.1 9.6 Total fertility rate 4.6% Beijing Plan to Representation in parliament 5.8 94.2 Child mortality rate (per 1000 of Action and has Representation in administrative 12.71 87.29 1-4 years age group) 56.5% 45.5% ratified the and managerial positions Maternal mortality rate (per Convention for Professional and technical 18.75 81.25 100,000 live births) 539 Elimination of all position Contraceptive prevalence rate 28.5% forms of Source: UNDP, 2004 Pregnant women receiving Discrimination Against Women (CEDAW) and many more Human rights antenatal care by trained health instruments. These reaffirm women's right to be equal and be treated personnel 27.6% equally by the state. Deliveries by trained personnel 9.0% Deliveries occurring in health 1.2. The Reproductive Health situation of Nepali Women facilities in rural areas 5.1%
Source: UNDP, 2004, Healthnet.org.np (downloaded in 2006) Reproductive mortality and morbidity are major problems for Nepali remain less empowered than men in economic, political and women, the full extent of which is not exactly known, until recently, professional domains. Although directly productive work-force Nepal was one of the few countries in the world where women had a participation rate among women is 46% compared with 69% for men lower life expectancy than that of men. This has now improved (CBS 1995), women’s share of earned income is about half that of men. significantly, with women’s life expectancy increasing from 53.5 years in
Women’s access to and control over resources is also limited. Of the 1991 to 61.5 years in 2001, surpassing the life expectancy of 60.5 years total landholdings, women own only 8% and the average size of their for men. Although the mortality for children under 5 years of age has land is just two-thirds that of an overall average holding. Only 4% of declined, it is still higher for girls, at 112 per 1,000, compared with 105 households have female ownership of both house and land (UNDP, per 1,000 for boys. Studies have shown that girls are discriminated in 2004). child rearing practices, such as feeding patterns and health care.
Despite significant gains in female literacy-from a mere 12% in 1981, to Women and girls suffer form inadequate nutrition in both quantity and 43% in 2001 – women still lag for behind men in literacy and quality of food, perform excessive labour and have limited assess to educational attainment. The difference between the male and female health facilities and family planning services. Approximately 70% of literacy rates between 1981 and 2001 remains the same, at 22% points. women of childbearing age are anaemic, a result of early childbearing (an estimated 40% have given birth to at least one child between the Despite this gloomy picture, more and more women are seen in the ages of 15 to 19) and because of poor maternal health care and public sphere. National and international organizations have made nutrition (UNDP, 2005). every effort to bring women to the fore, helping to internalize the importance of gender mainstreaming in many national instruments. The maternal mortality rate (MMR) of Nepali women (539 per 100,000 live births 1) ranks among the highest in the world. One out of every 185 Thousands of women have participated in interaction programmes, and pregnant women die because of pregnancy and child-birth related joined networks and alliances. This has provided opportunities for complications. Currently, only 53.4% of women receive any antenatal women to share their experiences and pain and bring their issues of care, though this has increased form 28.4%, in 1991, and only 18.8 concern into development and political discourse. As a result, studies
1 The 2006 Demographic and Health Survey Suggest's this has now decreased to 281 per 100,000.
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receive post natal services. Almost all deliveries take place at home; a also thought to play an important role in the development of uterine health worker assists only 18% of deliveries. prolapse (www.nlm.nil.gov/medlineplus ).
The mean age at marriage has risen from 16.8 years in 1971 to 19.5 Uterine prolapse can be prevented by performing pelvic floor exercise to years in 2001 for females and from 20.8 years in 1971 to 21.9 years in strengthen the muscles of the pelvic floor, this tightens the pelvic floor 2001 for males. This indicates some improvement, but this is not muscles and prevents the uterus descending downwards uniform, and early marriage is still the norm in many rural areas. (www.netdoctor.co.uk ). However, once the prolapse is established, it is
much more difficult to control with exercises. At the early stages it can Various forms of violence against women exist in Nepal. Sexual be held inside and prevented form falling further by inserting a rubber violence and family violence (domestic violence, polygamy, and early marriage) have significant reproductive health consequences. The ring called a pessary. However, at the final stages, when it comes out, surgical removal (hysterectomy) is the only option (RHEST & PHECT, levels and types of violence and exploitation against women vary with 1997). religion, caste, class and geographical location. Following the ratification of national and international laws and conventions on this, three is increasing attention to reducing violence against women in Nepal. The problems of uterine prolapse exist throughout Nepal and drastically However, the problem remains, and even appears to be increasing- affects women’s quality of life. For women living with this condition, life’s partly because of the lack of comprehensive law on domestic violence. basic activities are a challenge. Urinating, defecating, walking, standing and sitting are difficult and painful, which in turn loads to various forms 1.3. Uterus Prolapse of psycho-social and physical disorders.
Uterus (or uterine) Prolapse (UP) is widespread chronic problem among 1.4. Study Area women in Nepal, particularly in hill areas. It is defined as falling of the womb, when the muscles of the pelvis are strained to a point where they Siraha and Saptari districts fall into four ecological zones: can no longer support the positioning of the uterus. The uterus drops Chure - the first hill range arising north of Indo-Gangetic plain; from its normal position in the pelvic cavity, descending into and geology and soil compostion consists of clay stone, eventually, in extreme stages, out of the vagina. It is a progressive sandstone, conglomerated and loamy skeletal condition that typically occurs in post menopausal women in most Bhabar - the zone along the southern Chure front where the countries. However, it can also occur in younger women (SMNF, 2005), ground water of the Terai plain is recharged; usually and frequently does in Nepal. only suitable for rain fed agriculture Medically, four stages of uterine prolapse are defined: Doon - an alluvial broad flast-bottomed river valley within the • Stage I is descent of the uterus to any point in the vagina above chure range or between the Chure and Mahabharat the hymen ranges, also called inner Terai; soil composition • Stage II is descent to the hymen consists of fine to coarse loam) • Stage III is descent beyond the hymen Terai - the flat plains area
• Stage IV is total aversion or procidentia. Table 3: Populations in Siraha and Saptari Districts Uterine prolapse is always accompanied by some degree of vaginal wall Particulars Description Unit Siraha Saptari prolapse (www.emedicine.com ). No one definite cause of the problem Population Population No. 569,686 569,812 has been firmly established, as women from different economic strata, a (Annual growth in 2001 (Persons) wide range of ages, belonging to various ethnic groups and from all rate =2.24%) ecological regions from east to west suffer from it. Experience indicated Households in No. 100,010 101,141 that it is the result of hard physical labour, such as carrying heavy loads, 2001 especially during and immediately after pregnancy. Other often-cited VDCs/ No. 108 115 causes are prolonged labour during childbirth, forced delivery by Municipalities untrained persons, lack of postpartum rest, insufficient spacing between Size of the area ha 118,800 136,300 births, bearing a large number of children with inadequate spacing and (Source: Laubmeier and Warth , 2004) poor nutrition. (RHEST & PHECT, 1997, WOREC, 2003). The loss of The castes and ethnic groups that make up the populations have varied muscle tone and loosening of muscles, which are both associated with backgrounds. Yadavs, the traditional animal herders and farmers, are normal ageing and a reduction in the female hormone oestrogen, are the largest group in Siraha and Saptari Districts, accounting for 25%
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and 20% of the population respectively. Tharus, the indigenous people of the Terai, are the second largest group, accounting for 5% of the The specific objectives were: population in Siraha and 13% in Saptari. Both districts have a significant • To find out the prevalence, characteristics and factors causing number of landless agricultural labourers from Terai/dalit castes (so uterine prolapse in Siraha and Saptari districts. called untouchables), such as Mushahar, Chamar, Dusadh, Khatwe, • To test the following assumptions regarding UP, for better Kewat and Dom, in total these disadvantaged castes make up 34% of understanding: the population in Siraha and 28% in Saptari. Maithili is the most widely Prevalence of UP is lower in more accessible areas. spoken language in these districts, followed by Tharu. Patriarchy is a root cause of UP. Poverty and ethnic background affect UP prevalence. The economy of the two districts is predominantly agricultural. Among Frequent child bearing is an important factor in UP. the economically active population, the majority are either farmers or agricultural wage labourers. Many people also go to India (e.g Punjab) 3. Conceptual Framework to work as agricultural wage labourers. There is gross economic inequality, as 7% of the households own nearly 50% of the land. A number of reasons are suggested as causes of UP, as noted above. Landlessness varies between 12% and 33%, and is highest among the So far, the majority of these are linked to medical issues, and thus disadvantaged castes (FRP, CAED 2005). efforts to address the problem have been mainly medical, such as insertion of ring pessaries or surgical removal. The medical view A total of 24 VDCs in the two districts were selected for the survey. To suggests malnutrition, heavy workloads, early pregnancy and frequent support the programme focus on dalits and other economically deprived births as key direct causes of UP. However, these causes are the effects of other issues such as the lack of education and information, Table 4: lack of ante and post natal care and gender-based violence. These in Social Strata of Siraha and Saptari turn are linked to fundamental issues such as poverty and a patriarchal societal construct. These issues are inter-dependent, being both causes Siraha Saptari Description and effects with a complex chain of feedback loops. In order to eliminate # % # % the problem, one has to go the primary causes. Genetic makeup may High caste 160,470 28 124,047 22 also be a direct pre-disposing factor and its effects can be magnified by Middle caste* 146,122 26 218,347 38 the other causes.
Dalits 196,371 34 157,431 28 Diagram 1: Muslim 41,670 7 47,239 8 Root and Symptomatic Causes of UP
Unidentified group 15,289 3 12,024 2 Other minority group 9,764 2 10,724 2 Root Causes Secondary Causes Symptoms Total population 569,686 100 569,812 100 and or Symptoms groups, survey areas were chosen where numbers of dalits and indigenous settlement was high. The selected VDCs are located at distances 2 km to 10 km distance from the highway, as proximity to Patriarchy M alnutrition road-heads is important for landless people to ensure availability of Gender Discrimination work as wage labourers and seasonal vendors. Heavy Workload No Reproductive Rights Early M arriage Uterus 2. Purposes and Objectives of the Study Prolapse Frequent Birth (One of many This survey was carried out for two purposes: No Access to Education Consequences)
a) To identify the intensity and map the distribution of uterine Poverty prolapse prevalence in the study area and No M edical Access b) To produce a document for programmatic use (design, Genetic Gender-Based Violence operation and advocacy) No M aternal Care
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For the purpose of this study, three primary or root causes of are identified: poverty, patriarchy and genetic makeup. The first two themselves have a mutually influencing relationship. Secondary causes are considered as an outcome of one or both of the first two primary causes, and lead directly to prolapse of the uterus. Gender discrimination and denial of reproductive rights are considered as a function of patriarchy.
Women have no voice or decision-making power even in domestic activities, and no access to or control over family resources, even though they perform all the household chores and farming activities. A belief is established that the role of women is to perform household chores, take care of the family and produce children for as long as they are able. The strength of this belief is so great, among both men and women, that women’s time for thinking and contact with the outside world is limited by their domestic chores and this restricts their access to information and further reduces their decision making power. Women have become less powerful and less influential in the society and reduced to a very low status in society.
Women are considered creators but have no choice about when to create. This power lies with men. The preference for sons (in line with the patriarchal power base) means women are forced to keep bearing children until they give birth to sons. It is therefore necessary to address UP through a rights based perspective on patriarchy. In other words, this paper does not view UP as purely a medical problem but a consequence of patriarchy.
***
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4. Research Methods and Study Design Semi-structured Interviews: Some semi-structured interviews were carried out for further information and different opinions on UP, included
as case studies. 4.1. Rationale for Selection of the Study Area 4.5. Reliability and Validity of the Data To date, it has been accepted that uterine prolapse is mostly prevalent in the hill areas - the far-western in particular. It is believed that hill Strategies for maximising the reliability and validity of the research women are more prone to the condition because of the heavy work were: associated with farming in the hills and lack of any wheeled transport. • Use of local women enumerators who were properly orientated This study focuses on areas in the eastern terai in Siraha and Saptari on the topic and questioning skills. districts in order to make a comparison with geographically, culturally • Building rapport with the interviewee before asking questions. and with different social groups. • Administering the questionnaire in the local language. • Use of key informants gain information about local realities. 4.2. Research Design 4.6. Definitions, Selected Concepts and Variables
The design of research is exploratory and descriptive. The study is 4.6.1. Working Definitions based mainly on qualitative questions with only a few with quantitative questions. The design takes into account variations in educational Uterus prolapse or fallen womb status, economic status and ethnic diversity. Each question was given a Uterus prolapse is a falling of the womb (uterus) downwards from its normal position due to weakened pelvic muscles. It may eventually code, to aid tabulation and analysis. The questionnaire was developed come out of vagina. Used as synonymous with uterine prolapse (word in the most commonly used local language, Maithili, in order to help the prolapsed as an adjective doesn’t exist in normal English Dictionary) local enumerators understand and communicate easily with respondents. Nepali and English questionnaire is annexed at the end of Patriarchy the document (Annex VI). A system of society in which the father or eldest male is the head of the family, making all major decisions and controlling family resources. Since uterine prolapse is a socially sensitive issue, it is also considered Descent and inheritance are reckoned through the male line. This a social taboo to discuss it. To make it easier for women to talk, system, although originally family based, has been transferred to bilingual local women were selected to collect the information using the organisations and government. local language. They were given an intensive orientation on the issues regarding uterine prolapse prior to starting the survey. The survey was Reproductive rights undertaken in March 2006. The power to make decisions about one’s own fertility, child bearing, child rearing, gynaecological health and sexual activities.
4.3. Sampling Midwifery practices
In the 24 selected VDCs of Siraha and Saptari there are 22,928 The care provided to women during pregnancy, during and after child households. The survey covered a total of 2,268 households, just under delivery. This is traditionally provided by the sudeni, or traditional birth 10%, with a total of 2,268 married women respondents from the age attendant, a local woman with little or no formal training. group 16 to 60 years and from different social groups, including dalit Food sufficiency groups, indigenous groups (janajati), Brahmin and Chettris. A clustered As understood and mentioned by villagers, referring to their perceptions stratified sampling method was used to cover the major ethnic groups in of quantity and quality, without any analysis of nutritional value in the VDCs. scientific terms.
4.4. Data Collection Techniques Gender Based Violence
Secondary Information: Secondary data/information was collected Gender-based violence, or violence against women related to gender through the review of available literature and publications. issues, that includes domestic violence, polygamy, sexual violence and child marriage.
Interviews: A direct interview with questionnaire was carried out with Hysterectomy one woman from each family from the selected households. Surgery carried out for removal of the uterus.
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Basic Literate A person who can read and write, from formal schooling or non-formal 5. Review of Literature classes. Medically UP is a part of Reproductive Health and is regarded as a 4.6.2. Social Groups public health problem. This section reviews how UP is treated in the
Hill Dalit Kami, Damai, Sarki, Sunar literature under two broad categories: medical and sociological.
Terai Dalit Chamar, Khatwe-Mandai, Dom, 5.1. Uterine Prolapse as a Medical Problem Sada(Sadaya), Dhobi, Tatma, Sunihar, In various papers and publications, UP is defined as falling of the womb/ Ram, Magar, Ghangar, Sonar, Paswan uterus, when the muscles of the pelvis are strained to such a point Hill Janajati Rai, Magar, Tamang, Gurung, Newar, where they can no longer support its normal positioning. The uterus Danuwar, Sunuwar drops from the normal position in the pelvic cavity and descends into
Terai Janajati Tharu, Kumahar, Dhanuk-Mandal, and gradually comes out of vagina. Different stages and forms are Dhami described in Bonetti et al, 2002.
Other Hill ethnic Group Bahun, Chhetri, Bhujel UP is a specific type of pelvic organ prolapse, which may be thought of as a type of hernia. For example, weakness in the abdominal wall can Other Terai ethnic Group Yadav, Suri, Saha, Kalwar-Chaudhari, lead to intestines bulging through the muscular support causing an Mehta, Pandit, Mukhia, Malia, Mali, abdominal hernia. Similarly, weakness in the muscles and ligaments of Sutihar-Sharma, Singh, Thakur, Barhi, the pelvic floor can cause loss of uterine support and lead to uterine Das, Dev, Kamait, Karhoriya, Rajput, prolapse. Pregnancy, childbirth, obesity and chronic coughing and lifting Rajdhob, Mahato, Karma, Jah, Haluwai, are some of the factors that predispose a woman to developing uterine Amat, Sardar prolapse. Uterine prolapse is a progressive condition that gets worse Others Bin, Kipot, Kewat over time if not treated (www.intelmedical.org ). Muslim All Muslims Symptoms of UP are: pelvic heaviness or pressure, pelvic pain, sexual 4.7. Data Processing and Analysis dysfunction, lower back pain, constipation, difficulty walking, difficulty urinating, urinary frequency, urinary urgency, urinary incontinence Information has been tabulated in an Excel Worksheet and SPSS (Upreti et al. 2001). (Statistical Package for Social Science) software has been used for data The best option is to prevent the prolapse in the first place. Performing processing and analysis. Data are analysed through various pelvic floor exercises on a daily basis to strengthen the muscles of the perspectives. Basic mathematical and statistical tools have been pelvic floor is recommended, especially during and after pregnancy. applied. These can be done anywhere and at any time by simply tightening the pelvic floor muscles, as if trying to stop the utrine flow (Upreti et al. 4.8. Limitations of the Study 2001).
• Literature available on uterus prolapse issue is very limited. Uterine prolapse can be treated with a vaginal ring pessary or surgery. • Previous studies on reproductive health as a whole, including If the uterus has dropped moderately, a ring pessary is inserted into the uterus prolapse, have been based on clinical study only, vagina to hold it in place. For complete drop of uterus outside the without including grassroots experiences. vagina, surgical removal of uterus is the only option (hysterectomy) • Since, UP is a sensitive subject and social taboo, a problem (Upreti et al. 2001). related to the private parts of women, physical verification was not possible. Figures and information could be under reported, Bearing in mind the magnitude of the UP problem in Nepal and other as women may not feel able to talk about it openly. parts of the world, there is little related literature available. An internet • Since the researcher has no medical background, no analysis search shows that most literature against the word 'UP' (search engine from a medical perspective was carried out. AltaVista browsed on 30th March, 2007) is confined to the clinical handling of hysterectomy cases. The same is true with other
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publications. In fact, more educated people are found to know of According to WHO estimates, reproductive ill health accounts for 33% of prolapsed uterus in animals rather than humans. the global disease burden in women, compared with 12.3% among men. Despite this significant figure, in many South Asian countries the Following the International Conference on Population and Development magnitude of reproductive morbidity has not been adequately defined (ICPD), the Cairo Action Programme, 1994, aimed to incorporate (WHO, 1995). Since the Safe Motherhood Conference in Kenya 1987, Reproductive Health issues together in a holistic way. Women's Health reduction of maternal mortality is a primary concern in international in general was given importance and incorporated into existing public health agendas and a priority in many developing countries (IOM, strategies such as Primary Health Care (PHC) and activities identified 2006). Yet morbidities, which cause so much suffering, are hardly for different reproductive health components at various levels. In Nepal mentioned. Exact data on the status of reproductive morbidity are not the National Reproductive Health Strategy (NHRS) was revised in 1996 available in Nepal, although a World Bank report estimated that 1,500 to facilitate the implementation of the Cairo Action Programme within Nepali women per 100,000 suffer from serious complications related to the existing health care system. The concept of Reproductive Health as reproductive health problems (WB, 2003) a central theme in women's health was further endorsed during the fourth World Congress on Women held in Beijing in 1995. 5.2. Uterine Prolapse as a Social Issue The Nepal RH strategy included the following eight key components: UP can be viewed as a function of unequal gender relationships and an • Family Planning expression of the subversion of women and denial of their rights, • Safe Motherhood although no specific studies have been carried out to further explore this • Child Health (including care of the newborn) thesis. The limited literature available on reproductive morbidity and • Prevention and Management of the Complications of Abortions gender indicates a connection between UP and gender issues. As a • Prevention and Management of Reproductive Tract Infections, result, UP programmes focus on addressing gender issues as a STDs and HIV/AIDS preventive mechanism for UP (CAED, 2005, 2006), (Rajbhandari, • Prevention and Management of Infertility 2005), (Gurung, 2006). Other literature also suggests that UP can be • Adolescent Reproductive Health prevented if there is a reduction in gender discrimination (Upreti et al, 2001), (SMN, 2005). Closer examination of most direct causes of UP • Reproductive Health Problems of Elderly Women provides further evidence and support for this. Thus uterine prolapse or pelvic organ prolapse or genital prolapse is not specifically mentioned in the Second Long Term Health Plan, it is only Gender activists generally perceive the causes of uterine prolapse as covered Reproductive health problems of elderly women . However, both gender discrimination, gender violence, women’s lack of control over young and older women have been found suffering from uterus and their health and lack of rights. Activists such as Dr Renu Rajbhandari, pelvic organ prolapse, so this does not adequately address the issue. Dr Arun Upreti, Kamala Bhasin are leading advocates for the concept of Sporadic clinical and community research studies, observations and UP as an outcome of patriarchy. Medical doctors (Pers. Com. Drs news reports suggest that even teenaged girls and mothers are affected Gurung, Dangal, and Mahaseth, 2006) who have provided surgical (CAED, 2006, Ravindran et al, 2005). Yet, the adolescent reproductive treatment of uterus prolapse agree that it is an issue of reproductive health component, which could contribute significantly to the prevention rights of women and can be prevented to some degree if gender of UP, contains nothing on this issue. One of the recognised causes of discrimination is reduced. To fulfil the strong desire for sons within UP is unsafe delivery and frequent child bearing (Bonetti et al, 2002, families, women are subjected to multiple pregnancies. Even if they Ravindran et al, 2005). Uterine prolapse occurs most commonly in have given birth to one or more sons, in many of the parts of the country women who have had one or more vaginal births women do not have access to contraceptives devices. (www.inletmedical.org ). Yet there is little mention of the issue in the safe motherhood component. Some see a more direct relationship between gender discrimination and UP. Shakya (2006) argues that the problem of uterus prolapse leads to The family planning component of the strategy also does not mention gender based violence and the vice versa. In a study undertaken in a UP, although it is an outcome of frequent and inadequately spaced gynaecological camp in Rautahat and Saptari, 67 out of 109 women pregnancies; a family planning issue. UP is also associated with were found to have suffered from gender based violence, out of which abortion - induced abortions in particular (Ravindran, 2005), but women 40% of UP cases were attributed to such violence. Similarly in Kirtipur, are not warned of this risk in information packages. 52% of uterine prolapse cases (out of a total of 42 cases) were found due to gender based violence.
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Women suffering from uterus prolapse are considered impure and leads to pregnancy complications, malnutrition and reproductive looked down upon by husbands, families and society, which isolates morbidities. Women do not have access to medical facilities, even if them from social activities. Husbands threaten to take another wife they are available, since they have no part in decision making. The when they do not get sexual satisfaction, which may cause various government is also not responsive to women’s health needs. These problems for the women and even lead to breakdown of the family, with unequal gender relations and associated issues have not been attendant adverse effects on the lives of the rejected women and their addressed, either by government or by women rights organisations and children. Such treatment has been reported by a number of women donors. suffering from UP (CAED, 2006). One woman reported suffering violence from her husband dating from the onset of her UP. Violence In a report on Maternal Health and Pregnancy-related Care in India, it is and battering associated with forced sexual intercourse have also been stated that where women’s decision-making is restricted and women’s reported (Ravindran et al 2005). Uterine prolapse has been shown to illnesses are low on the family priority list, decisions regarding health seriously compromise the quality of life of affected women, with far care for pregnancy and pregnancy-related complications are frequently reaching consequences not only for their physical health, but also for delayed, often with dire health consequences (Gittelsohn et al., 1994; their sexual lives and their ability to work and earn a livelihood. Jeffery, Jeffery and Lyons, 1989). Even educated women are not (Ravindran et al 2005). always the main decision-maker when they are sick (Ganatra and Hirve, 1995; Ganatra, Coyaji, and Rao, 1998). In the slums of Delhi, for Gender-based violence or violence against women is a major public example, as many as 81% of pregnant women required permission from health and human rights problem throughout the world. Violence against other family members such as husband or mother-in-law to access women has profound implications for health but is often ignored. The antenatal or delivery care, even in the case of an emergency (Bhandari WHO World Report on Violence and Health notes that "one of the most and Mayank, 1999). An in-depth case study of pregnancy-related common forms of violence against women is that performed by a experiences in Andhra Pradesh, Madhya Pradesh and Orissa reports husband or male partner.” This type of violence is frequently invisible that 9% of women experiencing postpartum complications were denied since it happens behind closed doors and legal systems and cultural care by their families, and of those who sought care, only 13% of those norms do not treat it as a crime, but rather as a "private" family matter, with complications and 26% of those without complications made the or a normal part of life (www.who.int/gender, 2006). The lack of decision to seek care themselves (Murthy and Barua, 2001). understanding among policy makers and implementers of the ways in which health relates to social and gender issues and the importance of Financial and opportunity costs further limit women’s access to health a rights-based approach means the core causes of uterus prolapse care. In general families, including women themselves, spend less time, have not been addressed. All stakeholders need to understand that effort and money seeking health care for women and girls than for men prolapsed uterus is an outcome of gender based violence, (Chatterjee, 1996) and women are unlikely to have independent control discrimination against women and the patriarchal society (Rajbhandari, over the resources required to seek care (Jejeebhoy, 2000b). Women's 2006) . illness ranks low among family priorities, especially when the condition is perceived as non-threatening or self-limiting, thus delaying the Women are the victims of Diagram 2: decision to seek care (Ganatra and Hirve, 1995; Thaddeus and Maine, discrimination during their VAW Types and Consequences 1994), reported in Maternal Health and Pregnancy Related Care, whole life cycle, from birth published in India. until death. Gurung (2005) states in his paper that girls 5.3. Review of Previous Studies are discriminated against and neglected from childhood, in No international studies on UP were found, except one or two from areas such as in nutrition, India. WHO has reported global prevalence of UP to be between 2% health care and education. and 20% in women under the age of 45. In China, She, Shao and They are again disadvantaged Weng found that uterine prolapse is one of only two female diseases for during adolescence through which the government provides free care (WHO, 2003). early marriage, early pregnancy and early India unplanned and frequent child There are occasional references to studies in India, mostly bearing combined with a reporting on prevalence. Bhatia (1997) reported 3.4% prevalence heavy workload. This often in Karnataka, South India. Kumari et al (2000) found 7.6% in North India. However, a study in 1952-54 found that among Source: Gurung, 2006
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5,494 women visiting private clinics in Bengal, Delhi, Punjab and almost four times (Younis et al 1993). However, it appears that Uttar Pradesh with gynaecological complaints, one in five was people working on RTI are unaware of this relationship. In suffering from uterine prolapse. Another more recent study, in Accham and Doti 25.1% women were reported with different 1991, conducted in Eastern India, found that genital prolapse degrees of UP. In Accham, 22.2% of the women reported the constituted 20% of all gynaecological admissions (Ravindran et al onset of prolapse before the age of 20 and 43.8% reported onset 2005). A study in 1951-1954 of 214 women admitted to the between the ages of 20 and 29 years. The cases in Doti were gynaecological ward of the Osmania Hospital, Hyderabad, also very similar. The peak onset was found during younger observed that uterine prolapse was not necessarily the outcome reproductive years. Bonetti et al (2002) studied the practices of repeated childbirth but often followed damage to the pelvic used during childbirth and during the post natal period for women floor as early as after the first delivery. In five women the with UP, their working pattern and nutrition status. Various prolapse had followed surgery; sterilisation in three cases, tangible factors associated with UP were noted, including induced abortion in one case and removal of fibroids in another. delivery by untrained (traditional) birth attendants, forced Another woman had developed symptoms of uterine prolapse delivery, excess pressure on lower abdomen, prolonged labour, following a miscarriage. (Ravindran et al 2005). Ravindran et al performing heavy work (lifting and carrying loads) during (2005) carried out an elaborative qualitative study on the pregnancy and the post natal period, multiple births and poor characteristics and causes of UP. Another study, conducted in nutrition. Causes related to diet and excess intra-abdominal Southern India to assess long-term morbidity following childbirth, pressure are mentioned by Bonetti (2000). found that among 3,844 women who had given birth up to 24 months prior to the study, 3% experienced uterine prolapse and 2005: Uterus Prolapse: A Key Maternal Morbidity Factor amongst urinary incontinence and two reported recto-vaginal fistulae Nepali Women is a study undertaken by the Safe Motherhood (Srinivasa et al, 1997). A synthesis of six community-based Network Federation-Nepal (Deuba et al, 2005), where prevalence studies of gynaecological morbidity in India reports prolapse in of uterus prolapse in 10 districts was found to average 9%. 1% to 7% of all women surveyed (Koenig et al, 1998). Among hill women this was 15% compared with 5% amongst Nepal terai women. This essentially clinic based study was undertaken Most of the few studies carried out in Nepal are clinic-based, only in gynaecological camps organised in different districts. giving an indication of prevalence. Annex I summarises estimations of prevalence from different sources. The studies 2006: Reproductive Morbidity in Nepal (IoM, 2006). A hospital based discussed below have also made some attempt to look at causes. study from the Maternity Hospital in Kathmandu, which reports that, out of the total 1,147 gynaecological patients, 9.6% were 2002: Reproductive Morbidity: A Neglected Issue? (Bonetti et al, found to have uterine prolapse, (Ranabhat R. 1996). A clinic 2002), is a report of a clinic based study in far-western Nepal, based study carried out in eight districts in terai, hill and mountain undertaken jointly by GTZ, UNFPA and the Nepal government, areas showed that, on average, 10% of women were suffering which seeks to identify the causes of UP. This report provides a from prolapsed uterus, ranging from 7% to 44%, with a good account of the literature on UP in Nepal. Quoting Watson surprisingly high prevalence in the terai (Rautahat 44%). The (1975), it states that Shining Hospital in Pokhara had found diversity of prevalence of uterus prolapse in different ethnic 1,500 women suffering from UP, indicating that the problem was groups was studied, different types and degrees of prolapse, age already identified 46 years ago. However, it was not taken at first prolapse, childbirth and prolapse, duration of suffering and seriously by any of the concerned sectors. It is astonishing that working patterns. The report notes that a study conducted by such a serious problem has remained neglected for so long. Abraham et al (2003) found that among married women who had Some activists (Subba et al, 2003) claimed the negligence is not yet been pregnant in Tamilnadu, Vellore, India, 0.7% had because it is a women's problem and not contagious, adding that history of genital prolapse. women activists are still far from addressing the issue. (Bonetti et al, 2002) quote various articles that say the exact etiology of Research documents mentioned that prolapse is a leading cause of ill uterine prolapse is unknown, but contributing causes include health among women of all ages from different social groups and multi-parity, excess intra-abdominal pressure, tissue atrophy geographical areas.
secondary to ageing and oestrogen loss, joint hyper mobility and congenital weakness, with the primary cause generally agreed to
be multiple births. It has also been reported that UP increases a
women's chance of Reproductive Tract Infections (RTI) by
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5.4 A Review of Institutions Working on Uterine Prolapse
Very few institutions have been working on UP. INF was the first institution recording any involvement, and still provides surgical and advisory services to women across the country. WOREC probably is amongst the first national institutions to bring the issue into the development discourse and to train people to work on prevention. Among the international agencies, the GTZ Health sector Support Programme (HSSP), has supported surgery and conducted a clinic based study. It supported CAED's initiatives in South-eastern Achham. CAED is a small pioneering NGO that brought the issue to public attention, through various media. PHECT-Nepal also supported CAED's initial activities in Achham, and later conducted hysterectomy camps in different parts of the country. RHEST is another institution involved in raising awareness about this issue. PHECT-Nepal and RHEST have covered the issue in detail in their joint publication Mahilako Lagi Dactar Nabhayema (Where there is no Doctor for Women). NESOG was involved in advisory work for HSSP. Lately, UNFPA has been working on the issue through ADRA-Nepal and PHECT-NEPAL. Many national and international institutions are now conducting camps in cooperation with the government.
The Safe Motherhood Network Federation has also worked on UP in recent years. Annex II lists the growing list of agencies involved in UP, as compiled by the UP Alliance in April 2007.
***
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Education 6. Findings and Analysis 80% of respondents were illiterate and 10% had only basic literacy. 2% 6.1. Respondent Characteristics of respondents had passed grade 1-4, 3% were from grade 5-7, 2% from grade 8-10, of whom 2% had passed SLC. The husband's Age Group education level was also studied in order to find out the correlation Women aged 16 to 80 years were questioned, with 70% falling in the between education level of respondents, husbands and prevalence of age group of 20-40 years. Among them, 43% of respondents are from uterus prolapse. This is not a study of individuals, but rather of whole the age group 25-34 years, followed by 22% from 30-34 years, 21% families. The education level of husbands is much higher than that of from 25-29 years, 17% from 35-39 years and 10% from 20-24 years. wives, with the illiteracy rate half than that of wives. Mostly husbands Only 4% were above 60 years and 1% from 15 -19 years age. have education levels ranging from basic literacy to SLC level. Some Graph 1: 2% have bachelor degrees. Age Group of the Respondents Graph 3: Education Level of Respondents Percent Percent
Age Group
Social Group The biggest group covered by the study was terai dalits, at 44.1% of the % of Respondents total, followed by other terai ethnic groups totaling 25.9%. Terai
Janajati, who are mostly Tharu, share 17% of total study population. Economic Status Graph 4: There are 4% of other hill ethnic groups, 3% hill Janajati, 3% Muslims, 20 % of households are 2% of hill dalits and 1% from unidentified groups. in the category of “better Economic Condition of Respondents off”, with sufficient food Graph 2: production from their Study Population: Social Group own land. 16% of households produce sufficient food only for six months, and go for
wage labour or as Percent seasonal vendors in
Percent Percent nearby towns or go to India. The remaining households have little land to produce food to make their living. Approximately, 50% of the respondents do not own land at all. Only 11% of households own agricultural land in Siraha and Saptari district (ISRSC, 2004). They mostly make their livelihoods out of waged labour, agricultural labouring on the landlord's farm and work in India. Most of
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the men from the eastern terai go abroad, for example to the Gulf By Social Group countries, Malaysia, Korea. Among all the seven social groups, dalit women have the highest rate of UP occurrence, at 36%. Other terai ethnic groups follow with 30%, and Age of Marriage Graph 5: terai janajati (indigenous groups) with 21%. Among hill ethnic groups, The mean age of data does not show the prevalence rate to be high, however, the Age of Marriage of Respondents marriage of women number of hill ethnic group respondents was much less than the terai was found to be 16 ethnic group, so comparisons may not be accurate. The same is true for years. 56% of the Muslim group. The data indicates that women from all the social women were groups do suffer from UP. married at the age Graph 6: of 15-19 and 33% UP Prevalence: Social Group at the age of 10-14. Only 6% women Percent were married at the
age of 20-24. Some women were even married at the age of 5. These Percent figures show that Age Group 92% of women get married under the age of 19. This indicates a high prevalence of early marriage. This pattern has been found in all the ethnic groups.
6.2. Prevalence
However, prevalence of UP among social cohort have been found The average prevalence of uterus prolapse was found to be 37% in Siraha and Saptari districts. However, it varies between the districts, highest in Terai janajati with 45%, following with terai dalit with 31%. Total number of respondents form hill ethnic group and muslims were VDCs and different social groups in the area. small. Hence, it is considered incomparable to the terai respondents.
By District Graph 7: Out of 967 women from 12 VDCs in Siraha, prevalence of uterus UP Prevalence: Among Social Cohort prolapse was found to be 30%. Out of 1,301 women in 12 VDCs in Saptari, prevalence was found to be 42%, high even in comparison to other districts where the prevalence of UP has been studied (e.g. Bonetti, 2002, Deuba and Rana, 2005, IOM, 2006, Gurung, 2006). These figures indicate that UP is not necessarily less prevalent in accessible terai districts such as Siraha and Saptari, contrary to prevailing understanding. Saptari scores highest in uterus prolapse prevalence among all the districts ever studied by CAED (CAED Report,
2005). Percent
By VDC UP prevalence was found highest (72%) in Hardiya VDC in Saptari. The prevalence rate ranges from 11% to 72% among the 24 VDCs studied. Seven VDCs have 50% to 72% prevalence. Out of these, six VDCs are in Saptari district. (See Annex IV in detail).
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By Onset of UP 6.3. Characteristics of Women with Uterus Prolapse Among the 37% of women with prolapsed uterus, it first occurred in 58% at the age of 20-29 years, for 21% at the age of 30-39, 7% at 40-49 Duration of Suffering years of age and 2% at 50 and more years. Earliest onset on this The women had been suffering from UP for periods ranging from 6 survey is 14 years. months to 45 years. Among them, 29% had been suffering for 5-10 years, 20% for 10-20 years, 15% for more than 20 years and 14% for 0- Graph 8: 2 years. Age of Women at First Uterus Prolapse Graph 10:
Comparing the duration by DurationDuration of Suffering of Suffering age groups, 80% of women suffered from UP from the 20+ yrs 0-2 yrs age 15-19, 51% from 20-24 20% 14%
years. This data reinforces the indication of early onset, 2-5 yrs as a high number of women 21%
Percent of ages 20-65 have been 10-20 yrs found suffering from UP for 23% 10-20 years. An average 5-10 yrs duration of UP suffering was 22% found to be 11 years.
Age at First Delivery 65% of the women with UP gave birth to their first child before the age of 19, out of them 4% women gave birth to their first child under the age These figures show that uterus prolapse often occurs from a very early of 15. Only 33% gave birth to their first child after the age of 20. The age. This is confirmed by the data of prolapsed uterus against number graph also shows that 70% of women who have UP had their first of children. 38% of the women had UP after the delivery of their first pregnancy at age 15-19. This figure establishes that the earlier the first child, 23% the second child, 20% after the third child, 8% after the fourth pregnancy and childbirth, the earlier the uterus is likely to become child and 6% after the delivery of fifth child prolapsed. Graph 11: Age of First Child Delivery Graph 9: Uterine Prolapse after Which Child Delivery Percent Percent
Percent
Post UP Pregnancy Quite a number of women had given birth to 1 to more than 5 children even after their uterus had prolapsed. 21% said they had 1 child, 14% had 2, 10% had 3, 4% had 4 and 5% had more than 5 children after
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their uterus became prolapsed. Only a third of them had no further on wage labour, and further highlights the unequal gender relations children after the onset of UP. between men and women in the area.
Graph 12: Women from families who do not produce enough food from their land Number of Post UP Pregenc(y)ies have no choice of work. They have to work for landlords or work as seasonal vendors or labourers, all of which involve carrying heavy loads and/ or digging fields which causes strain to the pelvic area.
Sharing Problems In general, it is a social taboo for a woman to share a private problem such as uterus prolapse. Even the words uterus prolapse 2 are Percent Percent considered a bad to utter. In this study, 32% of women said they had not shared the problem with anyone, 35% shared with their husband, 25% with mother-in-law, 10% each with sisters and sisters-in-law, 5% with friends and 2% with other people, with whom they feel comfortable.
Graph 14: Problem of UP Shared With
Economic Situation Most of the respondents with UP were from the lower economic groups,
especially wage labourers who do not have any land or only a small plot Percent of land. Such groups account for 46% of the total women with UP. A further 19% were from families who produce food adequate for only 6 months of the year and 20% are from the group who produce sufficient food for more than 6 months but not enough for the whole year. Only 18% fall under the groups who produce sufficient food for the whole year and 5% belonged to the group that has surplus food.
The reasons for not sharing with anybody are: 66% embarrassment, Graph 13: 14% were scared, 10% thought the falling of uterus is normal for UP Prevalence & Economic Condition women, 6% thought nobody cares even if they tell them about their problem. 3% were afraid of loosing face in society and 2% were worried their husband would take another wife.
Perce nt Graph 15: Reasons for not Sharing UP Problem Percent Percent
This shows that women from all economic strata can have UP, but incidence is much higher in lower economic groups. It also indicates that even though the family may be better off, the fate of women remains the same. Women are low priority for receiving health care even in better off families. Another factor to consider is that better off farming families may have a heavier work load than even those who live 2 Ang khasne, patheghar khasne in central and eastern Nepal, Dheuko, Chelaghar khasne, Ghando khasne is far western Nepal, Bhanr nikalchhai in Tharu, Deh or Bachhadani nikalchhai in Maithili.
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(31%), white discharge with foul smell (34%), difficulty in walking (28%), There were various reactions from the families after they knew that the difficulty in standing (26%), problems in urination (25%), burning while women had UP: 57% did not say anything, ignoring the issue urinating (23%). 4% among them had ulcerated uterus. The data was completely. 13% suggested the women to seek treatment and 11% took compared with those women who did not have UP but had complaints her for treatment. 7% showed sympathy, 5% scolded the women. 4% related to reproductive health. Apparently more women with UP have of husbands beat them and 4% made the women lose face in society. more problems. Graph 18: Graph 16: Severity of UP Frequency of Fa lling of UP Reaction of Family to UP Problem Among those suffering from UP, 62% mentioned that it comes out sometimes, and 38% stated that it remains out all the time and does not go inside even while Percent Percent they lie with their feet sloping upwards.
Immediate Causes of Uterus Prolapse 33% women did not specify when their uterus falls. 35% said that their uterus falls when they squat. 35% said it happens when they are lifting a heavy load and 14% said it happens while they are carrying a heavy load. 8% women have frequent uterus falling, both when carrying and It is encouraging to note that more than a third of the women shared the lifting a heavy load. In 3% it happens when they cough. problem with their husband. However, when asked what the reaction was from the family after they shared, it's frustrating that it was mostly Graph 19: ignored. Immediate Situation for UP
Reproductive Health Related Problems
Women with UP noted various other reproductive health symptoms. These included: irritation in the vagina (68%), lower abdomen pain (43%), difficulty in sitting (38%), difficulty in defecating and urinating
Graph 17: 4 Ulceration 0 Symptoms of Reproductive Trouble 31 Difficulty defec-urin-ating 4 25 Inconsistent urination 4 Percent 12 Uncontrolled Urination 6 43 Lower Abdomen Pain 24 These factors can be considered as the tangible immediate causes of 23 Burning while Urinating 1 uterus prolapse. Mental or psychological problems have not been dealt 5 34 in the survey. Foul Smelling Discharge 16 68 Discovering UP Vaginal Itching 6 Women with uterus prolapse mentioned different situations when they 38 Sitting Difficulty 7 first knew their uterus 'fell off'. 24% women said it first happened when 28 Walking Difficulty 4 Women with UP they were squatting, followed by coughing, defecating and urinating for 26 Women without UP 20% women. 18% knew when they saw and touched their vagina they Standing Difficulty 6 could feel it was outside, 14% said it fell while they were carrying a 26 None 39 heavy load, lifting weight and when they had a heavy workload. A few 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 women also mentioned it fell when they were climbing up or down a Percent
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Graph 20: with literacy, but education above literacy level does not seem to make Discovering Falling of Uterus a significant difference.
Age of Marriage Graph 22: The practice of Age of Marriage of Women with UP 60 early marriage is 53 widely found in 50 Nepal - more in 40 the terai. Figures 31 show that women 30 from Siraha and Saptari get 20 mar r i e d very 10 8 6 early, as young 1 as 5 years old. 0 5-9 10-14 15-18 19-24 25-30 Percent
Percent The diagram shows that 53% of women with UP were married at the age of 15 -18 years, 31% at 10-14 years, 8% at 5-9 years and 6% at 19- tree. 10% women knew because of physical discomfort such as back 24 years. Only 1% of women with UP were found to have got married at pain, bleeding, lower abdomen pain, unease while walking and the age of 25-30. Among the total respondents, over 93% of girls were standing, irritation and weakness. 11% women with uterus prolapse did married under the age of 18. The Tharu community has the tradition of not mention any situation. 'gauna', which means that after an early marriage girls stay in their parents’ house for some years until they are more grown up. The Women with UP said they were doing different work when their uterus average age of marriage was found to be 15 years. fell. 40% mentioned they had a heavy work load, with continuous intense work and were feeling weak. 36% said they were lifting a load, Nutrition Graph 23: carrying a load, husking and pounding rice, grinding corn, collecting The number of meals per day water, chopping firewood, washing clothes and so on. 8% recalled that was taken as an indicator of Number of Meals per Day it happened during childbirth, 3% said they felt it when urinating, nutritional status for the defecating and coughing, 2% mentioned working in a squatting position. women. Women from the Two times 1% women stated it happened when their lower abdomen was pressed survey area mostly take food 34% hard by birth attendants to get the baby out, or when they wrapped 3 times a day (63%). 34% clothes tightly around their waist or were massaged after childbirth. have meals twice a day while Three
2% have only one meal a Two times times 63% 6.4. Factors Affecting UP day. Since the high 2% percentage who eat three Education Graph 21: times a day does not Among the women UP Prevalence and Education correlate with other socio- Four with UP, 85% were times economic indicators and illiterate, 9% had 1% there is no telling if the meal basic literacy 2% was sufficient in nutritional quality or quantity, closer observation and had passed grades discussion with women is required for confidence on this data. 1-4, 2% grades 5-7 and 2% each had Menstruation passed grades 8- Among the respondents, 65% of the women said they have a regular 10 and SLC. menstrual cycle, and 17% are irregular, with 8% having heavy bleeding Figures show that during menstruation. 10% women had already had the menopause. UP prevalence is The same trends were found with the women who had prolapsed highly correlated Percent uterus.
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Graph 24: Food Restriction during Menstruation Menstruation Women were not found to be much subjected to food restrictions during menstruation. 56% women do not have any food restriction. 41% do not take sour food and 1% each are restricted from having milk, fish and meat or some other food. These restrictions are very minor compared with the western hills, for example. Still prevalence of UP is not less than in the western hills. Graph 27: Food Restriction during Menstruation
Restrictions during Menstruation Restrictions during menstruation were not found to be strong. 76% women mentioned that they are not allowed to worship, 8% were restricted to some kind of food: mostly sour food, 7% women were not Percent allowed to cook, 6% are not allowed to go outside the surroundings of house and 10% are not allowed to sleep with their husband during menstruation.
Graph 25: Restriction: During Menstruation
Place of Giving birth A total of 91% of Graph 28:
respondents gave birth Place ofPlace Child Delivery of Child Delivery in their own In-laws (husband’s) house. House
Percent Only 5% went to 91% hospital for delivery and 2% went to their Cowshed parents’ house, which 0% is a common practice Not Parental across the terai. answered Hospital House Unlike in mid and far 2% 5% 2% Place of Stay during Menstruation west region, none of 95% of women stay inside Graph 26: the women had given birth in the field or in cowsheds. Despite the house during Place of Stay during Menstruation Period increased accessibility, the proportion of women going to the hospital is menstruation, 5% stay in low compared with areas studied in the far western districts. a separate room. Unlike Labour Pain in the mid and far western 24% women had labour pain for 1-3 hours before giving birth, followed hill regions, women of by 22% who endured labour pain for 1 day, 20% had labour pain for 4-6 Siraha and Saptari are not made to sleep out hours, 18% had pain for more than 1 day and 15% had labour pain for 7-10 hours. No reasonable correlation could found between a long with the animals or in labour and occurrence of UP. However, it is possible that both the 'chhaupadi' a small shed enumerators and the women may not have been accurate about timing. outside their house.
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Graph 31: Graph 29: 30 Duration of Labour Pain Birth Attendant during Child Delivery 24 25 22 20 20 18 15 15 Percent Percent
Percent Percent 10
5 2
0 1-3 4-6 7-10 1 Day >1 Day No answ er
Waist Wrapping Practice Graph 30: The majority of the women Women with UP: Wrapping Cloth in Siraha and Saptari do Food during the Post Natal Period Around Waist not wrap a tight cloth 54% of the women take normal meals of rice and vegetables during the All over the Waist post natal period, 33% take rice or roti with meat or fish, 22% take rice around their waist after (29%) childbirth. This may be due or roti with vegetables and milk products, 13% take rice or roti with to the hot climate or just lentils and beans. However, 11% women take only rice or roti with salt tradition. It was found that after child delivery. Most of the women are given only ginger and 59% do not practice this at From the No Practice jaggery, juwano, sathaura (a mixture of herbs) for at least the first six all, 29% wrap a cloth all Bottom 59% days after childbirth. over the waist after Graph 32: childbirth. 8% wrap the From the cloth from the top bringing Top Food Taken After Child Delivery it downwards and 4% wrap the cloth from the bottom, bringing it upwards. This contrasts markedly with practices in hill areas, where it is believed that it keeps the waist warm and strong and helps to make the belly firm. Wrapping the cloth downwards is not recommended medically, as it stretches the ligaments allowing the uterus to move down. The waist wrapping practice trends found among the women with UP were similar to those without, Percent indicating no correlation between this and UP.
Birth Attendance It was found that women normally receive help during childbirth from family, neighbours and TBAs. 52% women said they were attended by their mother-in-law, 50% received help from neighbours, 44% from TBAs. Only 10% received services from trained health workers and 2% said they had no help from anyone. Thus most women in the area 76% women are not allowed to have yogurt, 30% cannot have meat deliver their babies without a trained birth attendant. products, 24% are not allowed rice or roti and 24% cannot have vegetables after the birth. Some of the restrictions last for six months.
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it was noted that women have insufficient nutritious food and rest during pregnancy and the post natal period. Graph 33: Women with UP: food Restriction after Child Delivery 6.5. Perceptions of Women on Reproductive Health Related Issues
Perceptions on Menstruation In general, men and women Graph 35: perceive the menstruation as Knowledge on Menstruation Cycle the curse of God and women are considered impure during menstruation. There are
Percent many social taboos and restrictions during menstruation. Respondents were asked what they think about menstruation, as activities during this time can be a cause of UP. 46% said that it is made by God, 37% of Work during the Post-natal Period them do not know what to In general, women from most of the parts of Nepal start working soon think, 12% said that it is after childbirth. Among the women with UP in the area, 40% start light because egg gets matured in work within 12-15 days. 32% start within 11 days. 26% start heavy work ovary and comes out in a monthly cycle. 3% mentioned that it is dirty within 15 days. 2% even start heavy work in less than 6 days and blood which comes out in a monthly cycle, while 2% said blood gets deposited in uterus regularly and comes out in a monthly cycle.
Graph 34: Perceptions about Conception of a Girl or Boy Comparison: Start Light and Heavy Work 49% of respondents said that God makes the child a girl or boy, 56% said that it depends on the husband, 31% said that it depends on the wife and 10% did not know. Graph 36: Perception on Conceiving Boy or Girl Child Percent Percent Percent Percent
another 3% start within 7-11 days. Comparing the type of food given to the women during post natal period and the work they have to perform,
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Perception on the Causes of UP However, it was found that almost all the women did not know about A total of 37% of women have been suffering from UP in the study area, treatment after the onset of UP. A few mentioned use of ring pessaries and it was found that most of the women are aware of the causes. 43% and herbal therapy. Very few women said they went for treatment after child bearing at an early age, 43% said it is because of carrying heavy their uterus became prolapsed. loads during pregnancy, 37% said it is because of working immediately after childbirth, 32% said it is due to lack of care during the post natal Graph 38: period. 28% said pressure on the lower abdomen during childbirth, 16% said it is because of lack of a balanced diet and nutritious food, 9% said Perception on Prevention of UP it is due to multiple births. A few respondents (5%) said it is because of their fate and 2% said it is normal for women.
Graph 37: Perception on Causes of UP
Percent
*** Percent
Perceptions about Prevention of UP Women from the study area are not only aware of the causes of UP, most of them are also aware of the solutions. 39% said the solution would be taking a minimum of one month’s rest after childbirth, followed by 36% who said not doing heavy work during pregnancy and the post natal period. 31% said marrying girls at appropriate age (not too young), 22% said having nutritious food and good care the during post natal period. 18% also mentioned families sharing the work, 16% said using a trained birth attendant for childbirth, 8% by limiting childbirth. 2% said love and respect from the husband. 16% said there is no solution for UP.
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7. Summary, Conclusion and Recommendations
7.1. Prevalence
7.1.1. The average prevalence of uterine prolapse in Siraha and Saptari was found to be 37%, with Saptari an astonishing 42%, higher than any other district studied by CAED. The findings of this study therefore challenge the widely held belief that UP is not highly prevalent in the terai, compared with the western hills, and strongly indicate a high prevalence of UP in all parts of Nepal, whether hills or terai. The Nepal Institute of Medicine (IoM, 2005) found similar results from studies conducted in Rautahat (clinic- based study) and in Saptari and Siraha (community-based study), contradicting the findings of a clinic-based study carried out by Safe Motherhood Network Federation (SMNF, 2005) that the prevalence of UP amongst the hill women was 15% and among terai women 5%. Reasons for these low findings may be the small number of respondents covered in the study, since it was limited to those who came to the reproductive health camps, who are likely to be those with time or who live nearby or are economically not the worst off.
7.1.2. The study shows that women from all social groups suffer from prolapsed uterus, with those from dalit communities having the highest prevalence compared with the terai indigenous groups (mostly Tharu) and other terai groups such as Brahmin, Chhetris, Thakurs, Telis and Halwai etc. However, the difference in UP prevalence amongst the social groups covered in the study is not large, proving that women from all social groups are significantly affected. Women of all ages were also found to be affected, even those who are relatively young.
7.2. Causes
7.2.1. The survey shows a relatively strong relationship between UP and economic condition. Women from the families with land and adequate food for the whole year are less affected. Intuitively it would be expected that women from the lower economic strata would be malnourished, but most respondents said they eat three times a day, even those from poorer families. Without further investigation of the quality and quantity of this food or the honesty of the answers, it is not possible to establish a relationship between UP and nutritional status. Most of the women said they have normal food (rice or roti with daal and vegetables) during the post natal period following the first four to six days (during which they only have ginger and molasses). This widespread practice of food deprivation during the immediate post natal period does indicate a lack of nutrition during this critical time, when a woman needs to rebuild her
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strength. A report by Bonetti et al (2002) shows a positive children the women had, which ranges from 1-9, with 55% having correlation between poor nutrition and prevalence of UP. 3-5 children, 25% 1-2 children and 18% 6-10 children. It is not clear whether the women really agreed or wanted to have that 7.2.2. The hypothesis of multiple and frequent child birth as the major many children, and this needs further detailed study. The cause of UP is not supported by the findings of this study, as a statement by Acharya, that a woman in Nepal has no security if large number of the women with UP (59%) suffered first onset her fertility fails, would indicate that women agree to have many after giving birth to their first or second child. Rather it is children because they know it is expected, rather than because suggested that early child bearing is among the more important this is what they want or feel able to cope with. causes. In some cases first delivery was found to have been at a very young age, as young as 14 and 61% of women with UP had 7.3.4. The role of education has been found to be quite strong in the their first child at less than 19 years of age. Similar results were study, almost all the illiterate women had UP. Similar findings found in the studies of IoM, Bonetti, SMNF, including Ravindran were reported in the studies of IoM, SMNF, CAED, and Bonetti. (2005) in India. This also correlates with early marriage. Almost It can be concluded that women who do not have access to all the women in the study area were married before the age of education are more prone to prolapsed uterus. 20 years, with the mean age of marriage found to be 16 years. 7.4. Gender Relations and Self-Awareness 7.2.3. More than 95% of the women gave birth without trained assistance. Many national and international papers state that 7.4.1. Women in the study area have heavy work loads, with 10-14 one of major causes of uterus prolapse is intra-abdominal hours of continuous intensive work. They do not have the option pressure during child delivery. Although some of the women of stopping, even during pregnancy and the post natal period. reported being subjected to this treatment and afterwards being They also do not receive any special (nutritious) food during affected by UP, a clear conclusion on this could not be drawn. these critical periods. The women said their work includes a lot of However, Bonetti et al (2002) report that an increase in intra- carrying and lifting of heavy loads, which is associated with falling abdominal pressure especially during the immediate post partum of the uterus. Many noted the onset of UP while carrying and period, is a contributing factor for genital prolapse in Nepal. lifting loads during post natal period, when they were feeling weak. This indicates that lack of attention to women’s health 7.2.4. Cultural restrictions, such as untouchability or food restrictions needs, associated with discrimination, is a root cause of UP. An during menstruation and childbirth, were not found to be ADB report (1999) also mentions that social discrimination significantly practised compared with hill caste groups, despite against women is felt to be more severe in the terai communities the fact that the study area has a strong Hindu influence. and in the mid-and Far-Western Development regions in general.
7.3. Characteristics of Uterus Prolapse 7.4.2. Most of the women are aware of the causes of the UP, with a large number mentioning early marriage, carrying heavy loads, 7.3.1. Nearly 76% of the women with UP women reported occurrence working immediately after childbirth, lack of post natal care, intra- while lifting and carrying heavy loads, collecting water, chopping abdominal pressure. However, most were not aware of the firewood, husking and pounding rice. They also mentioned its treatment available, although they knew some preventive occurrence immediately after childbirth. Heavy work load appears measures, such as delaying marriage, taking rest during the post to be the most direct cause of UP, which points to a need for natal period, family sharing the work and limiting the number of information and gender education within families. children. The women do not seem to see any alternatives to their present situation that will prevent their developing prolapsed 7.3.2. Over half of the women first discovered their UP when in a uterus, mainly because of the social norms and traditions squatting position. Although this does not indicate that squatting practiced by their patriarchal society as well as the level of is the cause of UP, it does suggest that working in a squatting poverty in which they live. position is not good for women. This needs to be investigated in more detail. 7.4.3. The decision to use a family planning device needs further study. Most of the women said that husband and wife decide together 7.3.3. Most of the respondents reported that decisions about the on this. 59% of the women were not using any birth spacing number of children to have are made jointly by husband and wife, methods. Among those who were using something, the emphasis including use of family planning devices and abortion services. seems to be on devices used by women, with over 23% having However, this is contradicted by the high average number of had minilap surgery and 12% using depo-provera . Very few of
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the men were said to be using a family planning method. Acharya states that most contraceptives are directed to women, even for g) The government should look for funds from donors to support sterilisation the focus has been on women. specific work on UP and related problems.
7.4.4. It is not that women do not speak out about their problem. Over 7.5.2. Social aspects half of the women said they did tell their husbands about their a) Awareness on the prevalence and causes of uterine prolapse is prolapsed uterus. Study showed, 57% husbands did not show important, targeting different groups, such as adolescents in and any reaction to this information. This strongly suggests a male out of schools, newly married couples, husbands and mothers-in- dominated lack of concern for a “women’s problem” and the need law, health workers, volunteers and traditional birth attendants, for a rights based approach to UP, enabling more women to UP affected women. speak and obliging others to listen and help.
b) The above target groups need to be aware of both the social and 7.5. Recommendations medical causes of uterine prolapse. Since the most of the 7.5.1. Policy Interventions causes are related to gender issues, awareness should be a) Neither the National Reproductive Health Strategy nor the Second focused on gender discrimination, patriarchy, reproductive health Long Term Health Policy include UP as an important reproductive and rights of women. or public health issue. It is recommended that UP should be included in the Health Policy and Reproductive Health Strategy. c) Uterine prolapse should not only be viewed as a problem of This problem should be considered an important part of part of women, it should be taken as an issue of a families, society and Safe Motherhood and Reproductive Health as a whole. No UP the country as a whole. A mass campaign for reducing the services have been found at local health posts in the study area prevalence of uterine prolapse should be undertaken at the level and the same is true of other studies. UP must be included in the that has been undertaken for HIV/ AIDS. list of Essential Health Care Services, so that local health posts can provide clinical services and advice to the women suffering d) Women and men in the community should be organised to from uterine prolapse. demand the services needed for uterine prolapse at different levels. b) Health workers should be provided with orientation and training on both preventive and curative aspects of UP. e) Social researchers need to be introduced the UP problem to study it further from different sociological perspectives, to provide c) In the medium term, the government should allocate a budget for a basis for making UP a national issue. hysterectomy camps and prepare a strategy for providing hysterectomy (surgery) services in district or regional hospitals for 7.5.3. Medical aspects
women with severe UP. a) Practices during childbirth and the post natal period need to be studied in detail, as there is literature that relates prolapse of d) UP issues should be incorporated in the relevant curricula of uterus with unsafe practices during these critical periods, such as school grades 9-12, and for Health Assistants, Community intra-abdominal pressure and excessive massage during the post Medical Assistants and Auxiliary Nurse Midwives under natal period, especially in the terai. reproductive health topics. b) UP is noted in the literature as a part of public health; however, e) The government and concerned civil society organisations should people involved in public health do not appear to see it as a major work with the mass media to raise awareness on UP issues, public health issue. It is viewed as a problem for individuals only. through radio, TV, print media. More sustained and explicit This issue should be discoursed among sociologists and messages are necessary to draw attention to this. medical/health personnel. f) The government should allocate tasks for different sectors, such as curative service providers, social service sectors, human resource development and media for effective delivery of services. There should be a forum to exchange information and build synergy amongst the concerned stakeholders. ***
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The Cases References
The Pain of Living with Uterus Prolapse Acharya, M, 1997. Gender Equality and Empowerment of Women, UNFPA, Nepal. Sikilbatti Yadav, 40 , lives in ward no. 5 of Jamuni Madhyapura VDC in Saptari. She ADB, 1999. Women in Nepal, Country Gender Assessments. Asian was married at the age 16 and has two children. Her husband married her as a second wife, since the first wife could not have children. Development Bank. Anderson, M L, 1988. Women Health and Reproduction, Thinking About She developed a uterus prolapse after giving birth to her second child. Once, she felt Women: Sociological Perspective on Sex and Gender, USA that something was coming out from her vagina, while she was sitting (squatting). Bhasin, K, 2003. Understanding Gender, Women Unlimited, India Then she saw a part of her organ coming out of her vagina. She told to her sister Bhasin, K, Khan, NS, 2004. Feminism and Its Relevance in South Asia, about the problem. Her sister consoled to her that it will be alright and she was suggested to use herbal medicine, which she did for quite some time, but it did not Gender Basics, Women Unlimited, India help. Bhasin, K, 2005. Purush, Purushatwa ra Purush-wad: Kehi Prashna ra Bisleshan, Shtri Shakti, Kathmandu She told to her husband about the problem. He suggested her to go for surgery, but Bhasin, K, 2004. Patriarchy, Shtri Shakti, Kathmandu said she might die during surgery; she was scared and would not go for surgery. She Bonetti, TR, 2002. Reproductive Morbidity: A Neglected Issue? A had to face that problem all alone. She kept on telling her husband about the problem, but he did not care as he did not want to spend money for her treatment. She wants to Report of a Clinic-based Study held in Far-western Nepal. get rid of her problem even if she has to go for surgery, but she has no money to do it. Ministry of Health, GTZ and UNFPA, Kathmandu, Nepal. CAED, 2003. Sudur Paschimko Rupantaran: Kehi Abhyas ra She recalls her life in the past, when she was happy and well. It has been 18 years Anubhutiharu (Nepali text translated as Transformation of the since her uterus has fallen. She feels that she has been living a life in hell. She has Far western Nepal: Experience from Practice). CAED, difficulty in walking, sitting (squatting), standing, defecating and urinating. She has a white discharge continuously. With all these difficulties, she has to do her daily Kathmandu. chores. Her husband scolds her and does not care anymore. She does not know CAED, 2006. WRRP Activity Report # 2 & 3. Women Reproductive how she will live the rest of her life. She is frustrated with her life; she does not want Rights Program (WRRP), Progress Reports, Sustainable to participate in any social functions in village. Livelihood Program (SLP) Centre for Agro-ecology and Development (CAED), Kathmandu. A Woman with No Hope in Life CBS. 2002. Population Census 2001. National Report. Central Bureau of Statistics, Government of Nepal. "It is better to die than to live with this condition" says 70 years old Satyawati Devi Deuba, AR, and Rana, PS, 2005, A study on Linkages Between Ram of Madhupatti VDC in Saptari district. Satyawati was married at the age of 9 to a boy of 10. She had her first menstruation three years after she was married. She Domestic Violence and Pregnancy, SAMANAT-Institute for gave birth to her first child, a boy, at the age of 14. He died immediately after his birth. Social and Gender Equality, Kathmandu Altogether, she gave birth to 9 children; two died and she now has 5 sons and 2 Deuba, AR and Rana, PS 2005. Uterus Prolapse: A Key Maternal daughters. Her husband died after the birth of the youngest child. After the death of Morbidity Factor amongst Nepali Women: A Study. Safe her husband, she had to carry out all the work by herself, taking care of the children, Motherhood Network Federation, Kathmandu, Nepal. working in field and daily chores. One day, she found that her uterus had fallen off. She did not get any treatment for the problem. All her sons and daughters are married Gurung, R, 2006. Uterine Prolapse: A Hidden Tragedy for Women in and living separately, except a son who is physically impaired. She works for other Nepal. A Presentation in the Seminar organized by UNFPA on families to earn her living. July 2006. Hockey, J, 1997. Women and Health, Edited by Robinson, V and She has lived with her fallen uterus for 32 years. She was only 38 when her uterus fell Richardson, D, Women's Studies, London. for the first time. She gave birth to 3 children after this. She saw her uterus coming out when urinating. She thinks that her uterus fell because she had to work hard, IOM, 2006. Status of Reproductive Morbidities in Nepal. Institute of pounding rice, planting rice, carrying and lifting loads. She did not tell anyone about Medicine, Tribhuvan University. (A commissioned study by her problem because of shame. One day, she was planting rice with friends and went UNFPA). to pee in paddy field, her friend saw and said her womb had fallen off. Now everybody ISRSC, 2004. District Development Profile of Nepal. Informal Sector in her village knows. Research and Study Centre, Kathmandu.
She has difficulty in walking, sitting and working. Her fallen uterus is ulcerated. She MoH. 1996. National Reproductive Health Strategy. Ministry of Health, does not know where to go for treatment. She knows other women in her village also Government of Nepal. have the problem and are the same condition as her. She says they get scolded by Prolapse: A Qualitative Study from Tamilnadu, India. mothers-in-law and husbands when they cannot work. The men do not care about www.rhmjournal.org.uk/PDFs/sundari.pdf their wives, but rather look for another woman.
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Rajbhandari, RR, 2004. Mahila Swasthya, Ke, Kina ra Kasari, Newspapers and Magazines Kathmandu Rajbhandari, B, 2004. Sayapatri, WOREC, Kathmandu Janghamagar, B, 2007, Kantipur Daily (13 Falgun, 2063), Kathmandu Sama, 2001. Advancing Rights to Health: The Indian Context, Sama, Pant, DR, 2006, Kantipur Daily, Kathmandu India. Joshi, R, 2006, Himal Magazine, (1-15 Mangsir, 2063), Kathmandu Subba, B, D Adhikari and T Bhattarai. 2003. The Neglected Case of Laukal, T, 2006, Nari Magazine, Kathmandu the Fallen Womb. Himal South Asian, April, 2003, Kathmandu. Paradarshi National Daily, 2006, Chitwan (15 Bhadra, 2063) Gurung, R. 2006. Uterine Prolapse: a hidden tragedy for women in Bhattarai, T, 2003, Dheukho ko Pida, Kantipur Daily (1 Chaitra, 2059), Nepal. A presentation made on the same theme on 10 July Kathmandu 2006 organized by UNFPA, Kathmandu. Jhankri, RK, Bhusal TL, 2003, Rajdhani Daily (8 Chaitra, 2059) Tamang, S. 2004. Nepalma Bikase Naribad, Nepalko Sandharvama Chitrakar, J, 2003, Dheuki: Narika Pakchhama Maun Chitkar, Kantipur Samaj Shastriya Chintan. Social Science Baha. Himal Daily (24 Falgun, 2059) Association. Thapa, D, 2004, Nepal Samachar Patra, Kathmandu National Planning Commission. 2003. Tenth Five Year Plan (2059- Sharma, B, 2004, Rajdhani Daily, (21 Asar, 2060), Kathmandu 2064): National Planning Commission, Kathmandu. Poudel, A, 2004, Rajdhani Daily, (21 Asar, 2060), Kathmandu TK Sundari Ravindran, R Savitri and A Bhavani, Women’s Annapurna Post Daily, 2003, (1 Shrawan 2060), Kathmandu Experiences of Utero-Vaginal Prolapse Gorkhapatra Daily, 2003 (19 Asar, 2060), Kathmandu Upreti, A. Bhattarai, K. Onta, SR 2001, Ed. Where There is No Doctor, RHEST-Nepal, PHECT-Nepal. Upreti, A. Uterus Prolapse Problem and Solutions, 2006. Family Planning Association of Nepal, Kathmandu. Watson, R. 1975. Some Observations on Uterine Prolapse in Western *** Nepal. A journal of Nepal Medical Association. Kathmandu (referred in Bonetti, 2002).
Websites www.uterineprolapse.org www.intelmedical.org www.nlm.nih.gov/medlineplus www.netdoctor.co.uk www.emedicine.com www.rhmjournal.org.uk/PDFs/sundari.pdf
Papers Presented at Conferences
Rajbhandari R, 2006, Prolapsed Uterus: an indicator of Human Rights situation of Nepali women. Shakya T, 2006, Uterus Prolapse Leading to Gender Based Violence, RHIYA/PHECT-Nepal, Gurung, R, 2006, Uterine Prolapse - A Hidden Tragedy for Women in Nepal, UNFPA Dangal, G, 2006, Overview of Genital Prolapse and Experiences of Managing Genital Prolapse Surgically in remote places of Nepal. KMH-PHECT-Nepal
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Southern 44% Population 250 2000 Survey Annexes Achham based undertaken by CAED- Annex I Sustainable Livelihood Reports of UP Prevalence in Neal Programme'
Survey in 5 VDCs Coverage Preva- Type of Sample Year Remarks/Source, in Achham lence Quantification Size of Reference (%) Report TU, 70% Clinic based 420 1998 Dr Ashma Rana's Teaching Study among 8 districts 10% Clinic based 2,207 2006 A commissioned Hospital women consulting Study for UNFPA a Gynecologist over 2050-56 BS Siraha 30% Population 969 2006 Survey period (referred in based undertaken by Himal 1-15 CAED-Women's Bhadau, 2058) Reproductive Dharan and 81% Clinic based 100 1998 Public Health Rights Program- Biratnagar Expert Bimala Lahan Neupane – they Saptari 42% Population 1,301 2006 Survey had it at least for based undertaken by 15 years (referred CAED-Women's in Himal 1-15 Reproductive Bhadau, 2058) Rights Program- Jumla 17% not known not 1996 Mentioned in Lahan known GTZ/HSSP's 10 districts 9% Clinic based 4,518 2005 A Study by Safe Report Motherhood Network Pokhara 1500 Clinic based not 1960 Mentioned in Achham/Doti 25% Clinic based 2,072 2002 GTZ/HSSP's known GTZ/HSSP's mobile clinic in Report Doti, Achham - report Ramechhap 37% Clinic based not 2002 Among the known visitors of *** Manthali Health Post (Kantipur, 3/4/2059)
Dang 35% Clinic based 426 2002 Number of women
among affected
who required
immediate
surgery
(Gorakhapatra,
28/10/59)
Dolakha 20% Clinic based 985 2002 Data from the clinic (Rajdhani, 10/5/2059)
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Annex II 11 INF-Nepal Surkhet, List of Agencies Working on UP Nepalgunj, Mugu, S.N Organisation District Contact Person 12 Kirtipur Kathmandu - Rabinda B Shreatha 1 ADRA-Nepal Doti, Banke, Chandeshwari Tamrakar Volunteer Kirtipur 9851046921 Bardiya, Society Municipality 2 Britain Nepal Khotang Ram Deo Chaudhari 13 Merlin-Nepal Dang, Banke Medical Trust Panchthar 021-532653,532305 (BNMT) Shankuwasabha [email protected] 14 PHDC (Public Central, Far and Raghunath Giri Health Mid west region 2083162 3 CAED-WRRP Doti, Achham, Samita Pradhan Development (Women's Dailekh, Jajarkot, Moti Rai Centre) Reproductive Surkhet, Banke, 6632942, 9851070634 15 Phect-Nepal/ Kathmandu, Dr Ganesh Dangal Rights Bardiya, Siraha, [email protected] Kathmandu Dhanusha, Dr Basanta Maharjan Program- Saptari Model Hospital Mahottari, Centre for Saptari, Agro-Ecology Dadheldura, Doti and 16 RHDP/SDC Dolakha, Harka B. Thapa Development) (Rural Health Ramechhap, RHDP/SDC 4 COSAN Banepa COSAN Development Okhaldhunga 5522020 [email protected] Dhulikhel, 6631284, Bhaktapur Program) Kathmandu Pbox: 10279 Lamjung, [email protected] 17 RHEST Kavre, Dr Aruna Upreti Bharatpur, (Rural Health Sindhupalchok, 4437371 5 CREHPA Rautahat, Ananda Tamang and Makwanpur (Centre for Mahottari, CREPA Environment Research on Saptari, 5546487 Service Trust) Environment Kapilvastu [email protected] 18 RSDC Banke, Bardiya Jyoti Mishra Health & .np (Rural self 081-524624 Population Reliance Activities) Development 6 Doctor's Wives Kathmandu Neelima Kafle Center) Association [email protected] 19 Saathi Banke, Sulakshana Rana 9851038363 Kathmandu 9851096689 7 Family No Specific Dr Anu Kushawaha 20 Sahabhagi Darchula Shaligram Sharma Planning service area ; all 5524440 (Darchula Bharatpur-12, Chitwan Association- over Nepal 5524675 District 056-527388,532348 Nepal Hospital) [email protected] 8 FWLD Jhapa, Morang, Purna Shrestha (Forum for Kavre, Chitwan, 4242603 21 Sancharika Kathmandu Yogita Rai/ Babita Basnet Women on Kaski, Lalitpur, Law and Dhankuta Samuha 5546715/ 5538549
Development) 9 Helping Panchthar, Kalpana Shrestha 22 Safe Sarlahi, Banke, Shumbhu Jung Rana Hands, Nepal Sankhuwasabha, 4471920 Motherhood Kanchanpur 5011639 Parbat, Siraha, Network Dhankuta, Udaypur, Nuwakot, 10 HSSP-GTZ Doti, Achham Baitadi,
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23 SOWD Lalitpur Bimala Ghimire Annex III 5573498 List of VDCs, Partner Organizations and Number of Respondents 24 WOREC Udaypur, Siraha, Dr Renu Rajbhandrari District Collaborating VDC Total # Total # of Dalit Jana-jati Muslim Others (Women's 2126124 NGOs of HH Respondents Rehabilaitation
Centre) % % % % Samaj Sewa Dhodna 836 84 25 63 - 12 25 NeSOG All over Nepal Dr. Pramila Pradhan Samita 4486008 Bhadaiya 635 70 30 13 31 26 drpramilapradhan@yahoo. Taregaana 576 60 30 38 - 32 Govindapur com Dalit Mahila Raghopur 838 83 67 4 - 29 26 UNFPA All over Nepal Dr Peden Pradhan Sangh Sitapur 1,154 78 57 3 - 40 Everest Kalyanpur 1,004 96 35 18 4 43 Memorial kalabanzar Source: Uterine Prolapse Alliance, Safe Motherhood Network Siraha Youth Club Bhediya 777 78 23 23 - 54 Federation-Nepal Mahadava 707 70 39 40 - 21 portaha Samudayak Bhawanipur 711 62 60 - - 40 Bikas Manch kalabanzar *** Haunumana 691 73 60 8 1 31 Gar Pra Dha Haridya 647 65 22 23 - 55 Pipra Watawataran 511 67 18 63 - 19 Paschim Samrakchhan Kone Bishnupur 1511 151 79 13 - 8 KattI Muksar 615 62 53 24 3 20 Laligurans Ghoganpur 1,122 111 47 27 1 25 Waawaran Dharamkpur Samrakchhan Tatha 1,309 131 43 23 1 33 Swastha Sewa Kendra Maitighar Jandole 905 90 35 46 6 13 Daiya Hariharpur Samuha 1,655 166 48 22 6 24 Malekpur
Saptari Saptari Dalit 1,438 138 43 14 - 43 Janagaran Jamuni 990 102 43 3 13 41 Sewa Samiti Madhyapura Gaunle Lohjara 1,995 200 52 4 - 44 Jagaran Theliya Samaj 735 74 60 27 4 9 Janchetana Madhupatti 800 80 47 43 - 10 Dalit Sangam haripur 766 77 72 13 - 15 Total Number of 22,928 2,268 1,060 472 59 677 People Percentage 10 47 21 3 30
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Annex IV Annex V Uterine Prolapse Prevalence by VDC Frequency Tables
No UP UP Total F. Table 1: F. Table 2: VDC # % # % Age Group of Respondents Study Population by Social Groups Haripur 49 64 28 36 77 Age Frequency Percent Frequency Percent Group Madhupatti 46 58 34 43 80 15-19 31 1 Hill Dalit 59 2.6 Hariharpur 91 55 75 45 166 20-24 231 10 Terai Dalit 1,001 44.1 Jandol 35 39 55 61 90 25-29 474 21 Hill Janajati 86 3.8 Jamuni Madhyapura 48 47 54 53 102 30-34 492 22 Terai Janajati 368 17 Malekpur 53 38 85 62 138 35-39 379 17 Other Hill Ethnic 68 3 Dharampur 114 87 17 13 131 40-44 267 12 Groups Ghoghanpur 93 84 18 16 111 45-49 150 7 Other Terai Ethnic 588 25.9 Hardiya 18 28 47 72 65 50-54 92 4 Groups Pipra Paschim 31 46 36 54 67 55-59 50 2 Muslim 59 2.6 Lohajara 114 57 86 43 200 60-64 53 2 Others 21 0.9 Theliya 58 78 16 22 74 65+ 49 2 Total 2,268 Raghopur 72 87 11 13 83 Total 2,268
Sitapur 50 64 28 36 78 Dhodna 45 54 39 46 84 F. Table 3: Education Level of the Respondents Taregana 30 50 30 50 60 Education Level Husband Wife Bhadaiya 23 33 47 67 70 Frequency Percent Frequency Percent Hanumannagar Pra-a 56 77 17 23 73 Lliterate 1,032 45.5 1,817 80.1 Bhawanipur 55 89 7 11 62 Basic Literate 318 14 231 10.2 Mahadeva Partoha 52 74 18 26 70 Class 1-4 151 6.7 51 2.2 Class 5-7 224 9.9 61 2.4 Bihsnuhari Katti 135 89 16 11 151 Class 8-10 210 9.3 52 2.3 Muksar 48 77 14 23 62 SLC Pass 200 8.8 47 2.1 Intermediate 53 2.3 2 0.1 Bhediya 56 72 22 28 78 BA or equivalent Plus 37 1.6 2 0.1 Kalyanpur-Kalabanjar 57 59 39 41 96 Not stated 43 1.9 5 0.2
***
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F. Table 4: Uterine Prolapse Prevalence by District Districts No UP Percent UP Percent F. Table 7: Uterine Prolapse after Which Child Birth Saptari 750 58 551 42 Child Birth Frequency Percent Siraha 679 70 228 30 None 3 0 Total 1,429 63 779 37 First 323 38
Second 190 23
Third 169 20
Fourth 67 8 F. Table 5: Fifth 25 3 Prevalence of Uterus Prolapse by Social Groups Sixth 9 1 Social Total number Number UP UP Seventh 12 1 Groups of of percent Percent Eighth 8 1 Respondents women within Among Ninth 2 0 with UP same Total Don’t Know 31 4 group number of Total 839 100 women with Up Hill Dalit 59 17 29 2 F. Table 8: Terai Dalit 1,001 306 31 36 UP Occurrence Years Hill Janajati 86 24 28 3 Age Group Frequency Percent Terai Janajati 386 172 45 21 Other Hill 0-2 Yrs 118 14 Ethnic 68 37 54 4 2-5 Yrs 174 21 Groups 5-10 Yrs 185 22 Other Terai 588 250 43 30 Ehnic Groups 10-20 Yrs 201 24 Muslim 59 26 44 3 20+ Yrs 164 20 Others 21 7 33 1 Total 839 100 Total 2,268 839 37 100
F. Table 6: F. Table 9: Age of Women at First Uterine Prolapse Number of Post UP Pregnanc(y)ies Age Frequency Percent # of Pregnancy Frequency Percent Below-14 1 0.1 0 273 33 15-19 99 12 1 173 21 20-24 280 33 2 115 14 25-29 208 25 3 87 10 30-34 97 12 4 35 4 35-39 77 9 5 23 3 40-44 40 5 6 11 1 45-49 17 2 7 4 0 50+ 20 2 8 2 0 Total 839 100 9 1 0 Not answered 115 14
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F. Table 14 F. Table 10: Symptoms of RH Problems UP Prevalence & Economic Condition Women without UP Women with UP Symptoms Food Sufficiency Frequency Percent Freq Percent Freq Percent Surplus 42 5 None 555 39 597 26 Sufficient for 12 Months 148 18 Standing Difficulty 84 6 235 26 Sufficient for 6 Months 168 20 Walking Difficulty 60 4 323 28 Sufficient for <6 Months 161 19 Sitting Difficulty 100 7 455 38 Vaginal Itching 50 6 570 68 F. Table 11: Foul Smelling 92 16 146 34 Women with UP Shared Problem With Discharge Persons shared Frequency Percent Burning while 225 15 284 23 Nobody 270 32 Urinating Husband 290 35 Lower Abdomen 220 24 195 43 Pain Mother-in-law 212 25 Uncontrolled 80 6 364 12 Sister-in-law 86 10 Urination Sister 86 10 Inconsistent 52 4 102 25 Friend 45 5 urination Brother 2 0 Difficulty defec-urin- 54 4 207 31 Others 13 2 atin Ulceration 5 0.3 36 4 F. Table 12: Reasons for Sharing UP Problem F. Table 15: Reasons Frequency Percent Immediate Cause of Falling of UP Embarassment 177 66 Causes Frequency Percent Scared 29 14 Various Working situation 170 32.9 All women have the same 24 10 Carrying heavy load 74 14.3 Nothing happens 15 6 Lifting heavy load 38 7.4 Lossing face 7 3 Squatting 181 35.1 Bringing 2 nd wife by husband 5 2 Coughing 14 2.7 Carrying & lifting 39 7.6 F. Table 13: Reaction of family Members on UP Problem F. Table 16: Reaction Frequency Percent UP Prevalence and Education Level Ignored 478 57 Education Level # of Women with UP Percent Sympathized 62 7 Literate 712 85 Scolded 46 5 Basic literate 74 9 Class 1-4 14 2 Beaten 32 4 Class 5-7 13 2 Looked down upon 70 8 Class 8-10 13 2 Took for treatment 95 11 SLC and above 13 2 Suggested to go for treatment 105 1 Others 5 1
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F. Table 17: Age of Marriage of Women with UP Age Group Frequency Percent 5-9 65 8 10-14 258 31 15-18 445 53 19-24 52 6 25-30 7 1 30-40 4 0 Don’t know 8 1 Total 839 100
F. Table 18: What can be the Solution for UP Problem? Solution Frequency Percent Don’t 574 68 Exercise 98 12 Herbal medicine 2 0 Ring Pessary 107 13 Surgery 24 3 Others 15 2 Ex & herb 8 1 Ex & ring 2 0 E, RP & Herb 8 1
F. Table 19: What was Done for Treatment? Treatment Frequency Percent Don’t know 612 73 Herbal medicine 104 12 Ring Pessary 104 12 Surgery 5 1 Others 11 1 RP & Herb 1 0 Total 837 100
F. Table 20: Where was the Treatment Received? Place Frequency Percent Nowhere 635 76 Health Post 102 12 Rajbiraj 15 2 Lahan 49 6 Biratnagar 22 3 Kathmandu 1 0 India 10 1 Rajbiraj+Lahan 2 0
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Annex VI Survey Questionnaire on Uterine Prolapse Issues 8_ kl/jf/ lgof]hgsf] ;fwgsf] s] k|of]u ug'{ x'G5 < kf7]3/ em/]sf] ;d:of ;DaGwL ;j]{If0fsf] nflu k|ZgfjnL e) What family planning method do you use? ub}{gf}+ Nothing vfg] rSsL Oral pills 1) Personal Description l8kf] k|f]e]/f Depo-provera s_ JolQmut / kfl/jfl/s ljj/0f g/KnfG6 Norplant tkfO{sf] slt slt hgf tkfO{ slt klxnf] klxnf] clxn] ;Dd slt k6s xfn kl/jf/ sKk/ 6L Copper T gfd / y/ jif{sf] x'g' ;Gtfg jif{ x'+bf k6s ;Gtfg slt k6s aRrf v]/ ;+Vof slt sG8f]d s] xf]< eof]< 5g\< ljjfx ue{jlt hlGd+bf ue{jlt x'g' uof]\< 5g\< Condom Name of Age Number of ePsf]< x'+bf slt slt jif{sf] eof]< # of # of total ldlgNofk Minilap respondent children Age of jif{sf] # of total miscarriage family Marriage x'g'x'GYof ]< pregnancy + children members Nofk|f]:sfkL Laproscopy x'g'x'GYof]< Age at first died Eof;]S6f]dL Age at first child birth Vasectomy pregnancy cGo Othere
r_ tkfO{x?nfO{ cfkm\gf] hUuf hldg af6 slt vfg' k'U5 < f) How much food sufficiency do you have from your own land?
jif{ e/L jif{ e/L ^ dlxgf 5 dlxgf hldg cGo vfP/ cfkm\gf] ;Dd eGbf sd 5}g, Other a]Rg v]t af/L cfkm\gf] cfkm\gf] Hofnf u/L k'Ug] af6 vfg v]t af/L v]t af/L vfg] pAhgL k'U5 af6 vfg af6 vfg No land, v_ >Ldfgsf] gfd s] xf] >Ldfgsf] pd]/ slt xf] < Sufficient wage Husband's Name Husband's Age x'G5 k'U5 k'U5 labour b) Surplus for whole Sufficient Sufficient year for 6 for < 6 months months u_ tkfO{+n] slt k9\g' ePsf] 5 < c) What is your education level? n]Vg k9\g n]Vg !—$ %—& *—!) P;=Pn OG6/ SofDk; ghfGg] k9\g sIff sIff k9]sf] l;= Intermediate Diploma 2. Nutrition Illiterate hfGg] k9]sf] k9]sf] Grade SLC @= kf]if0f Literate Grade Grade 8-10 s_ lbgdf slt k6s vfgf / gf:tf vfg' x'G5< k6s
1-4 5-7 a) How many times a day do you take food? Times
3_ tkfO{+ s] sfd ug'{ x'G5< v_ dlxgfjf/L x“'bf s] vfg] s'/f afg'{ x'G5 < b) Wjat food are restricted during menstruation? d) What work do you do? b'w, bxL, df5f, ;fu ;AhL s]xL klg cldnf] cGo s[lif Hofnf ug]{ hflu/ Jofkf/ 3/ cGo dxL, l3p df;' Vegetables afb}{g Sour food Other Farming Wage Service Enterprise Other Jojxf/ Milk Meat Nothing labour Managing product product House u_ ;'Ts]/L x'+bf s] s] vfg] s'/f vfg' x'G5 < c) What food do you take during post natal period (after child delivery)? df;', df5f, ;fu ;AhL, u]8fu'8 b"w, ;fdfGo bfn eft, eft eft, /f]6L L, eft l3p, eft, /f]6L /f]6L, g'g\ Rice, Meat, Rice, Roti, Rice, Milk, Normal: rice, Rice, Fish Vegetables Beans butter roti, lentils Roti, Salt
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3_ ljz]if ;'Ts]/L vfgf s] vfg' x'G5 < ª_ tkfO{n] aRrf hGdfp+bf s:n] s:n] ;'Ts]/L u/fof] < d) What special food do you take during post natal period (after child delivery)? e) Who helped you during last child delivery? alQ;f -;7f}/f_ d;nf cb'jf zSv/ h'jfgf]sf] cGo s;}n] kl/jf/sf >Ldfg\ l5d]sLsf ;'8]gL 8fS6/, cGo Mixture of 32 Herbs Ginger+Mollases emf]n Other u/fpPg dlxnf Husband dlxnf TBA g;{ Other herbs Soup of No Body Women Women Doctor, juwano members from neighbour Nurce family
ª_ ;'Ts]/L x'+bf s] vfg] s'/f afg'{ x'G5 jf vfg' x'+b}g< e) What food are restricted during post natal period (after child delivery)? r_ ;'Ts]/L u/fpg]n] s] s] u5{ < Efft /f]l6 df5f df;' bxL ;fu ;AhL cGo f) What do the birth attendants do during child delivery? Rice, Roti Meat, Fish Yogurt Vegetables Other an ug{ kfgL xft / 3'+8f aRrf tflg aRrf jf ;fn cGo nufp+5 vfg 6]s]/ pleg lbG5 jf lgsfNbf tNnf] Other Help to lbG5 nufp+5 aRrf lgl:sg k]6 lylr lbG5 r_ slt lbg ;Dd vfg' x'+b}g < lbg++======push Give Help kneel d4t u5{ Give pressure f) For how long above food is restricted ? Day(s)...... water down Help to pull to lower child out, abdomen take child out 3. Reproductive Health #= k|hggk|hgg\\\\ :jf:Yo 5_ kl5Nnf] aRrf hGd]kl5 slt lbg b]vL xNsf sfd z'? ug'{eof] < g) Which day did you start light work after child delivery s_ dlxgfjf/L s:tf] x'G5 < l7s} w]/} /ut hfg] a]nfdf gx'g] lbg a) How is your menstruation cycle? OK Heavy bleeding Irregular Days v_ dlxgfjf/L x“'bf tkfO{ sxf“, slt lbg ;'Tg'x'G5 < f) Where do you sleep during menstruation? h_ kl5Nnf] aRrf hGd]kl5 slt lbg b]vL xNsf, ux|f}+, ;a} sfd ug{ z'? ug'{ eof] < 3/df 5'6\6} sf]7fdf uf]7df cGo h) ) Which day did you start heavy work after child delivery At home Separate Cow Shed Other lbg (personal room Days room) lbg Days em_ tkfO{nfO{ klxnf] aRrf hGdfp+bf nueu slt 306fsf] a]yf nfUof] -klxnf] u_ tkfO{n] dlxgfjf/L x“'bf s] s] afg'{ x'G5 < a]yf nfu] b]lv aRRff ghGd] ;Ddsf] cjlw_< c) What food restrictions do you have during menstruation? h) How long did you have labour pain ? s]xL vfg] ksfpg] k'hf ug]{ lx8 8'n ug]{ nf]Ug] ;+u ;'Tg] cGo !–# 306f $–^ 306f &–!) 306f ! lbg ! lbg eGbf a9L Cooking Worshipping Going out Sleeping with Other afb}{g s'/f 1-3 hours 4-6 hours 7-10 hours 1 day More than 1 day Nothing Food husband
3_ kl5Nnf] aRrf hGdfp+bf sxf+ hGdfpg' eof] < Where do you give birth to last child? 3/df af/Ldf uf]7df dfO{tLdf c:ktfndf cGo Home Farmland Cowshed Parental house Hospital Other
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4. Uterus Prolapse Problems 6_ olb geg]sf] eP, lsg geg]sf] < $= kf7]3/ ;DjlGw k) If not told, why ? 8/n] Nfhn] OHht >Ldfgn] ;a} eg]/ s]xL cGo Scared Embarrassed s_ kf7]3/ em/]sf] 5, 5}g < 5}g eg] g+= $ sf] -9_ sf] k|Zg ;f]Wg'xf]; . em/]sf] hfnf csf]{ >LdtL dlxnfsf] x'+b}g eg]/ Other 5 eg] $ g+=sf] k|Zg ;a} ;f]Wg'xf]; . eg]/ Nofpg] 8/n] o:t} x'G5 Nothing Due to Husband happens a) Is your uterus prolapsed? if yes, ask following questions. If no, ask Q. 4. ... eg]/ even if told Prestige brings Normal for Issue another wife women v_ em/]sf] slt jif{ eof] < b) For how long ? u_ slt jif{sf] x'bf“ em/]sf]< c) How old were you? 3_ em/]sf] s;/L yfxf eof] < d) How did you know 7_ Kff7]3/ em/] kl5 kl/jf/sf] ;b:on] s:tf] Jojxf/ b]vfP< ª_ s] ubf{ em/]sf] < l) How did your family react when they knew you had UP ? e) What were you doing? s]xL ;xfg'e'lt ufnL s'6lk6 a]OHht pkrf/ x]nf, pkrf/ cGo r_ s'g aRrf hGdbf em/]sf]< eg]gg\ b]vfP u/] u/] u/] ug{ nu] 3[0ff ug{ Other After Which child ? f) Said Showed Scolded Beaten Insulted Took for u/] ;Nnfx 5_ em/] kl5 slt k6s ue{jlt x'g'eof]< nothing sympathy treatment Looked How many times did you get pregnant after UP? lbP g) down Suggested for h_ kf7]3/ s'g a]nf v:5 < treament h) When does your uterus falls off ? eml//xG5 slxn]sflx ux|f}+ ef/L ux|f}+ 6'S?Ss vf]Sbf cGo Continously sometimes af]Sbf prfNbf a:bf while Other 8_ tkfO{+nfO tnsf h:tf ;d:of -nIf0f_ 5g\ ls 5}gg\ < m) Do you have following symptom ? falls off when When While coughing carrying carrying Squatting 5}g plebf“ lx8\g a:bf of]lg of]lg lkzfa tNnf] lk;fj lk;fa lbzf 3fp No load heavy ufx|f] ufx|f] ufx|f] lrnfpg] af6 ubf{ k]6 b'V5 ubf{ k'/} ubf{ lk;fj ePsf] Vaginal Lowever x'G5 x'G5 x'G5 Irritation uGxfpg] kf]Ng ] v'n]/ lardf ug{ 5 Difficult Difficult Diffi cult abdomen Ulcerated kfgL Burn pain hfG5 /f]lsP/ ufxf] standing walking sitting while aU5 Inconsis- x'G5 F urinat- tent x'G5 em_ ;'t]sf] a]nfdf kf7]3/ leq hfG5—hfb}g< hfb}g hfG5 Smelly Difficult ing urination Consis- i) Does it go inside while lying down ? No Yes discharge tent defe- Urinatio- cating n
`_ kf7]3/ em/] kl5 To; af/]df ;a} eGbf klxn] sf] ;+u eGg' jf ;f]Wg' eof]< j) Whom did you tell when you came to know that your uterus fell off?
s;}nfO{ >Ldfg\ ;f;' H]f7fgL, lbbL, ;fyL bfh', cGo elgg Husband Mother-in-law b]p/fgL alxgL Friend efO{ Other Told no Sister-in-laws Sisters Brothers one
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5) Treatment of Uterine Prolapse u_ s] sf/0fn] kf7]3/ em{5 < %= kf7]3/ em/]sf] pkrf/ c) How do you think uterine get prolapsed? cfkm\gf] ;a} vfglkg ;fg} ;'Ts]/L ;'Ts]/L ;'Ts]/L ue{jtL w]/} aRrf sd{n] cfOdfOnfO{ gk'u]/ pd]/df x'+bf x'+bf eO{ ;s] x'bf+ j f hGdfpg' s_ kf7]3/ em/]df s] ug{ -s;/L ;dfwfg_ ;lsPnf< One's Lack of a) How do you think problem of UP can be solved ? o:t} x'g] aRrf hyfefjL :ofxf/ kl5 l56} ;"Ts]/L k/]]/ fate eP/ nutritious kfpg] k]6 gk'u]/ sfd ug{ x'+bf Giving s'g} pkfo yfxf 5}g zf/Ll/s 3/]n' l/ª ck/]zg cGo multiple Normal to food Lack of eP/ lyr]/ z'? u/]/ ef/L, child birth cEof; u/]/ cf}iflwn] k];/L u/]/ women Giving Lower care Starting kfgL nufP/ birth to abdomen after work child at pressure immediately af]s]/ child after child early during Carrying delivery delivery load age child during v_ kf7]3/ em/]sf] 5 eg] pkrf/ s] ug'{ ePsf] 5 < delivery pregnancy b) If you are suffering from UP, what treatment did you do? and post natal pkrf/ u/]sf] 5}g 3/]n' cf}iflw l/ª k];/L ck/]zg cGo period No treatment Herbal Therapy Ring Pessary Surgery Other u_ kf7]3/ em/]sf] pkrf/sf] nflu sxf“ hfg' eof] < 3_ kf7]3/ v:g glbg s] ug'{ knf{< d) How do you think UP problem gets solved ? c) Where did you go for treatment ? o:sf] kf}li6s pd]/ hfGg], ;'Ts]/L ;'Ts]/L ue{jtL kl/jf/sf] >Ldfg\n] yf]/} :yfgLo :jf:Yo rf}sL /fhlj/fh nfxfg lj/f6gu/ sf7df08f}+ ef/t cGo pkfo vfgf k'u]kl5 dfq tflnd x'+bf eO{ ;s] x'bf+ jf ;b:ox? n] dfof, aRrf Local Health Post Rajbiraj Lahan Biratnagar Kathmandu India Other ljjfx u/]df lnPsf] kf}li6s kl5 - ;"Ts]/L x'+bf a/fa/L cfb/ hGdfP/ 5}g vfP/ No Having Marrying at JolQm vfgf slDtdf ux|+f} ;fdfg 3/sf] u/]df Limiting solution nutritious appropriate ;+u vfP/ / ! gaf]s]df sfd Love child food age ;'/lIft :ofxf/ dlxgf_ Not u/]df and birth respect 6. Knowledge on Reproductive Health ;'Ts]/L u/]df cf/fd carrying Sharing load work by by u/fPdf With u/]/ jf husband care and during family ^= k|hggk|hgg\\\\ :jf:Yo af/] hfgsf/LM Safe xNsf pregnancy nutritious equally Child food sfd and post s_ dlxgfjf/L lsg, s;/L x'G5< Delivery during dfq natal a) How does the menstruation takes place? post u/]df period natal period Taking rest yfx 5}g kl/kSj c08f kf7]3/df lgold t /ut kmf]x/ / eujfgn] atleast Don't know lgl:sg] eP/ y'lk|g] eP/ ut lgl:sg] agfPsf] eP/ 1 Matured Eggs Blood deposition in eP/ God Made month uterus regularly after Dirty Blood child delivery v_ s:sf] sf/0fn] 5f]/f jf 5f]/L hGdG5< b) Whose role is there to conceive boy or girl? Yffx 5}g Efujfgn] >Ldfg >Ldlt Don't know God Husband Wife
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7. Gender Relations &= dlxnf / k'?ifsf] ;fdflhs ;DaGw af/]M s_ tkfO{ laxfg b]lv g;'t]Ghn ;Dd slt 306f sfd ug'{ x'G5< a) How many hours a day do you work ? * b]lv !) !! b]lv !% !^ b]lv !* == .... ===306f 306f 306f 306f ...... hours 8-10 hours 11-15 hours 16-18 hours >LdtLn] Wife >Ldfg\n] Husband v_ dlxnfn] slt pd]/df ljjfx ug'{ l7s x'G5< b) What is the appropriate age of marriage for girls/women? !$—!^ !&—@) @!—@$ @%—@* @(—#@ 14-16 17-20 20-24 25-28 29-32 u_ dlxnfn] ;fg} pd]/df ljjfx ubf{ s] x'G5 < c) What happens when girls get married in early age? 5f]/f 5f]/L a]nfd} k9\g kfp+b}g l56} aRrf w]/} aRrfn] cGo l56f] x's{G5 3/ a:5 No access of sdhf]/ hGdG5 :ofxf/ Other Children Settled education aG5 Give birth to kfp+b}g grow early in time Weak in many Children do early age children not get care
3_ tkfO{sf] kl/jf/df slt j6f aRrf hGdfpg] eGg] ljifodf s:n] lg0f{o u5{< d) Who decides in having number of children in your family ? eujfgsf] ;f;' ;;'/fn] >Ldfg\n] >Ldltn] >Ldfg\ >Ldlt cGo OR5fdf e/ k5{ Parent-in-laws Husband Wife b'j}sf] ;Nnfxn] Other Depends on God Both husband & wife
ª_ kl/jf/ lgof]hg ug]{ jf gug]{ ljifodf tkfO{sf] kl/jf/df s:n] lg0{fo u5{< e) Who decides in family planning methods ? lg0f{o ul/+b}g ;f;' ;;'/fn] >Ldfg\n] >Ldltn] >Ldfg\ >Ldlt b'j}sf] cGo No decision Parent-in-laws Husband Wife ;Nnfxn] Other taken Both husband & wife r_ ue{kft ug'{ k/]df s:sf] cg'dlt lng' k5{< F) Who do you have to consult to if you wish to abort ? ue{kft ug{' ;f;' >Ldfg\sf] d :jtGq 5' >Ldfg\ >Ldlt b'j}sf] cGo x'b}g ;;'/fsf] Husband Wife is free ;Nnfxn] Other Should not Parent-in- to decide Both husband & wife abort laws
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