A Voice For the Voiceless
The Advocacy Project helps marginalized communities to tell their story, claim their rights and produce social change. We recruit graduate students to volunteer as Peace Fellows with partners.
The Impact of Service
|
.jpg)
Translate this page:
SAVING THE WOMB – The fight against uterine prolapse in Nepal
By Iain Guest
June 1, 2010, Washington DC: On June 7, hundreds of experts on women’s health will gather in Washington at the 2010 Women Deliver Conference to review the challenge of maternal health in poor countries. Most of the discussion is likely to revolve around the risks of childbirth, one of the major killers of women. But as global rates of maternal mortality show signs of falling, there is growing interest in morbidity - complications arising from childbearing that rarely kill but have a devastating impact on a woman’s wellbeing.
I have spent the past three weeks in Nepal reviewing one such condition, which occurs when a woman’s uterus falls from her body. Up to now, uterine prolapse has received little international attention, but within Nepal it is a full-blown crisis. One 2007 study by the United Nations Population Fund (UNFPA) estimated that at least 600,000 Nepali women – 10% of the women of reproductive age – were affected. One third required an immediate surgery.
The decision to have a hysterectomy is not to be taken lightly, particularly for a young woman. But it cannot compare to the pain and humiliation of living with a distended uterus for year after year. Many women with prolapse try to hide the condition from their husbands. Many suffer divorce and ostracism. Destitute, and without their own property, they often forced to return to work for their former husband’s new wife.
According to Samita Pradhan, a Nepali activist who will be attending the Washington conference, prolapse causes such desperation that women resort to stuffing pieces of slipper, rubber balls, glass bangles and even vegetable husk into their vaginas to hold up the womb. Pradhan’s organization, the Women’s Reproductive Rights Program, began working on prolapse in 2000 when field workers in the West noticed that women were leaving a trail of pus and attracting flies. Shocked, they made inquiries and found rates of up to 30% in some villages.
Prolapse is caused by a lifetime of abuse, neglect and discrimination, most of which occurs in the family. It starts early, when sisters compete for scarce food with their brothers and invariably lose out. It continues with marriage. The legal age of marriage in Nepal is 18, but I met women who had married at ten. On joining their new family, new wives surrender their independence and forfeit everything to their husbands and in-laws.
Childbirth is extraordinarily hazardous, particularly for girls with an unformed womb. Most births occur at home under the supervision of village midwives. One government midwife told me that such birth attendants often push down on the woman’s lower abdomen, and even force women to give birth while standing up or hanging from rafters. This can expel the womb along with the baby and placenta.
The problem is compounded by cultural violence. In the West of Nepal, women are considered unclean after childbirth and banished for weeks to unsanitary cowsheds (chhapaudi). They are also denied dairy products at precisely the time when their bodies most need nutrition. Instead of prolonged rest, many return to work within days – carrying, lifting and squatting as they make mud bricks or fuel brickettes out of dung. This puts intense pressure on the muscles of the womb, which are softened by child birth.
All of this makes for a harsh and joyless life. One recent study of 8 districts by the UNFPA found that suicides accounted for 16% of the deaths among women aged 15 to 49. The findings are deeply worrying to the agency, one of the sponsors of next week’s conference in Washington.
The government’s response to the crisis has been lackluster. Every local community is served by a health post where women should, in principle, receive a check-up and basic services. Surgeries can be referred to district hospitals, or surgery camps run by NGOs. But many posts are in bad condition and short of staff. One supervisor in Siraha district, Ram Pratap Sajh, said he lacked the staff to even screen for prolapse and has been appealing for more support for two years. (Over)
Under pressure from activists, the government promised to fund 12,000 surgeries in 2009 but managed just 2,300. A national plan for prolapse is gathering dust in ministries. Prolapse is listed as a reproductive health priority, but local health posts are not distributing ring pessaries, which can treat and reverse early stage prolapse.
Fed up with the lack of action, women have followed the time-honored tradition in Nepal, and taken to the streets. In January, a group of women with prolapse invited around 30 health officials and politicians to a meeting in the eastern town of Siraha to explain why they had failed to fund a single surgery in 2009. The women even paid for five buses to bring officials to the meeting. No one replied or attended. Furious, the women then descended on the district health office and padlocked the door. Within four days they had extracted significant concessions: 140 surgeries, screenings, free pessaries and money for travel.
Rekha Yadav, the woman who led the protest, has become a heroic figure in the region and her success has galvanized other women into forming “groups of sufferers” to lobby the government for services. Some of the groups are moving beyond prolapse into new areas, including microfinance.
But as Rekha’s husband Saroj watched our interview with evident pride, I was reminded that ultimately it is men who hold the key to the reproductive rights of women. For every husband like Saroj who understands that his family’s welfare depends on his wife’s wellbeing, there is one who is abusive and ignorant. One recent UNFPA study in two districts found that 74% of the women questioned had experienced sexual violence.
In an effort to co-opt husbands and target young couples, the WRRP has deployed a network of campaigners to conduct house visits and launched a campaign of wall paintings that leave little to the imagination. Initially men objected to this public display of the female anatomy, but the paintings can now be found at street corners and even in schools. Women, too, are losing their inhibition. One woman with prolapse who had been abandoned by her husband stood up a local meeting and angrily revealed the full extent of her condition.
With next week’s conference in Washington, the campaign moves to an international stage. It recently achieved an important break-through in the US, when uterine prolapse was listed in a new bill (known as MOMS) on global women’s reproductive health, introduced by Representative Lois Capps.
But this is only the beginning. The campaign needs data from outside Nepal, to put Nepal’s extraordinary statistics into a broader context. Campaigners will also confront the tension between maternal mortality and morbidity. In Nepal, as elsewhere, mortality seems to be on the retreat, and one 2009 USAID survey found a decline from 539 deaths per 100,000 live births in 1996 to 229 last year. But USAID officials still worry about diverting trained Nepali medical staff to anything that is not life-threatening.
Advocates like Pradhan respond that prolapse can serve as a point of entry for a new approach to women’s health, which would empower women as well as deliver services. This, they say, would also address many causes of maternal mortality – ignorance, poor nutrition, bad birthing practices, early marriage, and the lack of family planning.
They cite one inspiring precedent: obstetric fistula, another excruciating condition that is also worsened by sexual violence but rarely kills. Prodded by civil society, UNFPA and USAID have launched innovative international programs against fistula. Nepali women are hoping for a similar outcome as they seek to rescue the womb.