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.
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> Uterine Prolapse ...
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Risk Factors:
Heavy Workload
Agar Devi Shah
Agar Devi Shah was doing work in the field when she first felt her uterus fall. She does not remember exactly what she was doing when she first felt it, but it was possibly lifting sacks of rice or weeding the rice patties.
“I felt like something had come out from inside,” she said.
Agar now suffers from discharge, pulsing pain, and backaches. This has caused difficulties standing, sitting, and lifting.
Her husband has not been as understanding and supportive as some of the others. He is blaming her for her condition and for doing nothing besides sleeping and eating. He says she doesn’t do work or do anything. Intercourse is painful for Agar, but her husband does not care. Agar’s husband has responded negatively to a situation caused by the arduous daily work that women in Nepal must do to survive.
Birma Pariyar
Birma Pariyar was married when she 15 years old. Like many of the women of rural Bardiya District, Birma married into a small nuclear family. Her husband’s parents had already passed away when she married him, and his older brother and brother’s wife lived in and maintained their own household. Like most women in these circumstances, Birma quickly became the sole person in the household to cook, clean, do the laundry, collect water, collect firewood, cut grass for the animals, graze the animals, and work the fields.
By the age of 16, Birma had given birth to the first of four children, three of whom would survive. She worked in the fields up until the hour she gave birth, and only rested from her heavy chores for nine to 10 days after the delivery. Birma’s husband was present for the delivery but did not assist her in anyway, and left the young Birma to go through her first childbirth alone.
Even while Birma was recovering from delivery, her husband did not help with any of the chores. He even refused to cook for her, so Birma was forced to make her own simple meals of rice and lentils. Sometimes she was too tired or in too much pain to cook, so she just didn’t eat. To make the situation worse, Birma’s husband often beat her when he was drunk.
A few years later, this pattern was repeated for Birma’s second birth. This time, after returning to work again after only a week’s rest, Birma’s uterus prolapsed. For 20 years since that day, Birma has lived with the pain and inconvenience of what is likely second-degree uterine prolapse. She says that sometimes her lower abdomen and back hurt so much that she feels like she is having labor pains, but she cannot afford pain killers and she cannot afford to stop working, so she continues to work from 5 a.m. to 8 p.m. every day.
In addition to the usual women’s duties of cooking, cleaning, and working in the fields and the jungle, Birma also does wage labor in town. For about 80 rupees ($1.20) a day, Birma harvests rice, pounds rice, carries heavy loads of grass or water, and does anything else that her employers demand of her.
Sometimes if Birma does not find wage labor for the day, she cannot afford to eat.
Birma first came to know about uterine prolapse five years ago, when a local community health volunteer was going door-to-door, calling women for an upcoming uterine prolapse screening and treatment camp. The volunteer spoke to Birma and discovered that she was among many women in the community suffering from the condition, but when she asked Birma’s husband if Birma could attend the camp, he said no.
Birma had not told her husband about her health problem, so he saw no reason why she should attend the camp. Although Birma’s descriptions of her symptoms suggest that she has an early stage of prolapse that would not require an expensive surgery, treatment is still out of Birma’s budget.
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Sajani Devi Chaudhary has given birth six times – four times with a prolapsed uterus. A combination of the heavy work common for Nepalese women and poor nutrition after giving birth prevented her body from healing properly.
Throughout her pregnancies, and even on the day of giving birth, Sajani carried out her work. Typical work included grinding, foot-milling rice, getting water, and doing field work. On the day that her uterus prolapsed, Sajani was carrying water home to her family as she did each day.
Compounding her heavy workload, Sajani’s poor nutrition did not ease the burden on her stressed body. After giving birth she ate nothing but dried ginger, salt, oil, and rice for twelve days.
At one point she told her mother about the problem and went to her house and was able to rest. Sajani was able to go to mother’s house and rest approximately for about 15 to 30 days each year. However, the relief was short-lived. When she started working again, her prolapse became much worse.
Sajani does not do the heavy work anymore because she is too old. Her prolapse has caused backaches and difficulty walking and lifting. Previously, she had a very bad infection, but it has been addressed with mediation. Her uterus is currently hanging out completely, including ligaments.
Sajani’s daughter-in-laws have the same problem. “What can I do? We are two and have to work,” she says. Asked why so many women have this problem, Sajani replies that most of them have to work hard and lift heavy – they do not have any other options.
Awareness
Anila Kumari Chaudhary
Anila is currently pregnant with her first child and experiencing uterine prolapse.
Treatment is not available to Anila at the moment because the district health office does not have any pessary rings. A pessary ring could relieve the symptoms that she has been dealing with and help to support her uterus to prevent further prolapse. There are no other places for Anila to go to receive a pessary ring.
The accessibility of health services in Nepal is limited, and those health posts that do exist do not always have the necessary treatment available for patients.
She has been evaluated by campaigners, and they believe she has early second-degree prolapse now. Her prolapse started suddenly, with pain and the sensation of something falling. She knew something was wrong when it happened, but she didn’t know it was her uterus. Since then, she has experienced increasing pain. Anila experiences stomach and back pain and also sometimes has vaginal pain.
Her whole family has been sensitized to the issue and is now trying to support her. Family members familiar with the condition know that it results from hard work, so they do not blame her for anything.
Her family members are also making sure she has the necessary care during birth, and they currently plan to have her deliver in a nursing home in Lahan. Fortunately for Anila, they live within an hour of such facilities and have the financial resources to afford the care.
Barabati
Despite the pain that she endured as a result of her prolapsed uterus, Barabati told no one about her symptoms. Like too many women, she was afraid that if she told even her husband about her personal health problems, she would be stigmatized – maybe even blamed for bringing the condition upon herself.
“If I told anyone, they would neglect me and treat me badly,” she said. “They would say that I am a bad woman.”
Instead, Barabati bore her condition stoically, continuing to labor in the fields of the Terai (Plains) region of Nepal. Her silence only ended when, 20 years after her first pains, a community volunteer arrived at Barabati’s door and began to talk about uterine prolapse.
At first, Barabati denied having ever heard of this condition. Knowing the high prevalence of uterine prolapse in poor agricultural communities such as Barabati’s, the community volunteer persisted. Eventually, Barabati admitted to her condition, and is now among a small group of women from her community who have shared their experiences with the community volunteer.
“Now that I have more information,” she says hopefully, “maybe I can seek treatment.”
Her optimism, however, is short lived. To treat her prolapse, Barabati will need a hysterectomy. Free surgery is sometimes offered through government surgery camps or the efforts of non-governmental organizations, but no such projects have been undertaken or are planned for the area where Barabati lives.
The minimum price of a hysterectomy is 15,000 rupees ( about $223). Average income in Nepal is equivalent to approximately $200, and Barabati, a poor farmer, is well below that average.
When Barabati finds out how much the corrective surgery will cost, a look of resignation passes over her sun-darkened face: “I do not have that much money,” she says simply. And just like that, Barabati rejoins the ranks of poor women in Nepal who must submit to a lifetime of discomfort and pain.
Dilsara Chand
Dilsara Chand is a female community health volunteer (FCHV). Among her primary duties, she is responsible for motivating local women to take advantage of local government health services.
Nonetheless, Dilsara didn’t know that she was experiencing uterine prolapse. Uterine prolapse affects over 600,000 women in Nepal, and yet information and public awareness of the issue is severely limited.
Dilsara does not know how long she has had this condition, but she remembers the day that she realized her problem was uterine prolapse. Five years ago, Dilsara was accompanying a patient to a general health camp that was being held in the area. As she listened to the doctor assess the patient’s symptoms and declare a case of uterine prolapse, Dilsara realized that she had many of the same symptoms. After the camp, Dilsara went home to conduct a self-diagnosis, which confirmed that she had uterine prolapse.
Dilsara, as an FCHV, is supposed to be an agent of behavior change and a promoter of openness with regard to health. But until the day of the interview, Dilsara had never told a soul about her condition.
Until women are confident enough to talk about their reproductive health and seek medical care for their problems, uterine prolapse will continue to plague communities at the high rate that it does in Baridya District.
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Garvi Devi Ram
Garvi Devi Ram knew something was wrong when her uterus fell. She just didn’t know what was wrong. She had never heard of uterine prolapse, and for twenty years did not know what afflicted her.
Garvi had her first child at age 15. Returning to work a week after the birth of her fifth child, she was bringing home soil when she felt her uterus fall.
“I was so surprised and scared and I did not know what happened,” she said.
Garvi did not know where to go for treatment, or even that there were treatment options available to her. She did not tell her husband or anyone else about the condition because she was afraid to talk about it.
Garvi spent 20 years silently dealing with her prolapse before she met a social mobilizer who educated her about the condition. The campaigner told her to go to Darhan for an operation, and her family supported her during her hysterectomy.
Garvi is now a spokeswoman for the issue of uterine prolapse at advocacy events. She no longer fears talking to others about her condition and is helping others access the same information she once needed about the condition.
Poor Nutrition
Chandar Kala Devi Yadav
Like so many other women, Chandar Kala Devi Yadav was married between the ages of 10 and 12 years old. She has five children, and her prolapse began after the birth of her third child.
The combination of early marriage, poor nutrition, and heavy work took its toll on Chandar. After the delivery, her family had trouble getting the good, nutritional food that Chandar needed to help heal. Added to that, she started working again only six days after giving birth. There was no one else to do the work in her home; all of the responsibilities fell to her.
This harmful combination prohibited her body’s recovery. While she does not remember exactly what she was doing when her uterus first prolapsed, Chandar was sure it was during heavy work.
There is no option for her other than to work. Even now she works in the rice field and does all the housework. She must ask her small daughters to help with what they can. Chandar wants to have surgery to help the prolapse and relieve her of the symptoms. Initially, her husband would not support her getting the surgery, but now he has given her approval.
Chandar, however, must still wait. It is planting season, and she must work. She says that after the season is over she will go for treatment.
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Sabitri Kohar
Just a month or two after giving birth to her first child at the age of 19, Sabitri Kohar became pregnant with a second child. She describes the second delivery as being much like the first one: both were relatively uncomplicated labors played out on the packed dirt floor of her thatch house.
At the end of both deliveries, the mid-wife attending her birth pushed and prodded Sabitri’s stomach in an effort to release the placenta. When describing her first two deliveries, Sabitra almost forgets to mention one crucial difference in her experiences: “That second time, I had not eaten for eight days before I gave birth,” she says. “We had no food in the home, so I did not eat.”
Although Sabitri does not consider her second birth to be remarkable, her body undoubtedly suffered from extensive stress during her second labor. Undernourished and still in the recovery stage from her first delivery, her reproductive system would have struggled to manage the second labor.
The effects of the mid-wife’s prodding after both deliveries also likely damaged the already sensitive and stressed muscles in her pelvic region. A year after Sabitri gave birth to her second child, the consequences of her dangerous delivery caught up with her.
Bending over to pick up a load of grass in the fields, Sabitri felt a sudden and sharp pain in her back and lower abdomen. That same day she noticed that something was protruding from her vaginal canal, but she told no one about it and did not think to go to a doctor.
A month later, Sabitri returned to her birth home and mentioned her persistent symptoms to an elder female relative, who told her that she was probably experiencing “pateghar khasne samasya,” which translates to “fallen womb problem.”
Too shy to share the details of her personal health with anyone else, Sabitri kept her problem to herself for the next 14 years. Even Sabitri’s husband has been ignorant of her condition for 14 years, during which time she gave birth to two more children and suffered silently through the pain and discomfort of a prolapsed uterus.
It wasn’t until a community health volunteer arrived at Sabitri’s door and began to talk to her about “pateghar khasne samasya” that Sabitri shared the details of her experience with anyone else. Since then she has gathered the courage to tell her husband, who agrees that she should seek treatment.
Sitting in a circle of other women who are suffering from uterine prolapse, Sabitri says she is happy that she met the community volunteer and finally told her husband. After 14 years of not being able to talk to anyone about her condition, she now knows that she has support and there is hope yet for her suffering.
Secrecy and Stigma
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Goulab Devi Ram
Goulab is now 35 years old and has been married for 20 years. She had her first child at the age of 20and her second at 25. Two to three years after the birth of her second child, Goulab’s prolapse occurred.
While lifting wood in the forest, Goulab felt pain in her abdomen. Her prolapse has become worse over time, and she has pain, difficulty walking, and weakness. She has also had to restrict the amount of food that she eats.
Goulab learned about uterine prolapse through a NGO that she used to work for. If it was not for this, she would not speak about the issue.
Now Goulab is making some money and hopes that a pessary ring will hold her uterus in place and help alleviate her symptoms. She is determined to prevent the same condition in her daughter. Goulab says that she won’t marry her daughter early, she will make sure that her daughter has a good diet while pregnant, she will make sure her daughter delivers in an institution, and her daughter will not lift heavy loads after giving birth.
Even though Goulab knows how to prevent uterine prolapse and talks about the issue freely, she is still afraid of telling her husband about her problem.
Early Marriage
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Kanni and Kaliya Devi Chaudhary
Kanni Devi Chaudhary (left), 71, and Kaliya Devi Chaudhary, 68, are sisters-in-law who were both married at the extremely young ages of six to seven. They both stayed with their own families until around age 14, when they were considered mature enough to move into their husbands’ homes.
Neither Kanni nor Kaliya knew about uterine prolapse or possible treatment until social workers talked to them. They had no idea they were suffering from uterine prolapse, and both kept their problems hidden from their husbands and others.
After talking with social workers, Kanni and Kaliya both decided to have hysterectomies to treat their prolapse. Both subsidized the operation through an NGO. Kaliya’s husband did not resist the surgery, and her sons contributed 750 rupees (about $9.73) toward the treatment. Kanni’s husband died by the time she learned of the possibility of treatment. Kanni raised 500 rupees ($6.48) through goat rearing to pay for her hysterectomy.
So far, none of Kanni or Kaliya’s daughters have problems with uterine prolapse. Right now, they do not do heavy work because their children are small. But when their children grow up, they will have to go to the fields. If they experience any problems, they plan to go to the campaigners for help.
Because of Kanni and Kaliya, the lack of awareness and knowledge in their family about uterine prolapse has ceased.
Birth Spacing/High Parity
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Anita Devi Sadaya
The combination of heavy fieldwork and two births in quick succession never allowed Anita Devi Sadaya’s muscles to heal properly.
Anita is only 19 years old, but she has already delivered two children and experienced uterine prolapse. She had her first child when she was 15 and the second at 16. She has experienced symptoms of uterine prolapse for almost five years, since right after her first delivery.
Anita felt her uterus falling while doing housework. She thinks it happened because of her work. Anita is responsible for all house and field work, and bringing wood from the fields. Her heavy workload continued up until labor and resumed only a week after the birth of her first child. Her second delivery was a lot harder than the first, as her uterus came out with the baby.
Anita’s mother, sister-in-law, and husband all know about her problem. A neighbor told a campaigner about her problem, and the campaigner came to talk with her. Her neighbor, the campaigner, and her husband have all encouraged Anita to seek treatment for her prolapse. Her husband walked with her to the health post a half-hour away.
Unfortunately, Anita and her husband do not have the resources to pay for a pessary ring that would hold her uterus in place. She and husband work as day laborers – collecting wood from the forest – and also farm on government land. Despite her prolapse, Anita still has to do field work and domestic work. She lifts a little less now. Her husband tries to help, but he cannot do it all.
Anita is most affected by the condition mentally, as she stresses about her problem and how she will manage. She also worries that others see her as less capable. Despite this, and her difficulties with the last delivery, Anita still wants to have another child. Both of her children are girls and she wants a son as well.
Chalidevi Regmi
At 55 years old, Chalidevi Regmi has already seen a lot in her life. She married at the age of 11 and followed her husband to a variety of towns and villages across Nepal in search of work. On top of the stress of an early marriage and following her husband, she has given birth to five surviving children as well as two stillborn children.
Chalidevi raised her family and ran a household on her own. Like most women from the area, she only took a break from her daily routine of domestic and agricultural chores for eleven days after giving birth to her children.
Twenty-four years ago, after the birth of her last child, Chalidevi developed uterine prolapse – a condition that is so common for women in this society. Unlike most women, however, Chalidevi had immediate access to health care, and was able to use a pessary ring to support her uterus and prevent further acceleration of the condition. She used the pessary ring for more than a decade until she suffered a serious accident while grinding rice.
The force of the accident caused Chalidevi’s uterus to fall into what is likely fourth stage prolapse, at which point a pessary ring is no longer a viable solution. She hasn’t sought treatment since.
Chalidevi isn’t interested in having surgery to treat her prolapsed uterus. She has given up on the idea of an improved life, and she is ready to die.
Nabinisa Saha
“Mera parivar,” Nabinisa Saha says, pointing to a photo of herself surrounded by her children. My family. Her broad smile betrays her modesty and shows traces of a much deeper sense of accomplishment.
For a woman like Nabinisa, having eight children is something to be proud of – a mark of her contribution to the household and her ability to raise a large and healthy family. With such an achievement, however, also comes the consequences of high fertility.
Five years after giving birth to her last child, Nabinisa began to experience severe pain and vaginal bleeding. At first she thought her condition was related to her diabetes, and chose to wait out her symptoms in silence. When the bleeding still hadn’t stopped after two months, however, Nabinisa decided to seek medical attention.
Forty-five minutes away, in the nearest major town, Nabinisa had a check-up at the women’s hospital and discovered that her uterus had prolapsed. The staff of the hospital gave her medicine for a related infection and sent her home, telling her that the bleeding should stop and the condition should improve.
However, after taking themedication for a month, Nabinisa had not experienced any improvement, and continued to be confined to her bed by pain and bleeding. She had no one to talk to about her condition and little knowledge about why it had happened to her or what she could do about it. When Nabinisa raised the issue with her husband, he told her it was normal—that all women who have given birth experience this, and that it would get better over time.
Nabinisa is lucky, because after six months of deteriorating health, she was eventually able to convince her husband that she needed further treatment. Wary of the ineffective treatment that she had received from the local women’s hospital, however, Nabinisa had to seek other options. Through a friend of her husband’s, Nabinisa found a private hospital in India that would perform a hysterectomy – a surgery that would to treat her advanced stage of prolapse.
Despite the fact that she was unable to walk or sit comfortably because her uterus was fully extended from her body, Nabinisa made the journey from the Terai region of Nepal to India, where she was finally operated on and given relief from her prolapsed uterus.
When asked why she thought she had prolapse, Nabinisa just shrugged: “I’ve never asked myself. Why question it? This is just something that happens.”
Uterine prolapse is, for women like Nabinisa, just a part of life that comes with being a wife and mother.
Poor Birthing Practices
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Kapurni Kumari Raja
Kapurni Kumari Raja’s prolapse occurred during the birth of her first child, highlighting the negative consequences of giving birth at home with untrained attendants.
Kapurni’s birth attendants put pressure on her stomach during the delivery, thus weakening her muscles and ligaments and forcing her uterus to come out a bit. After this, she was not able to conceive for three years. With each subsequent birth, her uterus fell a bit more. Now, Kapurni has second-degree prolapse.
When Kapurni told her mother-in-law about her problem, her mother-in-law started scolding her. She has even threatened to marry Kapurni’s husband to another woman. Kapurni still has not shared her problem with her husband, and has not received any treatment for her prolapse.
“If I say to my husband, he won’t be able to manage treatment and also he will start scolding, so what is the use?” she said.
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Logani Devi Sadaya
Logani Devi Sadaya’s uterine prolapse is the result of poor birthing practices during the delivery of her second child. She now has six children, all born at home. She had birth attendants with her for each delivery. However, these birthing attendants helped cause the problem that Logani has suffered with for so many years.
During her second delivery, Logani’s birth attendants pressed with their hands and feet and even stood on her stomach to force the baby to come out. Such pressure irrevocably damaged the muscles and ligaments in her pelvis. This is when her prolapse began.
“During the birth I saw a red thing that came out of me and I cursed at the birth attendants,” Logani remembers. The birthing attendants knew about the problem from the moment it occurred, but they could not do anything to fix it, she said.
At that time, Logani did not know anything about uterine prolapse, possible treatment, or any other women suffering from the condition. The prolapse has progressed gradually since the birth of her second child and did not interfere with the births of her subsequent children.
Her main symptom has been back pain, which makes working difficult. She has trouble walking and cannot go far. Since Logani received information about uterine prolapse and treatment, she wants to have surgery but is afraid.
Financial difficulties could also make receiving treatment difficult. Her husband has said he would not leave her, and that he would try to do what is best for her. Logani says that, as a birth attendant herself, she has never caused this to happen in others.
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Sili Bati Yadav
The combination of heavy work that Sili performed both during and after her pregnancy and the actions of the birth attendants during her labor probably equally contributed to her uterine prolapse.
During the delivery, the birth attendants were pressing on her back with their legs. Only two or three days after giving birth, Sili returned to doing her normal housework. After only six days, she returned to fieldwork. This is when Sili first noticed that something was wrong.
It is quite possible that even though Sili noticed the prolapse while doing work, it actually happened during the delivery. Her prolapse occurred when she was only 18 years old. She is 47 now and has endured her condition for almost 30 years with no treatment.
Sili told the birth attendants who had helped her during her labor about her symptoms. They did not know what to do and only referred her to other attendants who might be able to help. Her mother-in-law was also unable to help, as she had never had this problem.
Without the help and information she was looking for, Sili did not do anything about her problem. Up until a year ago, Sili did not even know that treatment was available. Sili has not had treatment yet, because her husband says that he has no money to pay for the cost of treatment. However, her neighbors have offered to take up a collection to contribute to the cost of surgery.
Cultural Taboos
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Mansala
For Mansala, the history of her prolapse starts at the age of 15, when she married and moved into her husband’s home.
For the last 35 years, Mansala has maintained a regular routine: wake up at 4 am to cook, clean the house, feed the animals, and do the laundry. At 1 p.m., she finishes her housework and heads to the jungle and the fields to graze the animals and haul heavy loads of grass, wood, and water.
For five days a month, when Mansala has her menstrual cycle, her routine varies slightly. This is because in the region where Mansala is from, cultural beliefs maintain that women are ritually impure at the time of menstruation. Women who are menstruating must therefore be secluded and isolated from contact with food and other humans, lest they anger or offend the gods.
The small huts where women from these communities go during their monthly periods are called chaupadi. They can vary greatly in size and condition. The worst of these chaupadi are not even tall enough for a person to stand, and barely big enough for a few to sleep close together. Often, they are constructed of simple twigs and mud, and sometimes they double as animal sheds. In these cases, women are made to eat and sleep in the company of their family’s livestock.
In many of these communities, menstruating women are seen as the source of curses, so they are confined to the chaupadi until their cycles are finished. They cannot cook, so they eat what their family serves them: often left-over rice, or perhaps a few roti.
The physical and social isolation that women experience in the chaupadi is not only psychologically traumatic, but it can also be fatal. It is not uncommon for women to fall ill from snake bites while staying in the chaupadi. Recently, a 14-year-old girl died of diarrhea while she was confined to a chaupadi: Nobody would help her or take her for medical care, because they were afraid they would become impure if they touched a menstruating girl.
Mansala’s situation is not as severe. She says that because she has no mother-in-law (and mothers-in-law are quite frequently the enforcers of such traditional practices), her husband is lenient. Her chaupadi is attached to the house, and large enough to hold a bed that her husband built for her. She says that if she had had a mother-in-law, she would have to sleep on the ground.
With the benefits of not having a mother-in-law, however, also came the hardships. Traditionally, a menstruating woman must stay in the chaupadi all day and all night, so that she doesn’t risk spreading her impure status throughout the community. Mansala, however, does not get the “luxury” of rest during her period. Because there are no other women in the household and her husband refuses to pick up any of the chores other than cooking, Mansala is forced to work in the fields during the days of her period and return to the chaupadi at night.
Mansala, like most women in her village, also gave birth in a chaupadi. Notions of female impurity correspond to menstruation and birth. Women are thought to be polluted at the time of child delivery and for 10 days following a birth.
Birth attendants are not available in Mansala’s village and men do not attend to births (nor can they enter the chaupadi), so she gave birth alone. For 10 days she remained alone in the chaupadi, where no one was allowed to visit or touch her or her newborn child. Her husband cooked for her, but Mansala was otherwise left to do her own washing, bathing, and childcare.
Mansala recently underwent a successful hysterectomy to treat an advanced stage of uterine prolapse, from which she had been suffering for two years. She was identified and sponsored for the surgery by an non-governmental organization (NGO) in her home district of Jazarkot in the Far West. But qualified teams of gynecologists, surgeons, and anesthetists at reputable hospitals are not available in the Far West, so NGOs have opted to send women like Mansala to Nepalgunj, where the hospital accepts patients from NGOs on a voucher system.
It took Mansala three days to reach the hospital – one day in a bus and two days of walking. Although she suffered from back pain, heavy bleeding, and difficulty walking because her uterus protruded from her body, Mansala had no choice but to make the journey.
Although Mansala is now cured of the pain that she suffered from a prolapsed uterus, she has not been relieved of the hard work and isolation that she suffered for years at home and in the chaupadi.
Violence Against Women
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Parvati Poudel
Parvati Poudel has four children: three daughters and one son. Her prolapse happened seven years ago, at the age of 37, just one year after her youngest child was born.
For three years now, she has struggled with the pain in her back and stomach and started eating less. If she eats too much the pressure of the food “makes it hurt more, and can even make it come outside; even now with the ring if I eat too much both come out.”
Her husband has not reacted well to her condition. “This disease has driven a fracture between us,” she says. “He has refused me any money for my disease or ANY help.”
Parvati reports that he is even turning her children against her, giving her eldest daughter money to run the house along with instructions to not give Parvati any money at all. Compounding the situation, Parvati’s in-laws – who substitute for her own parents after marriage according to traditional Nepali custom – are very unhappy about her inability to work and are encouraging her husband to take a new wife.
The peak of her difficulties occurred when, after being beaten, she was cast out of the house and told she could not return. She explains that she has been wandering around for a month, staying with friends and relatives and trying to raise money from them as well as various women’s groups so she can pay for treatment.
She hopes to have the surgery because of the “big, big problems” she is facing. “This disease is my enemy because it keeps me from doing my work,” she explains.
Instead of the heavy manual labor required of Nepali women, she can only do “sitting work” now, “small things that are not very difficult.” Not being able to contribute in the expected way, she is left feeling like a burden on her family, unable to fulfill her duty or earn her keep.
Despite the severity of her prolapse, doctors conducting a free camp in her area recently were not able to offer her a hysterectomy due to an infection she had from the pessary ring that she uses to keep her uterus inside her body. Rather, Parvati was given a prescription for about seven medications she should take for 15 days and told she should then travel to the private teaching hospital several hours away from Gaighat and pay for a hysterectomy from a location with permanent facilities.
Realistically, as she will not likely be able to raise the money necessary for the operation (about $300-500), Parvati will likely have to wait until she hears of another free camp somewhere in the area. Hopefully, by that time, her infection will not have returned and she can have the surgery.
Padma Kumari
Because of her prolapsed uterus, Padma experiences sharp pain during sex. Her husband, however, does not believe that she is telling the truth. For 13 years he has ignored her pleas, and Padma has become a victim of marital rape.
Padma first experienced uterine prolapse six months after the birth of her first child, when she was only 14 years old. Initially she travelled to a mission hospital in India, where she was able to receive a pessary ring to treat her early-stage prolapse. She had the ring changed at the hospital twice, but after that she removed the ring herself.
As the wife of a day laborer and an occasional day laborer herself, she could not afford the transportation or time costs of going to the hospital in India – the nearest facility that could provide prolapse services.
After removing her pessary ring herself, Padma spent the next 13 years trying to ignore her symptoms. Heavy work was difficult and caused her severe back pain, but her husband told her he would not help. After the birth of her subsequent children, Padma was back to work within 10 days, because her husband refused to assist her with anything other than cooking.
Then, Padma’s prolapse suddenly became worse. She began to suffer from fever and exhaustion, and she had so much discharge that her sari (wrapped several times around her waist) was visibly stained in the rear. She could not hide the signs of her condition, and as the neighbors began to talk about her health, she found that no one would hire her for day labor, making it harder for her to maintain a productive role in the household.
Padma’s husband has protested that he has no money to spend on any kind of treatment. Female community health volunteers told him that if he didn’t make the investment now, his wife would soon be in much pain that she wouldn’t be able to do any work, and the family finances would truly suffer. He didn’t seem convinced by the concept of a preventive investment.
Faced with a husband who continually rapes her and who will not spend the money necessary for treatment, the future does not look hopeful for Padma.
Accessibility of Health Services
Bishna Maya Bandari
About three years after giving birth to her son – her first and only child – at age 22 Bishna Maya Bandari felt her uterus fall.
For the past 25 years she has struggled with her prolapse without access to the health services she needed, and without treatment.
When she spoke about her problem with her husband, he said nothing at first. After some time, he allowed her to go see a traditional medical healer. Unfortunately, those methods were unsuccessful and her pain and discomfort continued.
Despite this, Bishna counts herself as lucky because 15 years ago her son was married, and her new daughter-in-law became a major source of support and assistance with her domestic responsibilities.
When I feel pain, I lie down and ask my daughter-in-law to bring me some hot water,” Bishna said. When asked what she did in the 10 years before she had this support, she frankly replied, “What could I do? There was work to be done.”
Though her husband never gave her the financial resources to go see a doctor, he did not stop her from finding them herself. Thus, with some money sent home by her son, who works as a wage laborer in Quatar, she bought a goat and then sold the offspring, along with some excess wheat and vegetables from her farm. With this money, she self-financed her trip to the gynecological camp in Udayapur in the hopes of receiving surgery for free.
After evaluation by doctors there, she was determined to have a “presidential” – a prolapse where the uterus is completely distended outside the body, and cannot go back inside. At this stage of the condition, hysterectomy is the only option.
After twenty-five years without any treatment, Bishna was able to have a hysterectomy that would end her pain and suffering.
Chandmati Pasi
Chandmati Pasi, a poor farmer from the Rupandehi District in Southern Nepal, has suffered from uterine prolapse for 18 years. She has accepted her condition and does not expect that she will ever be able to afford the surgery to correct it.
Chandmati was out collecting wood just 15 days after the birth of her last child when it happened. It was a rainy day and the roads were slick with mud, causing Chandmati to slip. As she fell, she experienced a sudden pain and the sensation of something dropping in her lower abdomen.
Despite the pain, Chandmati had more work to do. With the same unquestioning attitude with which she tells this story, Chandmati stood back up, adjusted the load of wood that was balanced on her head, and returned to her village to continue her day’s work.
Eighteen years have passed since Chandmati first felt her uterus fall. For 18 years she has suffered through pain, fever, difficulty walking and an inability to control her bladder. Sometimes she has to stay squatting in a field for up to an hour-and-a-half before she can overcome the pain that it takes to urinate.
Eating and drinking also cause her severe pain, so she has reduced her food and water intake – despite warnings from the local community health worker that she is cutting short her own life.
For Chandmati, treatment for uterine prolapse is not a realistic financial possibility. Unwilling to tell her husband about her condition at first, Chandmati turned to her mother-in-law, who helped her collect some money from friends and relatives for medical attention. Chandmati took this money to the local health post, where she was prescribed medicine that would cure a related infection, but would not treat her prolapse. She took the medicine for one week, with no improvement.
Years passed and Chandmati’s condition only worsened. At one point Chandmati consulted a local village doctor, who told her that her condition could be cured with six injections. Chandmati saved 100 rupees for the first injection, but after that was unable to pay for the remaining five. Chandmati has simply accepted the improbability of treatment and continued on with her life, cutting grass in the fields, collecting wood from the forest, and raising her surviving children.
Eighteen years after her first fall, Chandmati is undoubtedly now experiencing an advanced stage of prolapse that can only be treated by hysterectomy. For this surgery, Chandmati would have to travel to the nearest major town and then pay at least 5,000 rupees to have the surgery performed.
Chandmati says she cannot even afford to make the journey: “How can I pay for treatment?” she asks. “If someone can pay for my treatment, then I will go for surgery. Otherwise, I cannot. I am a farmer. I have a family to take care of.” Back
Profiles
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Risk Factors:
- Heavy Workload
- Awareness
- Poor Nutrition
- Secrecy and Stigma
- Early Marriage
- Birth Spacing
- Cultural Taboos
- Violence Against Women
- Accessibility of Health Services
- Poor Birthing Practices
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Heavy Workload
Agar Devi ShahAgar Devi Shah was doing work in the field when she first felt her uterus fall. She does not remember exactly what she was doing when she first felt it, but it was possibly lifting sacks of rice or weeding the rice patties.
“I felt like something had come out from inside,” she said.
Agar now suffers from discharge, pulsing pain, and backaches. This has caused difficulties standing, sitting, and lifting.
Her husband has not been as understanding and supportive as some of the others. He is blaming her for her condition and for doing nothing besides sleeping and eating. He says she doesn’t do work or do anything. Intercourse is painful for Agar, but her husband does not care. Agar’s husband has responded negatively to a situation caused by the arduous daily work that women in Nepal must do to survive.
Birma Pariyar Birma Pariyar was married when she 15 years old. Like many of the women of rural Bardiya District, Birma married into a small nuclear family. Her husband’s parents had already passed away when she married him, and his older brother and brother’s wife lived in and maintained their own household. Like most women in these circumstances, Birma quickly became the sole person in the household to cook, clean, do the laundry, collect water, collect firewood, cut grass for the animals, graze the animals, and work the fields.
By the age of 16, Birma had given birth to the first of four children, three of whom would survive. She worked in the fields up until the hour she gave birth, and only rested from her heavy chores for nine to 10 days after the delivery. Birma’s husband was present for the delivery but did not assist her in anyway, and left the young Birma to go through her first childbirth alone.
Even while Birma was recovering from delivery, her husband did not help with any of the chores. He even refused to cook for her, so Birma was forced to make her own simple meals of rice and lentils. Sometimes she was too tired or in too much pain to cook, so she just didn’t eat. To make the situation worse, Birma’s husband often beat her when he was drunk.
A few years later, this pattern was repeated for Birma’s second birth. This time, after returning to work again after only a week’s rest, Birma’s uterus prolapsed. For 20 years since that day, Birma has lived with the pain and inconvenience of what is likely second-degree uterine prolapse. She says that sometimes her lower abdomen and back hurt so much that she feels like she is having labor pains, but she cannot afford pain killers and she cannot afford to stop working, so she continues to work from 5 a.m. to 8 p.m. every day.
In addition to the usual women’s duties of cooking, cleaning, and working in the fields and the jungle, Birma also does wage labor in town. For about 80 rupees ($1.20) a day, Birma harvests rice, pounds rice, carries heavy loads of grass or water, and does anything else that her employers demand of her.
Sometimes if Birma does not find wage labor for the day, she cannot afford to eat.
Birma first came to know about uterine prolapse five years ago, when a local community health volunteer was going door-to-door, calling women for an upcoming uterine prolapse screening and treatment camp. The volunteer spoke to Birma and discovered that she was among many women in the community suffering from the condition, but when she asked Birma’s husband if Birma could attend the camp, he said no.
Birma had not told her husband about her health problem, so he saw no reason why she should attend the camp. Although Birma’s descriptions of her symptoms suggest that she has an early stage of prolapse that would not require an expensive surgery, treatment is still out of Birma’s budget.
Sajani Devi Chaudhary
Life for many women in Nepal is filled with grueling daily work, which can have disastrous reproductive health consequences.Sajani Devi Chaudhary has given birth six times – four times with a prolapsed uterus. A combination of the heavy work common for Nepalese women and poor nutrition after giving birth prevented her body from healing properly.
Throughout her pregnancies, and even on the day of giving birth, Sajani carried out her work. Typical work included grinding, foot-milling rice, getting water, and doing field work. On the day that her uterus prolapsed, Sajani was carrying water home to her family as she did each day.
Compounding her heavy workload, Sajani’s poor nutrition did not ease the burden on her stressed body. After giving birth she ate nothing but dried ginger, salt, oil, and rice for twelve days.
At one point she told her mother about the problem and went to her house and was able to rest. Sajani was able to go to mother’s house and rest approximately for about 15 to 30 days each year. However, the relief was short-lived. When she started working again, her prolapse became much worse.
Sajani does not do the heavy work anymore because she is too old. Her prolapse has caused backaches and difficulty walking and lifting. Previously, she had a very bad infection, but it has been addressed with mediation. Her uterus is currently hanging out completely, including ligaments.
Sajani’s daughter-in-laws have the same problem. “What can I do? We are two and have to work,” she says. Asked why so many women have this problem, Sajani replies that most of them have to work hard and lift heavy – they do not have any other options.
Awareness
Anila Kumari ChaudharyAnila is currently pregnant with her first child and experiencing uterine prolapse.
Treatment is not available to Anila at the moment because the district health office does not have any pessary rings. A pessary ring could relieve the symptoms that she has been dealing with and help to support her uterus to prevent further prolapse. There are no other places for Anila to go to receive a pessary ring.
The accessibility of health services in Nepal is limited, and those health posts that do exist do not always have the necessary treatment available for patients.
She has been evaluated by campaigners, and they believe she has early second-degree prolapse now. Her prolapse started suddenly, with pain and the sensation of something falling. She knew something was wrong when it happened, but she didn’t know it was her uterus. Since then, she has experienced increasing pain. Anila experiences stomach and back pain and also sometimes has vaginal pain.
Her whole family has been sensitized to the issue and is now trying to support her. Family members familiar with the condition know that it results from hard work, so they do not blame her for anything.
Her family members are also making sure she has the necessary care during birth, and they currently plan to have her deliver in a nursing home in Lahan. Fortunately for Anila, they live within an hour of such facilities and have the financial resources to afford the care.
BarabatiDespite the pain that she endured as a result of her prolapsed uterus, Barabati told no one about her symptoms. Like too many women, she was afraid that if she told even her husband about her personal health problems, she would be stigmatized – maybe even blamed for bringing the condition upon herself.
“If I told anyone, they would neglect me and treat me badly,” she said. “They would say that I am a bad woman.”
Instead, Barabati bore her condition stoically, continuing to labor in the fields of the Terai (Plains) region of Nepal. Her silence only ended when, 20 years after her first pains, a community volunteer arrived at Barabati’s door and began to talk about uterine prolapse.
At first, Barabati denied having ever heard of this condition. Knowing the high prevalence of uterine prolapse in poor agricultural communities such as Barabati’s, the community volunteer persisted. Eventually, Barabati admitted to her condition, and is now among a small group of women from her community who have shared their experiences with the community volunteer.
“Now that I have more information,” she says hopefully, “maybe I can seek treatment.”
Her optimism, however, is short lived. To treat her prolapse, Barabati will need a hysterectomy. Free surgery is sometimes offered through government surgery camps or the efforts of non-governmental organizations, but no such projects have been undertaken or are planned for the area where Barabati lives.
The minimum price of a hysterectomy is 15,000 rupees ( about $223). Average income in Nepal is equivalent to approximately $200, and Barabati, a poor farmer, is well below that average.
When Barabati finds out how much the corrective surgery will cost, a look of resignation passes over her sun-darkened face: “I do not have that much money,” she says simply. And just like that, Barabati rejoins the ranks of poor women in Nepal who must submit to a lifetime of discomfort and pain.
Dilsara ChandDilsara Chand is a female community health volunteer (FCHV). Among her primary duties, she is responsible for motivating local women to take advantage of local government health services.
Nonetheless, Dilsara didn’t know that she was experiencing uterine prolapse. Uterine prolapse affects over 600,000 women in Nepal, and yet information and public awareness of the issue is severely limited.
Dilsara does not know how long she has had this condition, but she remembers the day that she realized her problem was uterine prolapse. Five years ago, Dilsara was accompanying a patient to a general health camp that was being held in the area. As she listened to the doctor assess the patient’s symptoms and declare a case of uterine prolapse, Dilsara realized that she had many of the same symptoms. After the camp, Dilsara went home to conduct a self-diagnosis, which confirmed that she had uterine prolapse.
Dilsara, as an FCHV, is supposed to be an agent of behavior change and a promoter of openness with regard to health. But until the day of the interview, Dilsara had never told a soul about her condition.
Until women are confident enough to talk about their reproductive health and seek medical care for their problems, uterine prolapse will continue to plague communities at the high rate that it does in Baridya District.
Garvi Devi RamGarvi Devi Ram knew something was wrong when her uterus fell. She just didn’t know what was wrong. She had never heard of uterine prolapse, and for twenty years did not know what afflicted her.
Garvi had her first child at age 15. Returning to work a week after the birth of her fifth child, she was bringing home soil when she felt her uterus fall.
“I was so surprised and scared and I did not know what happened,” she said.
Garvi did not know where to go for treatment, or even that there were treatment options available to her. She did not tell her husband or anyone else about the condition because she was afraid to talk about it.
Garvi spent 20 years silently dealing with her prolapse before she met a social mobilizer who educated her about the condition. The campaigner told her to go to Darhan for an operation, and her family supported her during her hysterectomy.
Garvi is now a spokeswoman for the issue of uterine prolapse at advocacy events. She no longer fears talking to others about her condition and is helping others access the same information she once needed about the condition.
Poor Nutrition
Chandar Kala Devi YadavLike so many other women, Chandar Kala Devi Yadav was married between the ages of 10 and 12 years old. She has five children, and her prolapse began after the birth of her third child.
The combination of early marriage, poor nutrition, and heavy work took its toll on Chandar. After the delivery, her family had trouble getting the good, nutritional food that Chandar needed to help heal. Added to that, she started working again only six days after giving birth. There was no one else to do the work in her home; all of the responsibilities fell to her.
This harmful combination prohibited her body’s recovery. While she does not remember exactly what she was doing when her uterus first prolapsed, Chandar was sure it was during heavy work.
There is no option for her other than to work. Even now she works in the rice field and does all the housework. She must ask her small daughters to help with what they can. Chandar wants to have surgery to help the prolapse and relieve her of the symptoms. Initially, her husband would not support her getting the surgery, but now he has given her approval.
Chandar, however, must still wait. It is planting season, and she must work. She says that after the season is over she will go for treatment.
Sabitri Kohar Just a month or two after giving birth to her first child at the age of 19, Sabitri Kohar became pregnant with a second child. She describes the second delivery as being much like the first one: both were relatively uncomplicated labors played out on the packed dirt floor of her thatch house.
At the end of both deliveries, the mid-wife attending her birth pushed and prodded Sabitri’s stomach in an effort to release the placenta. When describing her first two deliveries, Sabitra almost forgets to mention one crucial difference in her experiences: “That second time, I had not eaten for eight days before I gave birth,” she says. “We had no food in the home, so I did not eat.”
Although Sabitri does not consider her second birth to be remarkable, her body undoubtedly suffered from extensive stress during her second labor. Undernourished and still in the recovery stage from her first delivery, her reproductive system would have struggled to manage the second labor.
The effects of the mid-wife’s prodding after both deliveries also likely damaged the already sensitive and stressed muscles in her pelvic region. A year after Sabitri gave birth to her second child, the consequences of her dangerous delivery caught up with her.
Bending over to pick up a load of grass in the fields, Sabitri felt a sudden and sharp pain in her back and lower abdomen. That same day she noticed that something was protruding from her vaginal canal, but she told no one about it and did not think to go to a doctor.
A month later, Sabitri returned to her birth home and mentioned her persistent symptoms to an elder female relative, who told her that she was probably experiencing “pateghar khasne samasya,” which translates to “fallen womb problem.”
Too shy to share the details of her personal health with anyone else, Sabitri kept her problem to herself for the next 14 years. Even Sabitri’s husband has been ignorant of her condition for 14 years, during which time she gave birth to two more children and suffered silently through the pain and discomfort of a prolapsed uterus.
It wasn’t until a community health volunteer arrived at Sabitri’s door and began to talk to her about “pateghar khasne samasya” that Sabitri shared the details of her experience with anyone else. Since then she has gathered the courage to tell her husband, who agrees that she should seek treatment.
Sitting in a circle of other women who are suffering from uterine prolapse, Sabitri says she is happy that she met the community volunteer and finally told her husband. After 14 years of not being able to talk to anyone about her condition, she now knows that she has support and there is hope yet for her suffering.
Secrecy and Stigma
Goulab Devi RamGoulab is now 35 years old and has been married for 20 years. She had her first child at the age of 20and her second at 25. Two to three years after the birth of her second child, Goulab’s prolapse occurred.
While lifting wood in the forest, Goulab felt pain in her abdomen. Her prolapse has become worse over time, and she has pain, difficulty walking, and weakness. She has also had to restrict the amount of food that she eats.
Goulab learned about uterine prolapse through a NGO that she used to work for. If it was not for this, she would not speak about the issue.
Now Goulab is making some money and hopes that a pessary ring will hold her uterus in place and help alleviate her symptoms. She is determined to prevent the same condition in her daughter. Goulab says that she won’t marry her daughter early, she will make sure that her daughter has a good diet while pregnant, she will make sure her daughter delivers in an institution, and her daughter will not lift heavy loads after giving birth.
Even though Goulab knows how to prevent uterine prolapse and talks about the issue freely, she is still afraid of telling her husband about her problem.
Early Marriage
Kanni and Kaliya Devi ChaudharyKanni Devi Chaudhary (left), 71, and Kaliya Devi Chaudhary, 68, are sisters-in-law who were both married at the extremely young ages of six to seven. They both stayed with their own families until around age 14, when they were considered mature enough to move into their husbands’ homes.
Neither Kanni nor Kaliya knew about uterine prolapse or possible treatment until social workers talked to them. They had no idea they were suffering from uterine prolapse, and both kept their problems hidden from their husbands and others.
After talking with social workers, Kanni and Kaliya both decided to have hysterectomies to treat their prolapse. Both subsidized the operation through an NGO. Kaliya’s husband did not resist the surgery, and her sons contributed 750 rupees (about $9.73) toward the treatment. Kanni’s husband died by the time she learned of the possibility of treatment. Kanni raised 500 rupees ($6.48) through goat rearing to pay for her hysterectomy.
So far, none of Kanni or Kaliya’s daughters have problems with uterine prolapse. Right now, they do not do heavy work because their children are small. But when their children grow up, they will have to go to the fields. If they experience any problems, they plan to go to the campaigners for help.
Because of Kanni and Kaliya, the lack of awareness and knowledge in their family about uterine prolapse has ceased.
Birth Spacing/High Parity
Anita Devi SadayaThe combination of heavy fieldwork and two births in quick succession never allowed Anita Devi Sadaya’s muscles to heal properly.
Anita is only 19 years old, but she has already delivered two children and experienced uterine prolapse. She had her first child when she was 15 and the second at 16. She has experienced symptoms of uterine prolapse for almost five years, since right after her first delivery.
Anita felt her uterus falling while doing housework. She thinks it happened because of her work. Anita is responsible for all house and field work, and bringing wood from the fields. Her heavy workload continued up until labor and resumed only a week after the birth of her first child. Her second delivery was a lot harder than the first, as her uterus came out with the baby.
Anita’s mother, sister-in-law, and husband all know about her problem. A neighbor told a campaigner about her problem, and the campaigner came to talk with her. Her neighbor, the campaigner, and her husband have all encouraged Anita to seek treatment for her prolapse. Her husband walked with her to the health post a half-hour away.
Unfortunately, Anita and her husband do not have the resources to pay for a pessary ring that would hold her uterus in place. She and husband work as day laborers – collecting wood from the forest – and also farm on government land. Despite her prolapse, Anita still has to do field work and domestic work. She lifts a little less now. Her husband tries to help, but he cannot do it all.
Anita is most affected by the condition mentally, as she stresses about her problem and how she will manage. She also worries that others see her as less capable. Despite this, and her difficulties with the last delivery, Anita still wants to have another child. Both of her children are girls and she wants a son as well.
Chalidevi Regmi At 55 years old, Chalidevi Regmi has already seen a lot in her life. She married at the age of 11 and followed her husband to a variety of towns and villages across Nepal in search of work. On top of the stress of an early marriage and following her husband, she has given birth to five surviving children as well as two stillborn children.
Chalidevi raised her family and ran a household on her own. Like most women from the area, she only took a break from her daily routine of domestic and agricultural chores for eleven days after giving birth to her children.
Twenty-four years ago, after the birth of her last child, Chalidevi developed uterine prolapse – a condition that is so common for women in this society. Unlike most women, however, Chalidevi had immediate access to health care, and was able to use a pessary ring to support her uterus and prevent further acceleration of the condition. She used the pessary ring for more than a decade until she suffered a serious accident while grinding rice.
The force of the accident caused Chalidevi’s uterus to fall into what is likely fourth stage prolapse, at which point a pessary ring is no longer a viable solution. She hasn’t sought treatment since.
Chalidevi isn’t interested in having surgery to treat her prolapsed uterus. She has given up on the idea of an improved life, and she is ready to die.
Nabinisa Saha“Mera parivar,” Nabinisa Saha says, pointing to a photo of herself surrounded by her children. My family. Her broad smile betrays her modesty and shows traces of a much deeper sense of accomplishment.
For a woman like Nabinisa, having eight children is something to be proud of – a mark of her contribution to the household and her ability to raise a large and healthy family. With such an achievement, however, also comes the consequences of high fertility.
Five years after giving birth to her last child, Nabinisa began to experience severe pain and vaginal bleeding. At first she thought her condition was related to her diabetes, and chose to wait out her symptoms in silence. When the bleeding still hadn’t stopped after two months, however, Nabinisa decided to seek medical attention.
Forty-five minutes away, in the nearest major town, Nabinisa had a check-up at the women’s hospital and discovered that her uterus had prolapsed. The staff of the hospital gave her medicine for a related infection and sent her home, telling her that the bleeding should stop and the condition should improve.
However, after taking themedication for a month, Nabinisa had not experienced any improvement, and continued to be confined to her bed by pain and bleeding. She had no one to talk to about her condition and little knowledge about why it had happened to her or what she could do about it. When Nabinisa raised the issue with her husband, he told her it was normal—that all women who have given birth experience this, and that it would get better over time.
Nabinisa is lucky, because after six months of deteriorating health, she was eventually able to convince her husband that she needed further treatment. Wary of the ineffective treatment that she had received from the local women’s hospital, however, Nabinisa had to seek other options. Through a friend of her husband’s, Nabinisa found a private hospital in India that would perform a hysterectomy – a surgery that would to treat her advanced stage of prolapse.
Despite the fact that she was unable to walk or sit comfortably because her uterus was fully extended from her body, Nabinisa made the journey from the Terai region of Nepal to India, where she was finally operated on and given relief from her prolapsed uterus.
When asked why she thought she had prolapse, Nabinisa just shrugged: “I’ve never asked myself. Why question it? This is just something that happens.”
Uterine prolapse is, for women like Nabinisa, just a part of life that comes with being a wife and mother.
Poor Birthing Practices
Kapurni Kumari RajaKapurni Kumari Raja’s prolapse occurred during the birth of her first child, highlighting the negative consequences of giving birth at home with untrained attendants.
Kapurni’s birth attendants put pressure on her stomach during the delivery, thus weakening her muscles and ligaments and forcing her uterus to come out a bit. After this, she was not able to conceive for three years. With each subsequent birth, her uterus fell a bit more. Now, Kapurni has second-degree prolapse.
When Kapurni told her mother-in-law about her problem, her mother-in-law started scolding her. She has even threatened to marry Kapurni’s husband to another woman. Kapurni still has not shared her problem with her husband, and has not received any treatment for her prolapse.
“If I say to my husband, he won’t be able to manage treatment and also he will start scolding, so what is the use?” she said.
Logani Devi SadayaLogani Devi Sadaya’s uterine prolapse is the result of poor birthing practices during the delivery of her second child. She now has six children, all born at home. She had birth attendants with her for each delivery. However, these birthing attendants helped cause the problem that Logani has suffered with for so many years.
During her second delivery, Logani’s birth attendants pressed with their hands and feet and even stood on her stomach to force the baby to come out. Such pressure irrevocably damaged the muscles and ligaments in her pelvis. This is when her prolapse began.
“During the birth I saw a red thing that came out of me and I cursed at the birth attendants,” Logani remembers. The birthing attendants knew about the problem from the moment it occurred, but they could not do anything to fix it, she said.
At that time, Logani did not know anything about uterine prolapse, possible treatment, or any other women suffering from the condition. The prolapse has progressed gradually since the birth of her second child and did not interfere with the births of her subsequent children.
Her main symptom has been back pain, which makes working difficult. She has trouble walking and cannot go far. Since Logani received information about uterine prolapse and treatment, she wants to have surgery but is afraid.
Financial difficulties could also make receiving treatment difficult. Her husband has said he would not leave her, and that he would try to do what is best for her. Logani says that, as a birth attendant herself, she has never caused this to happen in others.
Sili Bati YadavThe combination of heavy work that Sili performed both during and after her pregnancy and the actions of the birth attendants during her labor probably equally contributed to her uterine prolapse.
During the delivery, the birth attendants were pressing on her back with their legs. Only two or three days after giving birth, Sili returned to doing her normal housework. After only six days, she returned to fieldwork. This is when Sili first noticed that something was wrong.
It is quite possible that even though Sili noticed the prolapse while doing work, it actually happened during the delivery. Her prolapse occurred when she was only 18 years old. She is 47 now and has endured her condition for almost 30 years with no treatment.
Sili told the birth attendants who had helped her during her labor about her symptoms. They did not know what to do and only referred her to other attendants who might be able to help. Her mother-in-law was also unable to help, as she had never had this problem.
Without the help and information she was looking for, Sili did not do anything about her problem. Up until a year ago, Sili did not even know that treatment was available. Sili has not had treatment yet, because her husband says that he has no money to pay for the cost of treatment. However, her neighbors have offered to take up a collection to contribute to the cost of surgery.
Cultural Taboos
MansalaFor Mansala, the history of her prolapse starts at the age of 15, when she married and moved into her husband’s home.
For the last 35 years, Mansala has maintained a regular routine: wake up at 4 am to cook, clean the house, feed the animals, and do the laundry. At 1 p.m., she finishes her housework and heads to the jungle and the fields to graze the animals and haul heavy loads of grass, wood, and water.
For five days a month, when Mansala has her menstrual cycle, her routine varies slightly. This is because in the region where Mansala is from, cultural beliefs maintain that women are ritually impure at the time of menstruation. Women who are menstruating must therefore be secluded and isolated from contact with food and other humans, lest they anger or offend the gods.
The small huts where women from these communities go during their monthly periods are called chaupadi. They can vary greatly in size and condition. The worst of these chaupadi are not even tall enough for a person to stand, and barely big enough for a few to sleep close together. Often, they are constructed of simple twigs and mud, and sometimes they double as animal sheds. In these cases, women are made to eat and sleep in the company of their family’s livestock.
In many of these communities, menstruating women are seen as the source of curses, so they are confined to the chaupadi until their cycles are finished. They cannot cook, so they eat what their family serves them: often left-over rice, or perhaps a few roti.
The physical and social isolation that women experience in the chaupadi is not only psychologically traumatic, but it can also be fatal. It is not uncommon for women to fall ill from snake bites while staying in the chaupadi. Recently, a 14-year-old girl died of diarrhea while she was confined to a chaupadi: Nobody would help her or take her for medical care, because they were afraid they would become impure if they touched a menstruating girl.
Mansala’s situation is not as severe. She says that because she has no mother-in-law (and mothers-in-law are quite frequently the enforcers of such traditional practices), her husband is lenient. Her chaupadi is attached to the house, and large enough to hold a bed that her husband built for her. She says that if she had had a mother-in-law, she would have to sleep on the ground.
With the benefits of not having a mother-in-law, however, also came the hardships. Traditionally, a menstruating woman must stay in the chaupadi all day and all night, so that she doesn’t risk spreading her impure status throughout the community. Mansala, however, does not get the “luxury” of rest during her period. Because there are no other women in the household and her husband refuses to pick up any of the chores other than cooking, Mansala is forced to work in the fields during the days of her period and return to the chaupadi at night.
Mansala, like most women in her village, also gave birth in a chaupadi. Notions of female impurity correspond to menstruation and birth. Women are thought to be polluted at the time of child delivery and for 10 days following a birth.
Birth attendants are not available in Mansala’s village and men do not attend to births (nor can they enter the chaupadi), so she gave birth alone. For 10 days she remained alone in the chaupadi, where no one was allowed to visit or touch her or her newborn child. Her husband cooked for her, but Mansala was otherwise left to do her own washing, bathing, and childcare.
Mansala recently underwent a successful hysterectomy to treat an advanced stage of uterine prolapse, from which she had been suffering for two years. She was identified and sponsored for the surgery by an non-governmental organization (NGO) in her home district of Jazarkot in the Far West. But qualified teams of gynecologists, surgeons, and anesthetists at reputable hospitals are not available in the Far West, so NGOs have opted to send women like Mansala to Nepalgunj, where the hospital accepts patients from NGOs on a voucher system.
It took Mansala three days to reach the hospital – one day in a bus and two days of walking. Although she suffered from back pain, heavy bleeding, and difficulty walking because her uterus protruded from her body, Mansala had no choice but to make the journey.
Although Mansala is now cured of the pain that she suffered from a prolapsed uterus, she has not been relieved of the hard work and isolation that she suffered for years at home and in the chaupadi.
Violence Against Women
Parvati Poudel Parvati Poudel has four children: three daughters and one son. Her prolapse happened seven years ago, at the age of 37, just one year after her youngest child was born.
For three years now, she has struggled with the pain in her back and stomach and started eating less. If she eats too much the pressure of the food “makes it hurt more, and can even make it come outside; even now with the ring if I eat too much both come out.”
Her husband has not reacted well to her condition. “This disease has driven a fracture between us,” she says. “He has refused me any money for my disease or ANY help.”
Parvati reports that he is even turning her children against her, giving her eldest daughter money to run the house along with instructions to not give Parvati any money at all. Compounding the situation, Parvati’s in-laws – who substitute for her own parents after marriage according to traditional Nepali custom – are very unhappy about her inability to work and are encouraging her husband to take a new wife.
The peak of her difficulties occurred when, after being beaten, she was cast out of the house and told she could not return. She explains that she has been wandering around for a month, staying with friends and relatives and trying to raise money from them as well as various women’s groups so she can pay for treatment.
She hopes to have the surgery because of the “big, big problems” she is facing. “This disease is my enemy because it keeps me from doing my work,” she explains.
Instead of the heavy manual labor required of Nepali women, she can only do “sitting work” now, “small things that are not very difficult.” Not being able to contribute in the expected way, she is left feeling like a burden on her family, unable to fulfill her duty or earn her keep.
Despite the severity of her prolapse, doctors conducting a free camp in her area recently were not able to offer her a hysterectomy due to an infection she had from the pessary ring that she uses to keep her uterus inside her body. Rather, Parvati was given a prescription for about seven medications she should take for 15 days and told she should then travel to the private teaching hospital several hours away from Gaighat and pay for a hysterectomy from a location with permanent facilities.
Realistically, as she will not likely be able to raise the money necessary for the operation (about $300-500), Parvati will likely have to wait until she hears of another free camp somewhere in the area. Hopefully, by that time, her infection will not have returned and she can have the surgery.
Padma KumariBecause of her prolapsed uterus, Padma experiences sharp pain during sex. Her husband, however, does not believe that she is telling the truth. For 13 years he has ignored her pleas, and Padma has become a victim of marital rape.
Padma first experienced uterine prolapse six months after the birth of her first child, when she was only 14 years old. Initially she travelled to a mission hospital in India, where she was able to receive a pessary ring to treat her early-stage prolapse. She had the ring changed at the hospital twice, but after that she removed the ring herself.
As the wife of a day laborer and an occasional day laborer herself, she could not afford the transportation or time costs of going to the hospital in India – the nearest facility that could provide prolapse services.
After removing her pessary ring herself, Padma spent the next 13 years trying to ignore her symptoms. Heavy work was difficult and caused her severe back pain, but her husband told her he would not help. After the birth of her subsequent children, Padma was back to work within 10 days, because her husband refused to assist her with anything other than cooking.
Then, Padma’s prolapse suddenly became worse. She began to suffer from fever and exhaustion, and she had so much discharge that her sari (wrapped several times around her waist) was visibly stained in the rear. She could not hide the signs of her condition, and as the neighbors began to talk about her health, she found that no one would hire her for day labor, making it harder for her to maintain a productive role in the household.
Padma’s husband has protested that he has no money to spend on any kind of treatment. Female community health volunteers told him that if he didn’t make the investment now, his wife would soon be in much pain that she wouldn’t be able to do any work, and the family finances would truly suffer. He didn’t seem convinced by the concept of a preventive investment.
Faced with a husband who continually rapes her and who will not spend the money necessary for treatment, the future does not look hopeful for Padma.
Accessibility of Health Services
Bishna Maya BandariAbout three years after giving birth to her son – her first and only child – at age 22 Bishna Maya Bandari felt her uterus fall.
For the past 25 years she has struggled with her prolapse without access to the health services she needed, and without treatment.
When she spoke about her problem with her husband, he said nothing at first. After some time, he allowed her to go see a traditional medical healer. Unfortunately, those methods were unsuccessful and her pain and discomfort continued.
Despite this, Bishna counts herself as lucky because 15 years ago her son was married, and her new daughter-in-law became a major source of support and assistance with her domestic responsibilities.
When I feel pain, I lie down and ask my daughter-in-law to bring me some hot water,” Bishna said. When asked what she did in the 10 years before she had this support, she frankly replied, “What could I do? There was work to be done.”
Though her husband never gave her the financial resources to go see a doctor, he did not stop her from finding them herself. Thus, with some money sent home by her son, who works as a wage laborer in Quatar, she bought a goat and then sold the offspring, along with some excess wheat and vegetables from her farm. With this money, she self-financed her trip to the gynecological camp in Udayapur in the hopes of receiving surgery for free.
After evaluation by doctors there, she was determined to have a “presidential” – a prolapse where the uterus is completely distended outside the body, and cannot go back inside. At this stage of the condition, hysterectomy is the only option.
After twenty-five years without any treatment, Bishna was able to have a hysterectomy that would end her pain and suffering.
Chandmati PasiChandmati Pasi, a poor farmer from the Rupandehi District in Southern Nepal, has suffered from uterine prolapse for 18 years. She has accepted her condition and does not expect that she will ever be able to afford the surgery to correct it.
Chandmati was out collecting wood just 15 days after the birth of her last child when it happened. It was a rainy day and the roads were slick with mud, causing Chandmati to slip. As she fell, she experienced a sudden pain and the sensation of something dropping in her lower abdomen.
Despite the pain, Chandmati had more work to do. With the same unquestioning attitude with which she tells this story, Chandmati stood back up, adjusted the load of wood that was balanced on her head, and returned to her village to continue her day’s work.
Eighteen years have passed since Chandmati first felt her uterus fall. For 18 years she has suffered through pain, fever, difficulty walking and an inability to control her bladder. Sometimes she has to stay squatting in a field for up to an hour-and-a-half before she can overcome the pain that it takes to urinate.
Eating and drinking also cause her severe pain, so she has reduced her food and water intake – despite warnings from the local community health worker that she is cutting short her own life.
For Chandmati, treatment for uterine prolapse is not a realistic financial possibility. Unwilling to tell her husband about her condition at first, Chandmati turned to her mother-in-law, who helped her collect some money from friends and relatives for medical attention. Chandmati took this money to the local health post, where she was prescribed medicine that would cure a related infection, but would not treat her prolapse. She took the medicine for one week, with no improvement.
Years passed and Chandmati’s condition only worsened. At one point Chandmati consulted a local village doctor, who told her that her condition could be cured with six injections. Chandmati saved 100 rupees for the first injection, but after that was unable to pay for the remaining five. Chandmati has simply accepted the improbability of treatment and continued on with her life, cutting grass in the fields, collecting wood from the forest, and raising her surviving children.
Eighteen years after her first fall, Chandmati is undoubtedly now experiencing an advanced stage of prolapse that can only be treated by hysterectomy. For this surgery, Chandmati would have to travel to the nearest major town and then pay at least 5,000 rupees to have the surgery performed.
Chandmati says she cannot even afford to make the journey: “How can I pay for treatment?” she asks. “If someone can pay for my treatment, then I will go for surgery. Otherwise, I cannot. I am a farmer. I have a family to take care of.” Back