Birma Prayar’s dress is stained with grease and dirt. She is barefoot, and her hands—which she rubs nervously—are calloused. Her wrinkled face and frail body belie the fact that she is only 38 years old.
At first she is reluctant to talk about her medical problems, and she looks down at her feet or away to the fields when we ask her questions. Her husband is squatting just a few feet away in the doorway to their hut, monitoring the interview. When the female community health volunteers (FCHVs) tell Birma’s husband that he has to leave, he quietly gets up and walks away into the forest. Birma relaxes a little and begins to tell us about her life as a poor Dalit woman in this clay hut at the edge of the village.
Birma Prayar married when she fifteen 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. So 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 sixteen 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 ten 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.
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 twenty years since 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 five in the morning to eight at night 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 ($1.20USD) a day, Birma harvests rice, pounds rice, carries heavy loads of grass or water, or 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 is very much alone in her hut among the fields at the edge of the village. Her two daughters have married into families of their own; one daughter lives just a few hours away but is poor herself, and has neither the money nor the time to visit. Birma’s youngest son is studying in Kathmandu on a scholarship, but he has not been back to visit his family since he first left many years ago. Birma only has her husband, who often beats her when he is drunk.
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 has to this day 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. Second stage prolapse cases such as Birma’s can be treated with the application of a pessary ring that is inserted to hold the uterus in place and prevent it from falling. The nearest facility capable of providing such rings, however, is in another village; the cost of travelling to that hospital and purchasing a pessary is roughly equivalent to four days of Birma’s wage earnings. On top of that, pessaries must be changed every three to six months, and many poor patients like Birma are forced to abandon treatment because they cannot afford the constant travelling costs required to maintain the pessary.
Until pessary rings are made available at all health posts and sub-health posts, women like Birma will continue to live with prolapsed uteruses and will eventually progress from early stages to advanced stages. And although providing such services and training staff in thousands of health posts across Nepal to deal with pessary rings is a daunting task, it is probably the easier of the solutions that are necessary to address cases like Birma. Because until women like Birma live in a society where violence against women is not accepted, where husbands share chores with wives, and where women do not have to endanger their health just to feed themselves, the problem of uterine prolapse is not going anywhere.
Posted By Libby Abbott
Posted Sep 10th, 2008