Reproductive health and the conflict

For Shanta Karki, life simply could not get any better. Having already given birth to three healthy girls, her lifelong dream of finally having a son has come true. “I feel good. I’m happy. And I’m ready to go home,” the 32-year-old said, beaming from her bed at the Kathmandu Model Hospital, a private community-based hospital in the Nepalese capital. “There were no problems and no complications so I guess I’m lucky.”

But luck is just part of the equation, say experts, making Shanta’s case more the exception than the rule. In Nepal, many women continue to die during childbirth due to severe bleeding, sepsis, toxaemia, obstructed labour and the consequences of abortion – most of which could be prevented if essential obstetric care services were available.

In mountainous Nepal, however, a country crippled by the longstanding Maoist insurgency to overthrow the state – a conflict which has already taken the lives of more than 13,000 over the past decade - reproductive health has long taken a backseat to what some in the donor community might see as more pressing humanitarian needs, such as food, shelter, security and the plight of children.

Those issues not withstanding, the importance of reproductive health, particularly given the conflict’s impact, cannot be denied.

“Unfortunately, in times of war, women’s health, and more specifically, women’s reproductive health is overlooked,” Junko Sazaki, Country Representative for the United Nations Population Fund (UNFPA) in Nepal said in Kathmandu, emphasising the catastrophic consequences it had had on women, children and the community as a whole.

“Pregnancy and childbirth is increasingly becoming a nightmare for many women due to the disruption of health services,” Sazaki explained, particularly in rural areas of Nepal where the vast majority of the country’s 28 million inhabitants live.

According to the UN agency, reproductive health clinics have often been closed or destroyed in many conflict-affected areas, while elsewhere shutdowns, curfews and roadblocks imposed by both parties to the conflict have seriously disrupted the supply of essential medicines.

Additionally, fear and restricted freedom of movement have particularly affected pregnant women, with innumerable reports of pregnant women dying in childbirth due to reoccurring blockades or curfews.

Most troubling of all, the fact remains that most women in Nepal give birth at home, with only one in eight attended by a doctor or midwife, UNFPA claims.

And with women in Nepal having more than four children on average, that’s a disaster in the making.

“Only 18 percent of all deliveries nationwide are attended by skilled birth attendants,” Sazaki said, describing the country’s maternal mortality rate of 539 per 100,000 live births as one of the worst in Asia.

“That’s quite high and sadly, that’s preventable. “They [qualified health experts] can recognise a high-risk birth when they see it and can make the proper referral,” she said.

Yet with up to 80 percent of the country under Maoist control, according to some, such referrals are often all but impossible. Fearful of harassment from both sides of the conflict, health workers increasingly prefer to stay in the cities out of fear for their own personal security.

“It’s dangerous – plain and simple,” one health worker, who declined to be identified, maintained matter-of-factly.

Meanwhile, where health clinics have opened, frequent disruptions – including visits by combatants from both sides – challenge service providers and intimidate users, according to the UN.

Women with routine problems often face years of problems as a consequence – and conditions such as a prolapsed uterus, common in developing countries – particularly amongst younger women - reach epidemic proportions in rural areas.

According to UNFPA, 50 percent of women under the age of 20 are already married in Nepal, with one-fourth of them already mothers or pregnant.

“They start their reproductive life earlier which means they deliver when their bodies are not yet ready,” Sazaki explained.

Often attributed to lifting heavy objects or bearing many children, according to a report entitled ‘The Neglected Case of the Fallen Womb’, published in the Himal South Asian press, a prolapsed uterus describes a condition in which the uterus, a curved sack expanding at the top and narrowing towards the bottom, comes out through the vaginal opening, causing the utmost discomfort if not treated.

“They don’t know what it is and consequently don’t get the healthcare they need to rectify the problem,” Sazaki said. “It’s really something that can be treated immediately.”

But in Nepal, with awareness of such issues so limited, coupled with limited access to health care, the problem is exacerbated further, explaining why many women live with the condition for 10 to 15 years, often facing discrimination from their husbands and their families as a result.

Although there are no exact figures on the number of women suffering from a prolapsed uterus, according to the America Nepal Medical Foundation, over 25 percent of women in rural areas are estimated to suffer from utero-vaginal prolapse (UVP), otherwise known as a prolapsed uterus.

Such issues present innumerable challenges to UNFPA. As a rule, the agency works in collaboration with the government, thereby building up the government’s capacity by training through a top-to-bottom approach – an approach which would normally work if the conflict were not ongoing.

“It’s not working because conflict-affected areas are not getting the service they need,” Sazaki added. “Health workers do not dare to stay in the conflict area”.

In an effort to address just that, UNFPA has since November 2005 established 12 reproductive health camps in six of the country’s 75 districts, as well as mobile reproductive health clinics that can travel to conflict-affected areas and provide services directly to the community. “That way, they [the women] don’t have to travel to get to the health service,” she said, noting the enormous demand demonstrated by the women.

“If we go there, we are simply surrounded by women requesting assistance,” she said, adding that 20 percent of the women examined at the camps suffered from a UVP.

Despite the demand, however, such programmes will prove impossible unless further funding is made available. “The demand from communities is there, but we need funding,” Sazaki said. “We need to continue with what we started. We need to build on successful work and extend our programme of camps and mobile health clinics at the district areas worst affected by the conflict.”