Nuche Maya Maharjan suffered a discomforting medical condition for 35 years before she built up the courage to seek medical assistance. For years she had no idea what the condition was and whether it could be treated.
“I had just given birth to my first child and was working in the fields near my village. Suddenly I felt as if my insides were dropping out of me,” the 66-year-old recalled.
Baffled by what had happened, she told no-one - not even her husband – hoping the problem would go away.
But over the years, her prolapsed uterus (see box) got worse, to the point that it protruded from her vagina completely, making it difficult for her to walk or even sit upright. She required surgery, a fact prompting this uneducated Nepalese mother-of-five to finally seek help.
Maharjan is one of many rural women who regularly come to the Kirtipur public hospital on the outskirts of the Nepalese capital, Kathmandu, seeking treatment for prolapses - the leading cause of ill-health among women of reproductive and post-menopausal age in Nepal today, doctors say.
“This is more of a rural problem than an urban one,” Dr Ganesh Dangal, an attending gynecologist at the NGO-funded health facility in Kirtipur, told IRIN. “In rural areas, there are no hospitals to treat this condition, forcing many of these women to travel to the cities for help.”
What is a uterine prolapse?
Yet despite the obvious physical discomfort suffered by these women, many prolapse sufferers do not seek help due to the social stigma the condition carries - a fact only exacerbating this otherwise preventable condition.
“Most rural women don’t even look at this as a disease and don’t seek help,” Dangal confirmed. “Instead they seek comfort in the company of other women in their villages suffering from the same thing - which, regrettably, there are many.”
Given the social stigma associated with a prolapse, coupled with the woman’s inability to satisfy her partner sexually, some husbands remarry and sufferers and their children often find themselves socially excluded, ridiculed or abandoned.
Specialists estimate that more than 600,000 women in the Himalayan kingdom of 27 million inhabitants suffer from uterine prolapse, making it one of the leading causes of morbidity among lower caste and rural women.
For more acute cases, surgery is the only treatment. At a cost of US $200, most Nepalese women cannot afford this. The World Bank estimates that about 30 percent of Nepalis live below the poverty line.
A United Nations Population Fund (UNFPA) study undertaken in eight districts of the country in 2006 - including hill, mountain and southern Terrai regions - concluded that about 10 percent of all women of reproductive age suffer from the condition.
More than a health problem
But despite the numbers, many women suffer in silence.
“This is a multifaceted problem. It’s not just a health problem,” Dr Peden Pradhan, UNFPA assistant representative for Nepal, said. “When you are poor and not educated, you generally get married earlier in rural areas, which makes the prevalence of the problem more widespread there.”
The incidence of prolapse could be decreased by having more deliveries attended by trained paramedics, she said. More than 80 percent of Nepalese women give birth at home and inappropriate maneuvering by unskilled birth attendants during delivery increases the risk of prolapse.
Pradhan added that women in Nepal’s male-dominated society lack real empowerment over when they have children. In addition, they lack awareness of what a prolapse is and what to do about it.
Addressing the problem
UNFPA and the government of Nepal are working together to develop a three-fold national strategy to tackle prolapse.
“I didn’t know I could talk to people about this. I was embarrassed and ashamed,” said Maili Maharijan, another prolapse sufferer in Kirtipur who waited eight years to come forward.
Unaware that treatment was available, the 70-year-old would routinely push her uterus back in place herself, only to have it drop out again when she coughed or sneezed.
“It was very embarrassing and caused me a great deal of discomfort,” she said.
Such stories underscore the despair, rejection, isolation and stigmatisation felt by many prolapse sufferers in Nepal today.
Focus on maternal mortality
Reproductive health and the conflict