On June 7, 2010, hundreds of experts on women’s health will gather in Washington at the 2010 Women Deliver Conference to review the challenge of maternal health in poor countries. Most of the discussion is likely to revolve around the risks of childbirth, one of the major killers of women. But as global rates of maternal mortality show signs of falling, there is growing interest in morbidity – complications arising from childbearing that rarely kill but have a devastating impact on a woman’s wellbeing.
I have spent the past three weeks in Nepal reviewing one such condition, which occurs when a woman’s uterus falls from her body. Up to now, uterine prolapse has received little international attention, but within Nepal it is a full-blown crisis. One 2007 study by the United Nations Population Fund (UNFPA) estimated that at least 600,000 Nepali women – 10% of the women of reproductive age – were affected. One third required an immediate surgery.
The decision to have a hysterectomy is not to be taken lightly, particularly for a young woman. But it cannot compare to the pain and humiliation of living with a distended uterus for year after year. Many women with prolapse try to hide the condition from their husbands. Many suffer divorce and ostracism. Destitute, and without their own property, they often forced to return to work for their former husband’s new wife.
According to Samita Pradhan, a Nepali activist who will be attending the Washington conference, prolapse causes such desperation that women resort to stuffing pieces of slipper, rubber balls, glass bangles and even vegetable husk into their vaginas to hold up the womb. Pradhan’s organization, the Women’s Reproductive Rights Program, began working on prolapse in 2000 when field workers in the West noticed that women were leaving a trail of pus and attracting flies. Shocked, they made inquiries and found rates of up to 30% in some villages.
Prolapse is caused by a lifetime of abuse, neglect and discrimination, most of which occurs in the family. It starts early, when sisters compete for scarce food with their brothers and invariably lose out. It continues with marriage. The legal age of marriage in Nepal is 18, but I met women who had married at ten. On joining their new family, new wives surrender their independence and forfeit everything to their husbands and in-laws.
Childbirth is extraordinarily hazardous, particularly for girls with an unformed womb. Most births occur at home under the supervision of village midwives. One government midwife told me that such birth attendants often push down on the woman’s lower abdomen, and even force women to give birth while standing up or hanging from rafters. This can expel the womb along with the baby and placenta.
The problem is compounded by cultural violence. In the West of Nepal, women are considered unclean after childbirth and banished for weeks to unsanitary cowsheds (chhapaudi). They are also denied dairy products at precisely the time when their bodies most need nutrition. Instead of prolonged rest, many return to work within days – carrying, lifting and squatting as they make mud bricks or fuel brickettes out of dung. This puts intense pressure on the muscles of the womb, which are softened by child birth.
All of this makes for a harsh and joyless life. One recent study of 8 districts by the UNFPA found that suicides accounted for 16% of the deaths among women aged 15 to 49. The findings are deeply worrying to the agency, one of the sponsors of next week’s conference in Washington.
The government’s response to the crisis has been lackluster. Every local community is served by a health post where women should, in principle, receive a check-up and basic services. Surgeries can be referred to district hospitals, or surgery camps run by NGOs. But many posts are in bad condition and short of staff. One supervisor in Siraha district, Ram Pratap Sajh, said he lacked the staff to even screen for prolapse and has been appealing for more support for two years.