Uterine Prolapse in Nepal: an interview with Samitha Pradhan

  • Silphion: hi Samita, I’d like to start with a general overview of the situation in Nepal, now, after the elections. How easy, or difficult it is for you and CAED to go on with your activities? How does the situation differ from the last time I was in Nepal (summer of 2006)?
  • Samita: Nepal has electricity crisis at the moment, has only 16 hrs of electicity cut off per day, mainly concentrated in the evenings, and almost no running water at least in most of the cities and towns. Lack of sufficient supply of petrolium products, need to be in queue to get fuel and cooking gas etc.  we’re left with a maximum of 10 hours of electricity in the working period in a week.
    These are just the examples.

  • Si.:
    What is causing the shortages?

  • Sa.:
    The power stations are working only partially, because of the damage of the dam in eastern Terai caused by the last floods. Government simply cannot meet the demand of electricity by public. Supply is too low.
    Political-wise the situation is neither very stable nor secure, there is more violence, more protests, rallying and even killings.

  • Si.:
    What in your opinion is at the base of this situation?

  • Sa.:
    Whe change of regime from monarchy to democracy has risen the expectations of the people, and now people want to claim their rights.
    In the past we have had too much patience with the government, but we have to learn also not too be too impatient. And maybe this is a normal process to go through in critical process like this.
    However, dissatisfaction is understandable, life is not easy with no electricity and no water, which also means no work and no wages for many daily wager earners.  People have basic demands, and now they are angered, and although this is not all responsability of the maoists, they are now in charge. This is not only the demand of basic quality of life, people have been demanding their rights from different angles, such as on the issues of indigenous rights, federal state, people of Terai, dalits, women’s discrimination and violence against women (occupational caste) etc.
    There are protests everywere, even in small villages. Here in Kathmandu rallyes of students and strikes of taxi drivers are very common.

  • Si.:
    Problems and violence have risen even in the Kathmandu valley?

  • Sa.:
    yes, the Kathmandu valley is less secure than before, and, don’t know how much time it will take for us, when we leave home in the morning, to go to work or to get to the places where we need to be.
    The Terai regions, with so many different ethnic groups (Terai madhesis, tharus, dalits etc.) with different demands is also very unstable, while the Hilly regions are safer.

  • Si.:
    Is this having an impact on the project?

  • Sa.:
    All these strikes hamper the work of the project, many times we need to change the progam, and it is very difficult to plan things in advance.  This situation makes us feel insecure since incidences of killings have become common in Nepal.

  • Si:
    I would like you to introduce the subject of Uterine prolapse and the work you are doing in this field.
  • Sa.: The problerm with uterine prolapse was known for many years but it didn’t get any attention, even by NGOs working with women, nor by government. CAED started working in this field because it came as a burning issue of women in far western district, Accham.  in the yers more and more peoples and NGOs have become intere-sted in this and have given messages to people and policy makrs that something could be done. CAED named uterine prolapse focu-sed program as Women’s Reproductive Rights Program (WRRP).  It works at both the level from grassroot to policy level.  It mainly fo-cuses on Preventive Education, Campaign and Advocacy in order sensitize men and women on the social and medical causes and prevention and treatment of uterine prolapse.  It has been recogni-zed as one of the lead organisation in the country to work in this manner.  It has been successful in influencing to policy makers and donor to some extent.  WRRP adovcates the issue of reproductive rights of women including incorporating the uterine prolapse issue in National Health Policy and Reproductive Health Strategy.  An Allliance of organisations who are involved in working on uterine prolapse is established with its main role to coordinate and lobby and advocacy on the issue and now this is a overt subject of discussion.
    I cannot say it was because of the change in political power, but it came on gradually, in talking with the political persns, and also thanks to the pressure from the international donors.
  • Si.: Can you give us some details on the magnitude of the problem?
  • Sa.: on average 10% of women in Nepal suffer from UP, but if we survey the eastern Tarai region and the hilly regions the percentage rises up to  42%.  In a field work in the Eastern Terai region, we in-terviewed 400 women, of which 249 suffered from UP.
    In 2006, study carried out by United Nations Population Fund, 600,000 women have been suffering from this problem and it is  e-stimated 200.000 women are in need of surgery.  It does not stop at this number, obviously it is increasing because not many NGOs in-cluding government work on the prevention of uterine prolapse.  Another reason for increase in number is women have started spe-aking about it. It is no more a stigma, atleast in the areas where programs on uterine prolapse have been carried out.  However, the-re are other areas, which are not touched, it is still a stigma for them.
    In Easter Terai during the uprising 700 women came out demanding a cure, which is rare because Terai women are usually do not come out of their house and talk to other people openly, secluded in the house, culturally recluse. They spoke out because they know now that it is curable and women have rights to have access to health facility.
    Generally, in Nepal, women/adolescents get married as early as when they are 13-15 years old.  This means they give birth at early age.  In the study carried out in eastern terai, 38% get their uterus prolapsed ater first child deliver.  This shows that early marriages (before 20) are one of the reasons behind high occurence of UP, others being bad nutrition, immature uterus, excessive workload be-fore and after the childbirth (usually women start working only 3 days after the delivery). Also the lack of sufficient rest during post  partum period, and the  fact that many women delivery on their own, at home, withouth help of an attendant, sometimes putting too strong abdominal pression during child delivery. In the rural areas, 91% women give birth at home without any help of skilled birth at-tendant.  Other reasons are the high freqency of childbirth (multipa-rity), and the too low birth spacing.
    This is not a mere medical issue, this problem is deep rooted to gender based discrimination. For example, when girls are born, family is not happy, she does not get good care as her brother do-es, she does not get proper diet, they are discriminated in all the apects.  In the far west, girls are restricted to have milk and eggs from the age of 8/9.  This means that this kind of traditions prevents girls to have proper growth in their puberty age.
  • Si.: thus would you say that the root causes of this epidemic are mainly social?
  • Sa.: consider this, poverty is widespread, but the malnutrition is mainly derived by gender discrimination, because UP occurs with even women from well-off families. In a tipical Nepali household the daughter in law always eats at the end, if there is no food left, she does not eat. It is already late that she makes food for herself again.
    Moreover, these women do not have access to education, they work very hard in the house, from the age of 5 they never stop, they continue work even with UP.  Men are not aware either that this is a problem. Men and women both think this is normal to have UP after women gives birth to child.
  • Si.: Hence, what in your opinion are the strategies to focus on?

  • Sa.:
    Without any doubt we need to focus on preventive education to women ang their family as a whole.  Child marriage need to be stopped, family planning reducing multi-parity and increasing birth spacing, hygiene, nutrition, giving birth with skilled birth attandents having sufficient rest during pregnancy and post partum period.  Overall, women should have control of their own body and repro-ductive organs, they should have access to health facility and have voices on their rights.
    The solution lies in prevention and not in surgery. This year (2009) the governement planned 12.000 surgical interventions; this is in-deed a huge effort but it will not solve the problem unless it goes to-gether with preventive education. This is an issue which has been touched upon but it hasn’t been implemented on all the subjects, only on 2-3.000.

  • Si.:
    Samita, would you explain us how CAED, which is an agrofo-restry NGO, came to be involved with UP?

  • Sa.:
    CAED was founded in 1991 as an agroforestry and NTFP NGO, started working with a minority indigenous group “Chepangs”.  We had a good experience with the Chepang community, and we adapted our experience this in the far west region Achham district (?),working with Dalit community (so called untouchables and occu-pational castes).
    While working in the field our approach was to work with local cou-ple facilitators, while discussing gender situation in their are-a,women expressed their problems of prolapsed uterus , explaining that they were suffering a lot from decades. We thought that if we want to work on women rights issues it is not possible to ignore this problem.  We started working on UP issue formally in 1998.

    And practically speaking, what did you do?

    we started discussing with district officers, we brought women to discuss the issues at various levels, even to the ministry. We we-re trying to include this issue in the Public Health Scheme/Program. We also started speaking to the media, to bring out the problem to the mass and to the goverment and the donors to address this is-sue. We were fully aware that an NGO could not solve this pro-blems alone, and that it is a basic right of women to receive all the treatments they needed (pelvic floor muscular exercise, ring pessa-ries, surgery, etc.).
    Anyhow, we started teaching basic prevention strategies, methods to insert pessaries and pelvic floor exercises to women and gover-nment health workers, and also how to use herbal medicines.
    In particular we observed that the remedies most frequently used were sitz baths (semicupi) made with neem leaf (Azadiractha indica –  Meliaceae) powder in lukewarm water or a decoction of Mango (Mangifera indica –   Anacardiaceae) bark; these were however difficult to perform because in many cases the women did not have a bucket or a separate bathroom were to do it. Also used was the al-cohol from the fruit of the “butter tree” or  mahua, (Madhuca longifolia – Sapotaceae) applied as a medicine for weak muscles and, white discharge.
  • 400 health workers were trained in the far west and in eastern Terai., and 100 local campaigners are trained on uterine prolapse rela-ting to women right issues and gender discrimination. 14 Local NGOs have been taking lead to continue the work in district level.
    Main thrusts of our program now is:
    •    Capacity Building of local NGOs, local couple facilitators and government health wor-kers.
    •    Preventive Education at grassroots level
    •    Campaign and Advocacy at different leves (from Village, District to National level through media, political parties, local government and concerned ministries)
    •    Surgical Treatment (Very few)
  • Si.: How successful were your efforts?
  • Sa.: We were to some extent successful, the issue of UP has been since introduced in the National Reproductive Health Strategy.  A national progmam on UP has been developed (focusing on surgical treatment), the media has done a lot of coverage,  both the electro-nic and the printed media, and the radio. 2 weeks ago, there Prime Minister expressed his concern on the problem of uterine prolapse in his speech broadcasted on television and radio.
  • We are not alone, at least not anymore, and other NGOs are working on UP, but I would say that CAED is the only one still com-bining the curative aspect to the prevention.
    Since the issue has become more widely appreciated, international donors have shown interests; obviously the NGOs are attracted. However, I sometimes feel it has become like a business since most of them concentrate only on the curative side and they charge a lot money for surgical treatment, at the same time we need pro-grams on prevention.
  • Si.: Samita, you explained that CAED firts became awarte of this in the far west. Is the situation any different in different areas of Nepal?
  • Sa.: As I said before, we discovered thet also Terai women were suffering from UP. In eastern  Terai we studied with 2300 women, out of those 37% prevalence of uterine prolapse is found  The go-vernment and most of the NGOs were unaware of this.
    I would dare say that in rural areas most women have this problem, as per some individuals tibetan origin people (for eg. Mustang di-strict) have  less problem, but there is a dearth of data available, hence it is difficult to give specific numbers.  A survey of mid and far-western Nepal, prevalence of UP is high, it is much higher in  Mugu district, Karnali region.
    One of the possible reasons for the prevalence in western rural are-as is the low status of women, the many taboos. However this is not the whole story, for in the Terai region they do not have the same problems and taboos for menstruation, so one wants to ask herself: “why the same prevalence”?
    And we come back to what we said before: lack of help by skilled birth attendant during delivery, very high levels of physical effort and hard work around pregnancy and birth.
  • Si.: would you say that religion plays a role in the prevalence?
  • Sa.: well, in easter Terai they are Hindu, and this has certainely something to do with gender differences, in himalaian region there are different religiona which place different stress on women role.
    It is found most of the women from Brahmin, Chhettri who practice Hindu religion have high prevalence. I do not mean it has direct re-lationship with religion, but becasue of faith and belief in hindu cul-ture, women are treated as untouchables during menstruation and during post partum period (atleast until 21 days).  There are so many social taboos which are related to religion, it must have relation to religion.
  • Si.: well Samita, in closing this interview, what would you say are the next steps necessary, or planned by CAED?
  • Sa.: briefly, CAED is actively involved in lobbying government to develop policy to address uterine prolapse, and in the short term it intends to share its experience with other NGOs in the country, by bringing out the issue to let more and more people know about the issue, let policy makers know about it and get their attention to ad-dress it from all the aspects, train more health workers, train NGO representatives, women activitists and counsellors, provide preventive education at local level, and continue its lobbying and advocacy work.
    In the longer term we need to promote a specific, nation-wide rese-arch on this problem, through the government. We need specific e-vidences on the contributing factors of uterine prolapse.
    But the issue which I feel is more pressing is the strenghtening of the suffering women, bring their voices to the authority, establishing networks of suffering women, because they are the main players to pressure government and donors to give attention on this issue.
    I have contacts with a US based NGO who has shown interest to campaign internationally on the issue (The Advocacy project).
    Finally, I would say that the next step for us is to establish ourself as a “resource” NGO, we have learnt so much from grassroots, we do have expertise on bringing out the issue, taking UP as an entry point to reduce gender discrimination and gender based violence.  We have experience of working both at grassroot level, at the same time building capacity and lobbying and advocacy at national level.

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