One in ten married women in Nepal is estimated to suffer from a fallen womb or prolapsed uterus. This condition occurs when the cervix, along with the uterus, moves down from its normal anatomical position, because the surrounding ligaments are unable to maintain support. A primary cause is unattended childbirth, accentuated by heavy manual labour too soon before or after giving birth. But rarely does a woman know what has happened and why, or that it can be treated. She is often too embarrassed to ask for help.

Bhagwati Mainali (left) is a health worker helping in a mobile reproductive health camp. PHOTOS COURTESY OF SUSHMA AMATYA

Nepalese women start carrying heavy loads and doing difficult labour at an early age. They marry young and usually have several childbirths at home without any help, which may stretch the pelvic muscles during long labour. Also manoeuvring by unskilled birth attendants and resuming heavy work immediately after delivery can cause further damage. "Our research shows that some 95 per cent of women in Nepal resume their household work within 45 days of delivery", says Dr. Rajendra Gurung, reproductive health specialist for the United Nations Population Fund (UNFPA). "That's just too soon, as the ligaments are still too soft. Even worse, more than 14 per cent are doing heavy work within seven days of delivery. This is just dangerous! The scale of the suffering is enormous-we are talking of 600,000 women and girls."

The first community-based reproductive morbidity study in Nepal has just been completed. Financed by UNFPA in collaboration with the World Health Organization, it was conducted by the Institute of Medicine at Tribhuvan University and covered some 2,070 women in eight districts. Preliminary findings also suggest that nearly 3 per cent of those affected by uterine prolapse are still in adolescence.

One solution has been to bring services through mobile reproductive health camps, where women can be fitted with a pessary ring, which holds back the uterus and prevents it from falling out. The ring, costing about 20 cents, is a practical alternative to surgical repair or uterus removal that cost anywhere between $150 and $250 and is out of reach of the poor rural women. Nirmala Khatri, 21 years old, kept the painful secret of her condition for six years before she gained courage to do something about it. Srimati Limbu, a grandmother, has been living with a hanging pouch-like thing for the past 42 years, and Jaya Maya Suwang, 72 years old, tolerated it for 40 years before finally seeking help. I met them at one such camp in August 2006 in Panchthar, a mountainous district on Nepal's eastern border with India. Their stories illustrate the very difficult life of rural women, whose prolapsed uterus becomes their hardest burden to bear.

Nirmala got married at 14 and gave birth to her first child at 16. "I could feel something coming out like a child's head when I went to the toilet the very day after my child was born", she told me. "I thought it was something that happens naturally after childbirth, but when I asked my sister-in-law, she told me it wasn't normal." Nirmala said her husband knew about her condition 11 days after but "didn't say anything". Her typical day starts at 4 in the morning, filled with household chores like cleaning, cooking, washing, fetching firewood and grass for the livestock, and carrying uphill six to eight vessels of water for home use. She had another child after 14 months, and both deliveries took place at home by herself.

Dr. Geetha Rana, project officer for women's health at the United Nations Children's Fund (UNICEF), commented: "In this patriarchal society, women are conditioned from childhood to accept heavy household work as their lot. Women like Nirmala, who have no family support system, end up going back to their chores too soon after childbirth." UNICEF implements programmes to improve reproductive health services in eight of Nepal's 75 districts. "The programmes stress the need for the whole family to be involved in supporting expectant mothers", says Dr. Rana. "We encourage families to bring expectant mothers to obstetric-care facilities, where they can give birth with the assistance of trained midwives and doctors. A great many cases of uterine prolapse could be prevented if mothers get trained help during delivery, and if their families make sure they do not have to do heavy work too close to the birth or too soon afterwards."

Talking about her experience, Nirmala recounted: "It felt so uncomfortable to walk or sit. There was a burning sensation all the time. It would come out more on days when I had worked harder and on rainy and cold days. On dry days and when I didn't work as hard, it would go inside." But she did not discuss her problem with anybody. "It is such a shameful thing. And what's the use of talking about it? It would only expose my problem. Everybody else is [unaware] like me and so they don't know much." When Nirmala heard about a camp where such cases were being treated free of charge with a rubber ring, she travelled about three hours walk and three hours bus ride away from her village. It took her a while before she got used to the inserted ring and she was still unsure that her problem had been taken care of, albeit temporarily. "The doctor told me the pain will go away and that I'll have to come back to have the ring cleaned after three months … I don't know", Nirmala said. Asked if she would share her experience with others, she replied, "I'll tell others about it only if it works, not otherwise".

Memories of a happy childhood when she was pampered by her grandmother flitted across Nirmala's face as she spoke about the days when she had to carry only two gagris [water vessels], fetch grass and sometimes cook. She wished she could have continued her studies, having gone until Class 7, and pondered: "Maybe if I hadn't married young and hadn't had children so early, maybe if I hadn't had to work so hard, I would have not had this condition." She said with determination: "I'll let my daughter study as much as she wishes and will get her married only when she wishes to."

Dr. Guna Raj Lohani (left photo), who has been working for two years in the Phidim hospital in Panchthar, has seen many cases of uterine prolapse. "Lifting heavy objects, doing hard labour, such as carrying loads of water, grass, wood or farm produce, soon after childbirth places a lot of stress on the weakened pelvic ligaments and is the major reason behind uterine prolapse." He said that what he had encountered in the village are mostly of second- or third-degree cases, when the uterus is partially or fully out. He recalled that one women suffering from a fully prolapsed uterus would stuff old pieces of clothing to try to keep the uterus back inside, but to no avail, and warned that the risk of infection in such circumstances is very high and can even be life-threatening.

Srimati Limbu, an 80-year-old grandmother who spoke only her native language, has been living with a third-degree uterine prolapse for the past 42 years. She recalled that her uterus "popped out" when she lifted a vessel of water seven days after giving birth to her youngest of four children. She never told anybody. "How could I tell others? It's such a shameful thing!" She said that frequent drippings of fluid from her uterus in the beginning caused her major problems. Asked if she would like to have her problem set right, she replied, "It would be good, but I don't have the money. Of course, I'll go if I get help." She still keeps herself busy with light household chores, cutting grass in the field and sowing seeds. "It hurts when I walk, but I have to do my work. Without working, we don't get to eat."

Srimati was vocal about her problem and willing to receive help, but Jaya Maya Suwang, who had been living with a similar problem for 40 years, came to the health camp complaining first of an aching thumb, then her head and slowly going downwards. The doctor, guessing it was a prolapse case, listened patiently until Jaya finally admitted that she did have a "problem". Bhagwati Mainali, a health worker for 14 years who was helping in the camp, said she had observed tremendous changes in people's attitudes. "Earlier they would threaten us with sticks when we dared ask if anybody suffered from uterus prolapse. Now, we just need to spread the word that we are setting up a free camp, and people come, walking for as long as four hours from villages from another hilltop. Cases like Jaya's take some time to understand, but many women, especially the older ones, have begun to talk about it, at least to get this temporary treatment."

Young Nepalese women discussing sex and reproductive health issues. PHOTO/SIMRAN UDAS/RHIYA NEPAL

Dr. Gurung noted that "due to caste-based discrimination, long distances, lack of health workers and low status of women, the poor just don't have access to appropriate health care and information". UNFPA works to address the problem by running reproductive health camps in remote areas, increasing the coverage and quality of reproductive health-care services and promoting awareness. "More than 16,500 people received help from these health camps in 2005 and 565 of them were women getting treatment for uterine prolapse", Dr. Gurung said. In discussions with women waiting for their turn to see the doctor, it was apparent that fear of ridicule and social exclusion-in some villages the condition is interpreted as resulting from having too much sex-as well as a sense of shame, all brought about by lack of awareness, prevented women from talking about their condition even with their closest family members or friends.

According to Dr. Gurung, "apart from the stress and emotional isolation, they risk abandonment or divorce by their husband, violence, abuse and discrimination. Any inability to work can further increase their poverty and their capacity to raise their families." He added. "Uterine prolapse is a major public health issue affecting the poorest and most vulnerable women in Nepal. There is a tremendous amount of work still to be done in treatment and in providing accessible services and raising community awareness to prevent the problem from happening in the first place."

From left top: nirmala khatri, srimati limbu and jaya maya suwang all suffered from prolapsed uterus.