2012 18n upresearch study nepal
TRANSCRIPT
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PrevalenceofUterineProlapseamongstGynecologyOPDPatients
inTribhuvanUniversityTeachingHospitalinNepalanditsSocio
CulturalDeterminants
StudyTeam
TeamLeader:Dr.AvaDarshanShrestha,SMNF
Coinvestigator:DrBimalaLakhey,SMNF
Hospitalcoordinator:Prof.Dr.JyotiSharma/Prof.Dr.MitaSingh,TUTH
Studycoordinator:BinjwalaShrestha,SMNF/IoM
FieldResearcher:SewaSingh,BBC
SafeMotherhoodNetworkFederation,(SMNF)
BeyondBeijingCommittee(BBC)
TribhnuvanUniversityTeachingHospital(TUTH)
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1.0 INTRODUCTION
Withthe
advent
of
the
International
Conference
on
Population
and
Development
(ICPD)
in
Cairo
1994, Reproductive Health (RH) and Women's Health, in general, were discussed in a more
holistic way. The Cairo Conference placed RH high on the agenda of national governments,
donor organizations and INGOs/NGOs. Its most significant achievement was the shift in
orientationfromfertilityreductionandpopulationpoliciestoRHandthesocioculturalfactors
that affect RH. Reproductive rights, women's empowerment, gender and equity were also
emphasized.Theseprincipleswereoutlined intheCairoProgramofAction inwhichNepal isa
signatory(ICPD,Cairo,1994).
TheConstitutionofNepal(1990)statesnondiscriminationandequalityasfundamentalrights.
Nepal has ratified CEDAW in 1991 without reservation and reaffirmed commitments in the
BeijingDeclaration
(1995)
to
work
for
the
equal
rights
and
inherent
human
dignity
of
women,
as
well as to implement the Platform for Action. The concept of RH as a central component of
women's development was endorsed during the Fourth World Congress on Women held in
Beijing.OneofthestrategicobjectivesinthePlatformforActionistoensureequalityandnon
discriminationunderthelawandinpracticeandtospecificallyrevokeanyremaininglawsthat
discriminateonthebasisofsexandremovegender bias intheadministrationofjustice.The
countrystraditionalandculturalvalues,andStatelaws,however,discriminatewomenforthey
stilllackaccesstomaternalhealthcareandprevention/treatmentofUterineProlapse(UP).
InNepal,reproductiveillhealthisamajorhealthproblemandisleastarticulatedbythegeneral
publicbecauseoflackofknowledgeanditisaculturaltaboo.TheGovernmentofNepals(GON)
strategy reflects the commitment to the ICPD. Although the Government and donors have
recentlygivenmoreattentiontosafemotherhoodissues,manyhaveraisedconcernsthatUPis
still neglected and oftenoverlooked. The Government has adopted several policies and taken
measurestomakeRHservicesavailabletoallNepalesecitizensthroughtheprimaryhealthcare
system.
TheMinistryofHealthandPopulationoftheGovernmentofNepalplannedtosupportservices
toaddressUPcasesanddeclaredUPasapriorityprogram,andin2008/9ExternalDevelopment
Partners (EDPs)togetherwiththeWorldBankallocatedabudgetpool fundtosupport12,000
UP cases for surgical services. The Government, however, took about six months to produce
operational guidelines on how to use the fund focusing on the processes, policies and
stakeholdersinprovidingservicestowomendiagnosedwithUPinscreeningcampsorhospitals
andthose
waiting
for
surgical
treatment.
Recently,
the
Government
developed
guidelines
for
UPscreenings,useofpessaryringsandreferralservicesforprimaryhealthworkersworking in
public health facilities located in the Village Development Committees. UNFPA supports the
GovernmentofNepalinachievingthegoalsandobjectivesoftheICPD,1994.TheFundfurther
supports the Government in achieving the outputs of the Nepal Health Sector Programme
ImplementationPlanandtheMillenniumDevelopmentGoals.EDPsandUNFPAarecontributing
tohelpeliminateUPcasesfromthecountrybysupportingtheUPcampsandsurgicalservices.
UPoccurswhentheuterus(womb)slipsoutofplaceandintothevaginalcanal.Theseverityof
UPisdividedintothreedegrees:
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First degree (mild)the cervix (the lower opening of the uterus into the vagina)
protrudesintothelowerthirdofthevagina
Seconddegree(moderate)thecervixprotrudespastthevaginalopening
Thirddegree
(severe)the
entire
uterus
protrudes
past
the
vaginal
opening
AccordingtoUNFPA(2005),600,000womeninNepalsufferfromUPand200,000womenneed
immediate surgery.A high 69.1% of the women had first degree pelvic organ prolapse (POP),
andtheother30.9%sufferedfromsecondandthirddegreeuterovaginalprolapsed(UVP).
Astudyconductedbythe InstituteofMedicine(2006)reportedthatPOPwasdetected in207
outof2070 (10%) women 30.9% suffered fromthe majordegree of UVP and would require
operative management, the second degree and third degree constituted 12.6% and 16.9%
respectively,while1.4%hadprocidentia.Schaafetal.(2007)reportedthat inaregion inWest
Nepal,25% of the visitorsof free female health care clinics were diagnosedwith first,second
andthird
degree
UP
and
procidentia.
In
Bajhang,
another
deprived
region
in
West
Nepal,
51.6%
ofthevisitorsofamedicalcampforwomenhadgynecologicalproblemofwhich36%concerned
UVP.1In2004,Bonetti,Erpelding,andPathakconductedaclinicbasedstudy,whichexamined
2,072womenwithgynecologicalcomplaints.TheyfoundthatoneinfourhadUP,ofwhich95%
selfreportedtheirprolapse.2
The causes of UP that have been generally identified are such as inaccessibility to quality
maternal health care (Skilled Birth Attendant and Emergency Obstetric Care), poverty, gender
discriminationrelatedtohealth(RH/maternalcare),nutrition(lifecycle),workloadduringpost
natalperiodanddomesticviolence.Inparticular,noadditionalfoodduringpregnancyandpost
natal period, absence of work load sharing during pregnancy and inadequate post natal care
contribute to UP. Prolonged labor, birth of big babies, unsafe abortions, sexual intercourse
immediately after delivery, tighteningof stomachusingpatuka (a piece ofcloth used to wraparound the stomach) after delivery 3,4 , hypertension and diabetes are supposed to be other
causalfactors5ofUP.
When a patient is diagnosed with first stage prolapse, the patient should avoid lifting heavy
weightswhileKegals exerciseandyogacouldalsohelp.Likewise,whenapatient isdiagnosed
with second degree prolapse, a vaginal pessary ring can be used until a patient is ready for
surgery.
The results from the study conducted in Western Nepal confirmed UP as a significant health
problem.ThemostcommonperceivedcauseofUPwasliftingheavyloads,includingduringthe
postpartum
period.
The
adverse
effects
reported
included
difficulty
urinating,
abdominal
pain,
backache, painful intercourse, burning urination, white discharge, foulsmelling discharge,
itching,anddifficultyinsitting,walking,standingandlifting.
Very few studies to ascertain the prevalence ofreproductive morbidity and underlying causes
havebeencarriedout.TheaimofthisstudyistodeterminetheprevalenceofUPasasignificant
public health problem in Nepal. The Safe Motherhood Network Federation Nepal (SMNFN) in
alliance with the Beyond Beijing Committee (BBC) proposed to conduct this study
acknowledging the urgency of the situation and the importance to give attention to and take
action regarding UP. As the study is designed to generate information from health service
institutions, the two organizations partnered with one of the most prominent hospitals in
Kathmandu,theTribhuvanUniversityTeachingHospital(TUTH).
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The information generated will contributeto the limited literature on UP that exists inNepal.
Likewise, it will contribute to the prevention programs and early management of genital
prolapsethat
can
reduce
this
significant
social
and
public
health
problem.
Thefindingswillbesharedwithnationalpolicymakersandotherstakeholders,suchas,health
serviceproviders,GOand INGOs,civilsocietyandacademicianssothatpolicies,programsand
servicesarepromotedtoreducetheprevalenceofUP.
2.0 OBJECTIVES
ThegeneralobjectivesofstudyaretodeterminetheprevalenceandincidenceofUPattertiary
hospital TUTH during the three month period from November 2008 to February 2010, to
understandhealthcareseekingpracticesandperceptiononriskfactorsofUPscreenedduring
thestudy
period,
and
to
come
up
with
recommendations
for
policy
makers
and
planners
based
onthefindingsofthestudy.
Thespecificobjectivesofthisstudyareto:
IdentifythemagnitudeofUP inspecificgeographical locationsandamongstwomenof
differentcasteandethnicgroups,agegroups,economicstatus,educationbackgrounds,
ages at first pregnancy, birth spacing, occupation and the status of women in the
family;
Find out the relationship between UP and accessibility of essential and emergency
maternalhealthcareatthecommunitylevel;
FindouttherelationshipbetweenUPandmaternalhealthcareseekingpracticesinthe
familyandcommunity;
DeterminetheimpactofUPonthequalityoflifeofwomen; UnderstandtherelationshipbetweenUPandgenderbasedviolence;and
ComeupwithactionsandpoliciestoaddresstheproblemsofUP.
3.0 METHODOLOGY
Information and data were generated from primary and secondary resources for the study.
SecondaryinformationwastakenfrompublishedreportsanddocumentsonUP.
TheTribhuvanUniversityTeachingHospital(TUTH)wasthemainsourceofprimaryinformation.
Three months (November 2008 to February 2010) worth of information was gathered from
patientsreporting/attending
the
gynecology
OPD
of
TUTH
with
gynecological
complaints.
These
patients were interviewed, examined and their illnesses were identified and listed. Women
diagnosedwithUPwerescreenedandtheyparticipatedinanindepthinterview.
The primary data was generated using four tools. Tool 1 was an individual screening
questionnaire,whichwasfirstadministeredtothepatients.Onceapatientwasdiagnosedwith
UP, Tool 2, which was a structured indepth interview questionnaire, was used. Patients
respondedtoquestionsregardingtheirsocioeconomicbackground,reproductiveandmaternal
health care history. Tool 3 consisted of case studies (using the specific case study guidelines)
paying attention to women with UP and Tool 4 comprised of focus group discussions (FGDs)
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conductedwithwomen fromacommunitysituatednearbyKathmanduandLalitpur,usingthe
FGDguidelines.
Differentand
diverse
patients
were
identified
for
case
study
recordings.
With
prior
consent,
the
researchassistantsvisitedandheldthecasestudyrecordingswiththepatientsandtheirfamily
membersintheirhomes.Theinformationobtainedenabledtheresearchteamtoascertainnot
onlythepatients'behaviorbutalsothefamilysandsocietalbehaviortowardswomenwithUP.
In total, four FGDs were conducted with UP patients and other female members in the local
community wards around Kathmandu. The FGD explored the KAP and issues of UP among
women,withat leastonechild, intheirreproductiveagegroup.The limitationofthisstudy is
that the study is hospitalbased, which is dependent upon the proportion of gynecology OPD
patients with UP. Hence, the study may not represent the prevalence of UP in the general
population.
TUTHisapublichospitaloftheTribhuvanUniversity.HealthcareservicesinTUTHarerelatively
cheaper than private hospitals but more expensive than government hospitals. TUTH is a
general hospital where out of total 440 beds only 25 beds are allocated for the Gynecology
ward. The service users are mostly from the central regions of Nepal and Kathmandu valley
althoughhospitalrecordsrevealthatpatientsfromacrossthe75districts,thosewhocanafford
totraveltoKathmandu,haveaccessedtheservicesinTUTH.Hence,thenumbersofUPservice
users in TUTH could be lower than those in governmenthospitals. The lack of awareness and
knowledgeaboutUPasapreventableandtreatableconditioncouldalsocontributetothelow
numbers.
4.0 FINDINGSOFTHESTUDY
4.1 SocioDemographicCharacteristicsoftheRespondents
Thefindingsofthestudyarebasedonthequestionnairesconductedwiththerespondents,the
FGDs and the case studies (Annex 1). The findings presented are on the respondents socio
demographiccharacteristics.TheinformationrevealsthatwomensufferfromUPirrespectiveof
their geographical location, caste/ethnicity, age and education while parity (number of
pregnancyandchildbirth),birthspacing,economicstatusandfamilydecisionmakingpatterns,
too,haveimplicationsontheoccurrenceofUPandhealthseekingbehavior.
4.1.1 MagnitudeofUterineProlapseCasesinTUTH
Therewere
3616
women
who
availed
the
services
of
the
Gynecology
OPD
TUTH
in
Kathmandu
duringthethree monthsof data collection. 93out of the3616women (2.6%)were identified
withUP.Thismeansthatinamonth,anaverageof3132newcasesisidentifiedandinayear,
384 new cases are estimated to be reported in the hospital. For the study, however, only 66
patients out of the 93 consented and responded to the study questionnaires. Only 2.6% of
patients reporting to the Gynecology OPD were detected with UP, while population studies
placedthefigures,theleast,at7to30%.
4.1.2 Geography
TherespondentswithUPwerefromfourdistrictsKathmandu(CentralDevelopmentRegion),
KaskiDistrict(WesternDevelopmentRegion),DangDistrict(MidWesternDevelopmentRegion)
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andKailaliDistrict(FarWesternDevelopmentRegion).TherewerenowomenwithUPfromthe
Eastern Development Region although there were patients who visited the Gynecology OPD.
Thus,thepatientsinthisstudywerefromacrossthecountry.
41.47% of the women were from Kathmandu, the capital city of Nepal, where access to
hospitalsandtreatment isavailable.20.28%patientswerefromDang,19.35%fromKailaliand
18.89%fromKaski.AsmostofNepalismountainousandhilly,amajorityofthehealthfacilities
can only be reached during the day time. Previously, it was believed that UP was commonly
prevalent among women with low socioeconomical status from the hilly regions but recent
studieshaveshownthatitisequallyprevalentinwomenfromtheTarairegion(plains)andwell
todofamilies.Thesedetailsareconfirmedwithinthefindingsofthisstudy.
TheprevalenceofUPwithwomenrangesacrossthegeographicalregionsandthisislargelydue
to gender discrimination and lack of care immediately after childbirth. During the FGDs, the
respondentsshared
that
one
of
the
main
reasons
they
avoided
seeking
health
care
is
because
they felt awkward sharing their problem with male superintendents or doctors, who are
primarilytheonesavailableatthehealthcarefacilities.Thus,thesewomenhidtheirproblems
foras long as they coulduntilthey couldno longer tolerate thepain, which led them toseek
treatmentatthehospital.
4.1.3 AgeofRespondentswithUterineProlapse
Table 1 reveals the age group of the respondents with UP. 6.06% of them range from 2330
yearsofage,whereas12.12%wereintheagegroupof3140years.Therespondentswithinthe
ages of 4150 years were 34.85%, while 21.21% were from the age group of 5160 years.
Another19.7%oftherespondentswerefromtheagegroupof6170yearsandtheremaining
6.06%werebetween7180yearsofage.Fromthetable,womenfromtheagegroupsof41to
50,recordsthehighestnumberamongall(34.85%).
Table1:AgeofRespondentswithUterineProlapse
Agegroup(years) N %
2330 4 6.06
3140 8 12.12
4150 23 34.85
5160 14 21.21
6170 13 19.7
7180
4
6.06
Total 66 100
4.1.4 MaritalStatus
86.36%oftherespondentswithUPwerelivingwiththeirhusbands,12.12%oftherespondents
werewidows,whereas1.52%oftherespondentswereseparatedfromtheirhusbands.
4.1.5 Caste/Ethnicity
9.68% of respondents were Dalits (the untouchables), 25.35% of them were Janajatis (the
disadvantaged)and4.61%werefromthedisadvantagednondalitTaraicastegroup,while less
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than1%camefromtheReligiousMinoritiesgroup.Respondentsfromtherelativelyadvantaged
Janajatis were 8.76% and a total of 50.69% respondents were from the upper caste.6 The
findingsrevealthattheprevalenceofUPcannotbeassociatedwithanyparticularethnicgroup,
althoughUP
is
more
common
among
women
who
are
poor
as
they
do
not
get
enough
rest
after
childdeliveryandhavenoaccesstohealthcareservicesshouldproblemsariseduringandafter
delivery.
4.1.6 Education
Literacyandeducationare important indicatorstounderstandthesocioeconomicstatusofan
individualanditalsoindicatesthelevelofawarenessamongthepeople.Throughtheresponses
ofthewomenduringtheFGDsandcasestudies,it isclearlyshownthattheyhad limitedorno
knowledge of UP. In fact, even when they knew that they were suffering from RH morbidity,
womenkeptitprivateanddidnotsharetheirproblemuntilthepainbecameunbearable.Most
ofthetimewhentheydidseekcare,itwastoolateandsurgerywastheonlysolution.
Table2presentstheliteracyandeducationallevelsoftherespondentsandtheirhusbands.The
findingsshowthat77.27%ofwomenwithUPwerenonliterate.Onthecontrary,7.58%ofthem
wereliterate,whereas10.61%ofthemhadcompletedtheirprimaryleveleducationand4.55%
of them had completed their secondary level education. None of the respondents received
education atthehigher secondary level.This meansthat womenwho werenonliterate were
more prone to having UP than those respondents who were literate. The figures in Table 3
revealthatthehusbandsof therespondentsweremoreeducated thanthem.Husbands, who
receivedaneducation,playanimportantrolefortheyinfluencethehealthseekingbehaviorof
womenandarethedecisionmakersintheirhouseholds.
Table2:LiteracyandEducationLevelsoftheRespondents
LevelofEducation N %
Nonliterate 51 77.27
Literate 5 7.58
Primary(15class) 7 10.61
Secondary(610class) 3 4.55
Highersecondary
Total 66 100
Table3:LiteracyandEducationLevelsoftheRespondents'Husband
Levelof
education
N
%
Nonliterate 33 50
Literate 18 27.27
primary(15) 5 7.58
secondary(610) 7 10.61
highersecondary 3 4.55
Total 66 100
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4.1.7 MajorOccupation
Mostwomencarryouttasksboth insideandoutsidetheirhomes.Theynotonlydohousehold
choresbutarealsoactivelyinvolvedinagriculturalactivities.ThisisbecauseNepalseconomyis
agriculturalbased,
which
includes
farming
and
livestock
rearing.
These
agricultural
activities
werethesourceofincomeandlivelihoodoftherespondentsandtheirfamilies.Theywerealso
involvedinanimalhusbandry.Thesewomenperformdoubletheamountofworkirrespectiveof
theclimateandtheirphysicalcondition.
Thedata inTable4revealsthat48.48%oftherespondentswere involved infarmingactivities
including selling farm products, whereas, 18.19% of them were wage laborers and performed
farmingactivities,simultaneously.Another18.19%oftherespondentswerehouseholdworkers,
7.58% were wage laborers and service holders, and 6.06% were farmers and small scale
business holders. Although 1.52% of respondents were involved in farming, they were also
dependentontheremittancefromothermigrantfamilymembers.
Table4: OccupationoftheRespondent
OccupationofRespondents %
Farmer 48.48
Farmersandwagelaborers 18.19
Householdwork 18.19
WagelaborersandServiceholders 7.58
FarmerandSmallscalebusiness 6.06
Remittance 1.52.
Total 100
4.1.8 SourceofIncome
Thefindingsrevealthat69.70%oftherespondentsweredependentonagricultureastheirmain
source of income. 3.03% of them relied on their businesses, 6.06% respondents provided
services, and 19.71% had two or more sources of income like farming and being a laborer,
conductingbusinessesandprovidingservices,etc.
4.1.9 Sufficiencyoffood
Thisitemshowsandindicatesthatrespondentsfromafarmingbackgroundsufferedmostfrom
UP since they have to perform tasks inside and outside their homes which often involved
strenuousworkandcarryingheavyloads.ThiswasalsoexpressedbyrespondentsintheFGDs.
Table5revealsthat9.1%respondentshadaccesstosufficientfoodforlessthan3monthsand
22.7%ofthemhadsufficientfoodfor36months,whereas66.7%hadsufficientfoodformore
than6months.
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Table5:SufficiencyofFoodoftheRespondents
4.1.10 Familytype
Outofthetotalrespondents,39.39%werelivingwiththeirextendedfamilyand31.82%ofthem
wereinjointfamilies7,whereas22.73%livedasnuclearfamilies.4.55%oftherespondentswere
femalehouseholdheads,while1.52%ofthemlivedinjointfamiliesledbywomen.Basedonthe
findings,women
in
nuclear
families
had
more
freedom
compared
to
those
living
in
joint
families.
Respondents living injoint familieshadmoreworkloaddespitethe factthatthereweremany
other family members to sharethe workload. Additionally and generally, itwas also truethat
daughterinlawsweregiventheresponsibilityofperformingmostofthetasksinthehousehold.
4.1.11AgeatfirstpregnancyandNumberofPregnancies
DatainTable6revealsthat65.16%ofthewomenwithUPwerefirstpregnantwhentheywere
intheirteensand34.86%werefirstpregnantinthe2232agegroup.
People living inruralcommunitiesgenerally lackawarenessandtheybelievethatchildrenare
gifts from God. They are also unaware about familyplanning. Thiswas expressed in the FGDs
andwas
well
reflected
in
the
data
as
33.34%
of
the
respondents
were
pregnant
for
more
than
5
times(69times),46.97%werepregnantformorethantwotimes(35)andonly13.64%were
pregnant for 12 times. Data also shows that 6.07% of women were pregnant between1013
times.
Table6:AgeatfirstpregnancyandNumberofPregnanciesoftheRespondents
Ageatfirstpregnancy N %
Teenage 43 65.16
2032 23 34.86
Total 66 100
Parity (No.ofpregnancy) N %
12 9 13.64
35 31 46.97
69 22 33.34
1013 4 6.07
Total 66 100
Duration
ofsufficiency
of
food
N
%
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4.1.12 Degreeofcervicaldescent
The respondents stated that they realized their problem when they experienced something
comingout
of
the
vagina.
Upon
examination,
93
cases
were
identified
as
UP
cases.
Over
three
months,66outofthe93womenagreedtobeparticipantsofthestudy.
Afterthe examination, therespondents with UPwere classified in descending order basedon
thethreedegreesofUPseverity.47%ofthetotalcaseshadthirddegreeprolapse,followedby
28%withfirstdegreeprolapsed,while24.2%oftherespondentshadseconddegreeprolapse.
ThesenumbersareevidentinTable7.
Table7:DegreeofCervicalDescentoftheRespondents
Degreeofcervicaldescent N %
1stdegree
19
28.8
2nddegree 16 24.2
3rddegree 31 47.0
Total 66 100.0
4.1.13 Prolapseandchildbearing
Table 8 shows that a maximum number of 25 (37.9%) respondents had prolapse after having
morethanfourchildren.Alargegroupof18(27.27%)realizedtheyhadprolapseafteronechild.
47%ofteenagepregnancycaseshadthirddegreeUP.Additionally,85%ofprolapseoccurredin
cases among respondents who had given birth for more than three times. What was more
shocking
was
that
even
after
having
prolapse,
the
women
in
29
cases
had
up
to
6
pregnancies
thereafter.
Table8: ProlapseandChildBearingofRespondents
No.ofchildbirthsafterwhichprolapsewasnoticed N %
Onechild 18 27.27
23children 19 28.79
Morethan4children 25 37.9
Donotremember 4 6.06
Total 66 100
4.2 Relation between Uterine Prolapse and Accessibility of Essential and Emergency
MaternalHealthCareatCommunitylevel
FGDs and case studies substantiate the quantitative data, which revealed doing heavy work
immediately after child delivery as the main reason for the occurrence of UP. Other reasons
shared during the FGDs were delivery facilitated by untrained assistants using push and pull
methods, and using traditional practices by seeking theJhakris (local faith healer) assistance.
Unsafetraditionalpracticesincludeaskingtheparturientwomantopushnotknowingthestatus
of cervical dilatation, putting hair into the mouth of the delivering woman for expulsion of
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placenta, and forcibly pulling out the baby from the mothers uterus. Most importantly, the
respondentsstated that inadequate healthservices and lack of skilled attendants during birth
werethereasonsfortheoccurrenceofUP.
4.2.1 Safemotherhoodpractices
Table 9 shows that almost 80% of the respondents had no antenatal check up. 78% of the
deliverieswereconductedbytheirmotherinlaworneighbor,whileabout8%wereconducted
by health care worker/staff nurse/ANM. 22.73% of the women delivered the babies by
themselves.Thus,atotalof89%oftherespondentsreporteddeliveringathomeandonly11%
haddeliveredatthehospital.
Table9:SafeMotherhoodPracticesoftheRespondents
ANCreceived N Total
No 52 78.79
ANC13timesduringpregnancy 14 21.21
Total 66 100
DeliveryAssistant
Motherinlaw/neighbor 45 68.18
ANM/Staffnurse 5 7.58
Self 15 22.73
Relativesandnurse 1 1.51
Total 66 100
Placeof
Delivery
Home 59 89.39
Hospital 7 10.61
Total 66 100
Afterdelivery,45%ofthesecaseshadrestedfor714dayswhile30%oftherespondentshad
postpartum rest for 1530 days. Very few cases had rest up to 2 months after delivery.
Generally,afterdeliverythemothershouldrestforatleastsixweeksfortheuterustodevelop
andthreemonthsforallthepelvicligamentsandorganstofunctionnormallyagain.Withinthis
periodofrest,sheshouldnotliftheavyweightsandbegivenpropernutrition.
Table10:
Post
Natal
care
of
the
Respondents
Durationofrestinpostpartumperiod N Percent
714days 30 45.45
1522days 15 22.72
30days 13 19.69
60days 4 6.07
morethan60days 4 6.07
Total 66 100.00
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4.2.2 Healthcareseekingbehavior
Nearly50%oftherespondentssoughtsomesortoftreatment,suchas,insertingherbsintheir
wombsoreatingherbsandspecialfoodorvisitingaJhakri(localfaithhealer). Almost26%of
the
respondents
used
pessary
ring
while
over
6%
combined
the
use
of
pessary
rings
and
consumed herbs, as shown in Table 11. It is reported that the respondents resorted to these
practicesbeforefinally,goingtothehospitalforcare.
Table11:TreatmentpracticeforUterineProlapse
Typeoftreatmentreceived N %
None 33 50
Herbs/specialfood 8 12.12
VisitedJhankri 3 4.55
Pessaryring 17 25.76
Pessaryring
and
herbs
4
6.06
DJ/herbs 1 1.52
Total 66 100
4.3 RelationbetweenUterineProlapseandMaternalHealthCareSeekingPracticesinthe
FamilyandCommunity
TheFGDs,casestudies,andthequantitativedatarevealthatwomenweretreatedasbeastof
burden and they also lacked adequate nutrition. Lack of information together with the
impoverished conditions of the families determined whether the women resorted to care.
Addressing problems of UP was not considered an important health issue by the family and
oftenthe
family
did
not
seek
care
as
they
did
not
have
the
necessary
funds
required
for
travel,
hospitalizationand ifneedbesurgery.Womenwerefoundnottobethedecisionmakersand
theirreproductiverightswererarelyrespected.
4.3.1 Women'sWorkloadafterDelivery
Postnatalperiod iswhenwomenneedamplerest,nutritiousfood,a lotofcare,andaffection
fromtheir family. InNepal,however,womenstillperformedheavytasks inthe field,cowshed
etc.soonafterdelivery.Table12showsthat78.79%oftherespondentsworkedoneweekafter
deliveryand1.52%afterthreeweeksofdelivery.Besidesthat,1.52%oftherespondentscarried
heavyloadsafterfourweeksofdelivery,whereasanother1.52%performedheavytasksafter2
3 months. This indicates that only 16.67% of the respondents were privileged to rest for 23
monthsafterdelivery. Thus, 84.85% of the overall respondentswerenot fortunate to get the
idealamount
of
rest
after
delivery.
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Table12:DurationofcarryingloadbytheRespondentsafterDelivery
Workloadafterdelivery N %
1week
52
78.79
3week 1 1.52
4week 1 1.52
23month 1 1.52
Total 55 83.35
noneedtowork 11 16.67
Total 66 100
4.3.2 TimeTakenbyRespondentstoSeekforTreatmentandDegreeofuterinedescent
Table 13 reveals that women waited from a few months to 30 years before they sought
treatmentat
a
hospital.
Majority
of
the
patients
(46.97%)
waited
for
15
30
years
before
seeking
treatmentatthehospital,whichisappalling,whileover15%ofcasessufferedfromUPfor312
monthsbeforetheysoughttreatmentatthehospital.
Table13:TimeTakenbyRespondentstoSeekforTreatmentintheHospital
DurationtoreachhospitalforUPtreatment N %
Onexamination 5 7.58
312months 10 15.16
15years 11 16.67
510years 4 6.06
1015
years
5
7.58
>15to30years 31 46.97
Total 66 100
4.3.3Familydecisionmakingforhealthcare
Usually,inNepalihouseholds,theheadofthefamilyisamanandhemakesthedecisionsinthe
family.Table14revealstheanswersofrespondentsonwhomakesthedecisionwhenitcomes
to seeking medical treatment. 6.1% of the respondents stated that they made their own
decisions when going for a medical checkup. 28.8%, however, reported that their husband
decided for them, whereas 45.5% said that it was ajoint decision by husband and wife. 1.5%
responded that they made the decision together with their relatives, while 18.1% stated that
theirfamily
members,
neighbors
and
health
workers
were
the
decision
makers
when
it
came
to
seekingmedicaltreatment.
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Table14:FamilyDecisionMakingforHealthCare
Decisionmaker
N
%
Self 4 6.1
Husband 19 28.8
Self&husband 30 45.5
SelfandRelatives 1 1.5
Familymembersandneighbors,
healthworkers
12 18.1
Total 66 100.0
4.3.4 FamilySupporttoSeekforTreatmentintheHospital
Data,
as
shown
in
Table
15,
reveals
that
43.9%
of
the
respondents
were
accompanied
by
their
husband,whereas25.8%ofthemwereaccompaniedbytheirrelativeswhenseekingtreatment
atthehospital.Friendsandneighborswentwith24.2%ofrespondentswhile1.5%wentaloneto
thehospital.
Table15:FamilySupporttoSeekforTreatmentintheHospital
Personwhoaccompaniedtohospital N %
Self 1 1.5
Husband 32 48.5
self&relatives 17 25.8
friends/neighbor
16
24.2
Total 66 100.0
4.3.5 Affordability
ManyoftheNepalipeoplearerankedbeneaththepovertylineandtheycannotaffordhospitals
fees. Based on Table 16, 30.30% of the respondents paid NRs. 3505008 to the hospital while
10.61% of the respondents spent NRs. 5011000. There were 9.09% respondents who spent
NRs.20016000,whereas27.27%oftherespondentsonlypaid a sumofNRs.3050.7.58%of
therespondentsstatedthattheyspentNRs.11002000whileanother7.58%saidthatthecosts
werearoundNRs.10,00016,000.TUTH,which isasemigovernmenthospitalrunbyuserfees,
doprovidesomebedsforfree,especiallyforpoorpatients.Thevariationofcost isduetothe
typeofserviceusedOPDandroutineinvestigationarelesscostlythansurgeries.
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Table16:Costofservice
Costof
service
(NRs)
N
%
3050 18 27.27
200300 5 7.58
350500 20 30.30
5011000 7 10.61
11002000 5 7.58
20016000 6 9.09
1000016000 5 7.58
Total 66 100
4.4 ImpactofUterineProlapseonQualityofLife
Findings from FGDs and case studies reveal that women with UP suffered both physical and
psychosocialproblems.Thephysicalproblemstheyexperiencedwerepain,areductioninfood
intake,difficulty inperformingtasks,sexualdysfunction,discharge, infectionandtissuedecay.
The psychosocial problems they faced were stress, emotional isolation, abandonment by
husband or divorce, ridicule and shame, inability to work, lack of economic support, risk of
violenceandabuseandmorenotably,discrimination.
Various complaints due to UP were expressed by the respondents. 56 out of 66 UP cases
(84.86%) had complained of lower abdominal pain and backache. 78.79% did not complain of
abnormaldischargefromthevaginawhile21%ofcasescomplainedofdischargewithasignof
infection.
Nearly
one
fourth
of
the
cases
complained
of
Dyspareunia
(pain
during
sexualintercourse). Other complaints included frequent micturations (as UP distorts the passage of
urinationandwhentheanatomyofurinarybladderchanges, itmaycauseurinary infectionas
well as increased frequency in urination) by 50% of the women, 28% experienced chronic
constipationand21%hadchroniccough.Inthechroniccoughgroup,40%weresmokers.
4.5 RelationshipbetweenUterineProlapseandGenderBasedViolence
4.5.1 DomesticViolence
Nepalisdominatedbyapatriarchalculturethatgivespreferencetomenfromtheirbirthtoold
age. The lower economic and social statuses of women reduce their ability to fight against
discrimination and injustice. As a result, women suffer from domestic violence. Although only
6.1%oftherespondentsstatedthattheywerephysicallyilltreated,itispossiblethatthe54.5%whodidnotwishtorespondtothisissuewerealsoilltreatedbytheirhusbands.Only39.4%of
therespondentsreportedthattheydidnotexperienceanykindofdomesticviolenceatallas
showninTable17.
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Table17:DomesticViolence
4.5.2 Husbandremarried
The women in Nepal are viewed as subordinate figures and thus, have lower societal status
comparedtomen.Therefore,asdisplayedinTable18,31.8%oftherespondentsreportedthat
theirhusbandhadmarriedagainaftertheysufferedfromprolapse.66.67%oftherespondents
stated
that
their
husband
did
not
remarry
because
of
UP.
1.52%
of
the
respondents
did
not
respondtothequery.
Table18:RemarriageofHusband
Husbandremarried N %
No 44 66.67
Yes 21 31.82
Total 65 98.48
noresponse 1 1.52
Total 66 100
5.0 CONCLUSIONANDRECOMMENDATIONS
5.1 Conclusion
ThestudyrevealsthatUPisamajorpublichealthissueinNepalwithlittleattentiongiventothe
problem.ItisclearthatwomenlackknowledgeaboutUP.UP isprevalentamongwomenfrom
acrossthecountryirrespectiveoftheirgeographicallocations.
Teenage pregnancy and too many pregnanciescontributedto the occurrencesofUP. Another
reason was that most of the women delivered their babies at home assisted by untrained
persons, and most of the parturient mothers or delivering women resumed work soon after
deliveryand
had
very
poor
nutrition.
Women primarily sought care from the hospital during the stage when most of them were
referred by other health facility for hysterectomy. Because surgical services are limited to
hospitals in the cities and are costly, women who are poor have no access to such medical
treatments.
The study also demonstrates that there is a need for a multipronged and multisectoral
concentrated effort to address problems of UP as the determinants for care range from
economic to social issues. These issues include raising awareness to address the culture of
silence,adversesocialattitudesandpracticesregardingchildbearing,lowstatusofwomen in
Historyof
Domestic
Violence
N
%
No 26 39.4
yes(physical) 4 6.1
Total 30 47.0
Donotwishtorespond 36 54.5
Total 66 100.0
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the family, community and the nation, nonavailability of finances, inadequate attention to
empowermentofwomenandVAW.Accesstogoodmedicalservicesanddeliverymechanism,
includingaccesstosurgery,lackofreferralincentivesandbottleneckslinkedwithtransportation
andtravel,
need
immediate
attention.
5.2 Recommendations
Increase in awareness programs that UP is a preventable and treatable condition. Timely
precaution and proper management during antenatal period, delivery by skilled birth
attendant, proper postnatal care play a major role in preventing UP. This can be done by
ensuring that women, husbands and inlaws are informed of preventive measures and
treatment strategies for UP at each stage. It is also important to emphasize that women
should get ample rest, share the work load and give their body time to recover before
resuming sexual intercourse as part of maternal health care services. Access to medical
servicesisanotherkeyfactorasqualityhealthservicesshouldbemadeavailabletoallwomen
accordingto
international
standards.
Preventive
measure
and
awareness
raising
components
shouldbepromotedeverywhere,andsurgeryasanoptionshouldbeprovidedandconducted
evenatthevillagelevel.Morespecifically:
To make prevention activities and treatment of UP as part of the Essential
ServicePackagewithinthehealthsectorreformpackages,whichshouldbefree
ofcharge.
TostrengthenANC,skilledbirthattendantsandPNCservices
TBAsmaybetrainedonsafedeliverypracticesaswellasreferralforprolonged
labor,UPetc.
FCHVscouldbeusedasthefirstlineforawarenessraisingcampaignsonUP.
Increase proportion of women amongst health providers doctors and
gynecologists,inparticular.
Mobile surgical camps should be arranged as a temporary measure till health facility with
surgicalfacilityisestablished.Qualitymanagement,too,shouldbeensured.
Sociocultural discrimination like early marriage, lackof education, lack ofequal opportunity
forgirls,weakdecisionmakingand lackofmaleparticipationsneedtobereduced.Primarily
since teenage pregnancy and multiparity are major reasons for the cause of UP, emphasis
shouldbegivenondelayingonesfirstpregnancy,planningagoodgapbetweenpregnancies,
and delaying first pregnancy together with the use of contraceptives in the targeted
population.
5.3 ActionPlans
Thesearetheactionsthatmustbetaken:
AdvocacyforRightsBasedApproach
Governmentpolicy/Policymakers
Review the present plan and lobby with the government to give special
attentiontoUP
LobbyforanincreasedinpreventivemeasuresandbudgetforUPcases
Awarenessraising
UPtobeprioritizedintheNationalPlanning
LobbyPolitician/Parliamentarian
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AwarenessraisingandsensitizationforCAMs
LobbyforinclusioninPartyManifestos
InformationonUP
Developfact
sheets,
IEC
materials
on
symptoms,
causes,
consequences
and
treatment
ofUP
IncludepreventionofUPwithinlifeskilleducationforadolescentboysandgirls,
and use community radio to spread messages. Sharing information about UP
withGO/EDP/NGO
Centraltocommunitylevel
Addressgenderdiscrimination
Social,cultural,economic
AccesstoRHservice
Publicprivatepartnership(PPP)
DiscussanddevelopstrategiestoworkonUP
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ANNEX1:CASESTUDIES
Case 1: Kanchi Ghimire is a permanent resident of Tasinchowl, Jharuwarasi VDC. She is a 78
yearsold
widow
suffering
from
UP
for
the
last
40
45
years.
Now
she
is
suffering
from
high
blood
pressure,weakness,backache,jointpain,anddizziness.Shehadgivenbirthtoherfirstbabyat
theageofsixteen.Shehadbecomepregnant10timesofwhichthreeweremiscarriages.Now
she has two daughters and one son. All the babies were delivered at home with the support
from her motherinlaw. After giving birth to her fourth baby, she realized she has UP which
graduallyincreasedafterdeliveringmorebabies.
SheaddressedtheproblembyusingaclothtosupporttheUP,restedforsometime,sleptina
supine position and ate sutkeri masala. These measures helped but only for a short time
during the initial period. She suffered from back ache, faced difficulty while sitting, lower
abdominal pain, pain when passing urine and stool, as well as watery and foul smelling
discharge.
She
had
shared
her
problem
with
her
husband
but
he
did
not
take
interest
forfour/fiveyears.Later,shebroughtherhusbandtothehospitalforhercheckupbutherhusband
abandonedand leftheralone inthehospitalwithout informing.Shereturnedhomewithouta
checkup. On one occasion, when the Ward Chairman visited her Ward, her UP problem was
takenup.Sheusedthepessaryringfor23years.She lostthepessaryringandhasbeenliving
withproblemsforthe last10years.KanchiGhimirenowwantstobeoperated ifanyfinancial
supportisavailable.
Case2: Bishnu Gurung is a permanent resident of Lumjung. Farming is her familys livelihood
andsource of incomeoccupation, which isjust adequateto feedthe family. She is livingwith
her secondhusband whohas an exwife. Her first pregnancy ended in a miscarriage, whereas
hersecondandthirdbabiesdiedatbirth.Shenowhasason. SherealizeshesufferedfromUPaftergivingbirthtoher firstbaby,andwhenshewascarryingabasketofgrass(doko)onher
back.Shehadresumedworkafter67daysofdelivery.ShedidnotshareherUPproblemuntil
lastyearwhenherneighbornoticedbloodspotsandfoulsmells.Shethensharedherproblem
withherhusbandasshecouldnotperformherdailychores.Herhusbandrespondedsaying,It
is not a serious problem. She was also suffering from seizure. She visited aJhakri with her
husbandandspentmuchmoneybutdidnotreapanybenefits.Afterknowingherproblems,her
motherandsisterinlawtoldhertovisitthehospitalandtheyprovidedthefinancialsupport.At
that moment, her husband denied going with her. When she decided to seek health care her
husbandaccompaniedhertoKathmandu.Nowshe istakingmedicineforepilepsyandgetting
betterwithoutanyepisodesofseizure.
Shefeltuncomfortablewhenamaledoctorexaminedher.Shestronglyrequestedforacheck
upeitherbyaladydoctororinthepresenceofherhusband.Accordingtoher,therearemany
UPcases intheirVillage.Thewomen,however,cannotdiscussortalkaboutitopenly.Theydo
nothavethefinancialmeanstogetcareanditisonlywhenthereisahealthcampforUPthat
womenoftheseremoteareascangetbenefits.
Case3:BalKumariTimelsenaisa53yearresidentofJalthalVDCJhapa.Sheisnonliterate.She
carriesouthouseholdtasksandfarmingactivities.Herhouseholdworkcompriseofsweepingin
andaroundthehouse,cleaningthecowshed,milkingthecow,fetchingwaterandpreparingas
well as serving tea and food for everyone in house, preparing food, and finally, washing the
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utensils. In the afternoon, she fetches grass and collects firewood. After returning, from work
sheprepareshereveningmeal.Afterthemeal,shewashestheutensils.Itisonlyat9p.m.,when
she finally rests. She performs all these tasks alone without her husbands help. During the
cultivationand
harvesting
season,
she
would
do
additional
tasks
related
to
farming.
Shewasmarriedattheageof14andshebecamepregnantwithherfirstchildat15.Sincethe
firsttwochildrendidnotlivetoseetheirfirstbirthdays,shehadgivenbirthto3morechildren
whosurvived.Butevenafterthedelivery,itwasdifficulttoescapefromthedailychoresandto
getsomerest.Likemostofthewomen,shemanagedtorestforonlyafewdaysafterdelivery
andthenfollowedbycarryingoutherdailyworkload.
Eighteenyearsagoshefirstbecameawarethatheruterushadfallen.Ontheeleventhdayafter
deliveringheryoungestchild,shediscoveredthatheruterushadfallenwhenshetriedliftinga
heavy load. With what had happened, she kept the problem to herself although it was a
treatablecondition.
Because
she
faced
difficulty
in
walking,
working,
moving
around,
her
family
wouldsaythatshewaslazy.Othersmembersinherinhousewouldsaythatshewaslazy.Last
year,whenthepainwastooexcruciatingforhertobear,shefinallydisclosedherconditionto
her family. Onceher family memberswereaware ofherproblem,she wastaken toTUTH for
medicaltreatment.
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ENDNOTES
1 Schaaf, J. M.; Dongol, A.; van der LeeuwHarmsen, L. (2008). Followup of prolapse surgery in rural Nepal.
International
Urogynecology
Journal
2007,19
(6),
851
855.
2 Bonetti,LR.;Erpelding,A.;Pathak,L.R.(2004).ListeningtoFeltNeeds:InvestigatingGenitalProlapseinWestern
Nepal.ReproductiveHealthMatters,12(23),166175.
3 United Nation Population Fund (EUPFA) Nepal. (2008). Reproductive Health. Web site:
http://www.unfpanepal.org/en/programmes/reproductive.php
4 Earth,B.;Sthapit,S.(2002).UterineprolapseinruralNepal:genderandhumanrightsimplications.Amandatefor
development.Culture,Health&Sexuality,4(3),281296.
5 BodnerAdler, B.; Shrivastava, C.; Bodner, K. (2007). Risk factors for uterine prolapse in Nepal. International
UrogynecologyJournal,18,13431346.
6
Nepalis
divided
into
4
castes
according
to
Hindu
mythology.
They
are
Brahmin,
Chhetri,
Baisya
and
Shudra.
There
iscastehierarchyinNepalandresearchhasrevealedthatwomenfromhighercastearemostvulnerable.Theyare
givenlesspriorityinthefamilyandsociety.Theirconditionsareverypatheticascomparedtowomenfromother
castes.
7 Extended family is composed of married sons living together with additional members e.g. mother or a sister
whilejointfamilyiscomposedoffatherandmotherwithmarriedsonsandtheirfamilies.
8 Thecurrencyexchangerateatthattime:79NRs=1US$
RFERENCES
BodnerAdler, B.; Shrivastava, C.; Bodner, K. (2007). Risk factors for uterine prolapse in Nepal. International
Urogynecology
Journal,18,
13431346.
Bonetti,LR.;Erpelding,A.;Pathak,L.R.(2004).ListeningtoFeltNeeds:InvestigatingGenitalProlapseinWestern
Nepal.ReproductiveHealthMatters,12(23),166175.
Earth, B.; Sthapit,S. (2002). Uterine prolapse in rural Nepal: gender and human rights implications. A mandate for
development.Culture,Health&Sexuality,4(3),281296.
Schaaf, J. M.; Dongol, A.; van der LeeuwHarmsen, L. (2008). Followup of prolapse surgery in rural Nepal.
InternationalUrogynecologyJournal2007,19(6),851855.
United Nation Population Fund (EUPFA) Nepal. (2008). Reproductive Health. Web site:
http://www.unfpanepal.org/en/programmes/reproductive.php