2012 18n upresearch study nepal

7/25/2019 2012 18N UPResearch Study Nepal

1/21

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)


2/21

WHRAPSAsubmissionCaseStudy1Nepal

2

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:


3/21


3

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).


4/21


4

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)


5/21


5

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)


6/21


6

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


7/21


7

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


8/21


8

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.


9/21


9

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

%


10/21


10

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


11/21


11

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


12/21


12

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.


13/21


13

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.


14/21


14

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.


15/21


15

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.


16/21


16

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


17/21


17

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


18/21


18

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


19/21


19

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


20/21


20

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.


21/21


21

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

2012 18n upresearch study nepal

Documents