Uterine prolapse: The hidden agony of Nepalese women

KAILALI, Nepal — She crouches, eyes squinting in pain, and drops the sickle with which she has been cutting grass since noon.

“I feel like a lump is slipping out of me,” Lakshmi Devi says hurriedly.

She clenches her fist and holds her belly tightly with the other hand; limping, she disappears behind the tall trees. A few minutes later she is back to slicing grass with dust-caked hands and says, “I pushed my uterus back in, it keeps slipping out. Sometimes it happens when I sneeze.”

Like 10 percent of Nepal’s 13 million women, Devi suffers from the painful and debilitating condition of uterine prolapse. The ligaments and muscles in her pelvic floor are too weak to hold the uterus, which slips into the vagina. The condition is often caused by overwork, not enough recovery time between pregnancies or pregnancy at a young age.

By sunset, she has carried more than a dozen loads — wood, water pots, cattle fodder, millet and dried cow-dung cakes. As the sky turns purple, she ushers the goats and cows into the sheds and takes her first break. A brood of hens runs loose and the smell of woodsmoke fills the spring air.

Sitting cross-legged in the courtyard of her mud-brick house, Devi stirs a pinch of salt in her black tea and, sipping it, says, “Five days after giving birth to my third child I was cutting crops and my uterus first slipped. Ever since, my back and lower abdomen hurts constantly; I feel heavy.” She looks much older than her 38 years, her face lined with wrinkles from age and hard living. Married at 15, she has six children and has had two miscarriages.

But engulfed by fear and shame, she kept her pain a secret.

“I was so scared my husband would find out about my problem. He won’t be able to have sex with me and he will get a new wife,” she remembers thinking.

A 2007 study by the Center for Agro-Ecology and Development reported that in Nepal, women with uterine prolapse are considered impure and isolated. About 32 percent did not tell anyone about their condition, of which 66 percent cited embarrassment as the reason for their silence, while 10 percent believed it was normal for a woman’s uterus to prolapse. 

The pain caused Devi to be slow in performing household chores, and her husband repeatedly called her a “lazy buffalo.” Two years ago, she confided in an aunt, who took her to a health care post a few villages away, lest someone might see her and inform her husband.

“My greatest fear was that there would be only male doctors,” she says. But it was a female doctor who inserted a rubber-coated ring pessary, advising Devi to change it every few months for fear of infection. “It was like a rubber bangle and gave some relief. But I hardly get time to go for checkups and replace it regularly.”

There is very little data about the prevalence of uterine prolapse globally. In 1996, the United Nations Population Fund (UNFPA) estimated that it could affect 2 to 20 percent of women under the age of 45. This condition is more common among older women, post-menopause. In 2001, The American Journal of Obstetrics and Gynecology reported that the median age of women seeking treatment for uterine prolapse in the United States is 61 years. 

But in Nepal, the condition is overwhelmingly affecting younger women, with tens of thousands of women in their 20s suffering from the most severe form of uterine prolapse.

According to a 2006 study by the UNFPA, one third of 600,000 women with uterine prolapse require surgery to strengthen the pelvic floor and tighten the walls of the vagina, or a hysterectomy. In less severe cases, exercise can strengthen the muscles of the pelvic floor, or a ring pessary can be inserted in the vagina to hold the uterus in place.  

“It is absolutely true that uterine prolapse is a global issue, affecting women in many countries. But in Nepal a perfect storm of factors has come together to create a human rights crisis affecting hundreds of thousands of women and girls,” says Audrey Gaughran, Amnesty International’s director of global issues.

Gender discrimination, lack of access to health care and education, and decades of official neglect are some of the major causes for the high incidence of the condition in Nepal, she explains. According to a 2014 report, “Unnecessary Burden,” by Amnesty International, “gender discrimination is the cause and the consequence of uterine prolapse.”

“Women and girls are in essence denied control of their own bodies and lives. Many are unable to decide if or when to marry or have children, whether to use contraception or how many children to have,” Gaughran says.

Even during and immediately after pregnancy, many women work long hours doing hard physical labor, propelled by family and societal expectations, Gaughran says. “Ensuring that they are able to access quality health care during pregnancy is often out of women’s own hands; decisions are often made by male family members. There is also a lot of social stigma around uterine prolapse.”

She adds that their research shows that some Nepali ministries were more interested in “passing the buck” to others than in dealing with the problem head-on.

When Chandrawati Mahato’s uterus prolapsed after the delivery of her second child, she thought it was her fault. Her mother-in-law said there was no cure for her condition. Mahato, 42, had a surgery a few years ago, after suffering in silence for 23 years.

“Women don’t support each other. Uterine prolapse is such a big problem and women are suffering in silence; they hide their condition and are ashamed. Women who are known to have it are looked down upon; some smell because of urine leakage, and even women say that you did something bad so you deserve this,” she says.

Manju Devi Yadav, 27, vividly remembers giving birth to her second child, when she developed uterine prolapse.