Uterine Prolapse

How do women get prolapsed uterus?
What are the contributing factors?
How prevalent is it in Nepal?
Who gets the problem most ?
what are the consequences of this problem?
what is life like for women who suffer from fallen womb?
How important is it to address this problem?
What are the remedies?
How can it be prevented? what are some of the pros and cons to surgical camps?

Uterine prolapse, a high morbidity condition, is defined as the falling of the womb, it occurs when the muscles of the pelvis can no longer support the normal positioning of the uterus. The uterus descends downwards in the pelvic cavity and eventually comes out of the vaginal orifice. In medical terms, the four stages of ‘prolapse’ are defined as: Stage I: descent above the level of introitus, Stage II: descent to the level of introitus, Stage III: descent below the introitus, Stage IV: total aversion of uterus or procedentia. In developed countries it is normally observed among women of menopausal age. NDHS, 2006, found up to seven percent of women of reproductive age group (15-49 years), with nearly three percent existing in adolescence and young age are suffering from uterine prolapse. In the study carried out by IoM and UNFPA, 600,000 women are suffering from different degrees of uterine prolapse, among them 200,000 women require immediate surgery.

WHO has reported global prevalence of uterine prolapse to be between 2 to 20 percent among women under the age of 45. It exists throughout Nepal both in reproductive and menopausal women. Sporadic studies show a high prevalence among women aged as low as 15. Below is the prevalence from major studies in Nepal:

The above studies have identified uterine prolapse as a consequence of unsafe motherhood practices and hard physical labor along with malnourishment particularly in pre-and-post-partum periods. Amplified by poverty, these risk factors are rooted in unequal gender relations. Uterine prolapse is reported to cause an array of psycho-social-economic problems leading to the breakdown of families. With such a high number of women suffering from uterine prolapse, it could be difficult to achieve international commitments such as Millennium Development Goals (MDG), Convention of Elimination of Discrimination against Women (CEDAW) and International Conference on Population and Development (ICPD).

Uterine prolapse is one of the consequences of unequal gender relationships and an expression of the subversion of women and the denial of their rights. Women are discriminated throughout their whole life cycle, from birth until death. Girls are often discriminated against and neglected from childhood in areas such as nutrition, health care and education. They are again disadvantaged during adolescence through early marriage, early pregnancy and early unplanned and frequent child bearing combined with a heavy workload. This often leads to pregnancy complications, malnutrition and reproductive morbidities. Women do not have access to medical facilities, even if they are available, since they have no part in decision making to receive health services. Gender-based violence is a major public health and human rights problem throughout the world. Violence against women has profound implications for health but is often ignored.

Occurrence of uterine prolapse can be prevented to a large extent by proper antenatal care, and care during child delivery and the post partum period. Proper pelvic floor exercise, good nutrition and avoiding heavy lifting in the post partum period are key factors for preventing the occurrence of uterine prolapse. Treatment for uterine prolapse beyond first degree is usually achieved through surgical intervention, either repair or hysterectomy. Ring pessary is used to treat women who are not fit for surgery and who do not wish to have surgical treatment in order to continue child bearing. In the present context of Nepal, women suffering from uterine prolapse are using ring pessary because of unavailability of surgical treatment at local health facilities or because they cannot afford such treatment.

On one hand, there is an urgency to respond to the plight of thousands of women who are already suffering from uterine prolapse, and on the other, there is an urgent need to work to prevent the problem. This demands a response to this urgency to address the problem from a multi-sectoral approach at different levels of government’s service delivery system to the people.

Table 1: Prevalence of Uterine Prolapse in Nepal

Location Prevalence% Type of Study Sample Size Year Source type
Kathmandu 9.6 Clinic Based 1,147 1996 Maternity Hospital*(in Bonetti, 2002)
Achham, Doti districts 20 Clinic Based 2,705 2002 GoN, GTZ & UNFPA(Bonetti, 2002)
10 hill and terai districts 9 Clinic Based 4,518 2005 SMNF-Nepal(Deuba & Rana, 2005)
8 High and mid hills and terai districts 10 Population Based 2,207 2006 IoM, UNFPA & WHO(IoM & UNFPA, 2006)
Country wide 7 Clinic and Population Based 14,696 2006 Nepal Demographic and Health Survey
Siraha, Saptari districts 37 Population Based 2,268 2007 WRRP-CAED(Pradhan, 2007)
Rautahat, Mahottari, Saptari districts 20 Clinic Based 7,750 2008 Kathmandu Model Hospital (Dangal, 2008)

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