The sixty-two-year-old woman sat huddled in the corner of the clinic in Banepa, near Kathmandu. The foul stench emanating from her body kept the other patients at a distance. A little further away in the makeshift clinic, her daughter-in-law clamped the loose end of her sari over her nose to block the smell as she spoke to the doctor about her ailing mother-in-law. "She's been like this for more than 20 years... My father-in-law left her and married again. Our relatives do not like her to visit them because of the foul smell. Everyone avoids her. Please help," she begged.
Dr Rajendra Gurung, reproductive health officer with the United Nations Population Fund (UNFPA), has attended to a number of such patients from the disadvantaged sections of society over the past decade or so. About the Banepa case, he says, "She had a uterine prolapse, which is treatable. However, patients continue to suffer because of lack of awareness and the feeling of shame."
The woman was suffering from an illness now prevalent among 10 per cent of women in the reproductive age group in Nepal.
Uterine prolapse is the displacement of the uterus from its normal position. It occurs when the muscles and tissues supporting the uterus weaken, causing the womb to sag, dragging along some parts of the vagina, bladder or rectum.
In the worst cases, the uterus may even fall out of the vagina, forming a fleshy protuberance that causes severe problems. Other than lower back pains and urinary disturbances, uterine prolapse causes pain when defecating; incontinence; and a foul-smelling discharge. Women suffering from second or third-degree uterine prolapse may be unable to walk or stand.
"If left untreated, it can lead to infections, bleeding and even cancer," elaborates Gurung.
"I suffered excruciating pain for 12 years without knowing the cause," says Meena Pariwar, 35, a mother of three. She and her husband work as a farm laborers. Meena works in the fields, lifting heavy loads of firewood. Even when she was pregnant, she worked till almost a day prior to her delivery, and resumed her strenuous work soon after giving birth.
"While doctors advise six weeks of rest after delivery, along with care, exercise and a balanced diet, women have to return to work sooner. In Nepal, poverty is the major cause of uterine prolapse," Gurung notes.
In most cases, work means manual labor. In the hilly districts, women have to carry heavy loads of firewood or ferry water over long distances. In the plains, they work in the fields. The delicate uterine tissues do not get time to heal after delivery, leading to their weakening.
The high rate of home deliveries as a result of the unavailability of healthcare services in the remote, mountainous areas is another factor contributing to the high incidences of uterine prolapse.
"More than 80 per cent of women give birth at home," says Dr Ganesh Dangal, consultant gynecologist at Kathmandu Model Hospital. The hospital, in partnership with UNFPA, offers treatment for uterine prolapse. "Unskilled maneuvering during delivery by the 'dais' (traditional birth attendants) increases the risk of uterine prolapse," he explains.
The Institute of Medicine (IOM) at the Tribhuvan University, Kathmandu's oldest university, was one of the first organizations to detect the high incidence of uterine prolapse in Nepal. About two years ago, it approached the UNFPA and World Health Organization for funds to conduct research on reproductive morbidity.
The study, conducted between 2005-2006, with a sample of 2,070 married women in the reproductive age group, covered eight districts, mostly in western Nepal. The preliminary findings suggest that 10 per cent of married women in the child-bearing age are affected by the condition. In the age group of 45 and 49 years, 24 per cent of women suffer from the ailment. This is the highest rate of incidence of the condition in Nepal. Nearly three per cent of the cases comprise that of teenagers, between 15 and 19 years of age.
Uterine prolapses are not unique to the hilly regions alone. When the Family Planning Association of Nepal (FPAN) began an awareness drive last year, it found a high prevalence of such cases in the Terai plains in the south, along Nepal's border with India.
"Our mobile health camps in the plains also reported frequent cases of uterine prolapse," says Babita Thapa, programme manager at FPAN. "The women are generally people from poor families, who have to do hard physical labor and are mostly illiterate. They are ashamed to tell their families or doctors about their problems and the concealment aggravates the condition."
"Currently, there are about 600,000 uterine prolapse cases in Nepal," says Dangal. "Of them, 200,000 - about 31 per cent - need immediate surgical treatment." Though there are no comprehensive surveys, Dangal feels the number of sufferers is on the rise.
He warns: "As Nepal 's population increases, the number of women in the reproductive age group is rising. Since economic and social conditions remain unchanged, there will be more women suffering from uterine prolapse. Also, add to this the worsening condition of the earlier cases that have been left untreated and a cumulative effect is created."
If detected at an early stage, uterine prolapse can be controlled by pelvic exercises. For more severe cases, the remedy is to insert a ring pessery - a rubber-coated ring pushed up the uterus to stop it from descending. Though the ring pessery can be administered by trained attendants at mobile health camps, the downside is that the ring has to be changed every four months.
In the rural areas, where there is a high level of illiteracy and a lack of health camps, women either neglect or forget to have the ring replaced. "A 60-year-old woman came to a camp with a severe problem," Gurung recalls. "She hadn't changed the ring for 30 years. It was badly infected and the consequences were terrible. Her husband left her, she was ostracised by the villagers for the stench around her, and she lost her capacity to work."
For the most severe cases, there is no remedy other than hysterectomy in which the uterus is surgically removed. The operation costs about US $250, a small fortune in Nepal, one of the poorest countries in the world.
"It is cheaper for a man to leave his wife and marry again," says Gurung. "We once successfully operated on a patient but couldn't save her from a family tragedy: her husband had left her earlier. It was her daughter and brother who accompanied her to the camp."
The UNFPA has started a major drive to raise awareness about the issue and to generate funds to treat the cases that need immediate surgical operations in Nepal.
"We estimate it will require at least $37 million," says Junko Sazaki, UNFPA's Nepal representative. "We are trying to raise the money from our donors in Nepal and abroad and for that we need a greater awareness about uterine prolapse. It is not just limited to Nepal. It is found in other developing nations - India, Bangladesh and Pakistan - where the economic and social conditions are similar."