All pics: Rojita Adhikari
Chukka Nepali, 41
Chukka Nepali, 41
Chukka is a mother of six in one of the remotest villages of Nepal’s remotest district. She was 14 when she had her first baby, and started fetching firewood and collecting fodder a few days after giving birth. Being a mother at a young age, chronically undernourished, and doing relentless back-breaking work soon after giving birth caused her uterus to start come out, and she has lived with that painful condition which has got steadily worse with every new birth.
Chukka Nepali was already suffering double discrimination for being a woman and a Dalit, but the uterine prolapse made her even more of an outcast. Neighbours taunted her children, saying their mother was a witch.
“They said my womb had fallen out because I was evil, and God had punished me,” Chukka told us, “for the past 25 years besides the physical pain I had to endure mental torture.” Her husband is the village tailor, and says he makes just enough to feed his family and cannot afford to take her to hospital. He is not aware that the government offers free surgery.
Biura BK, 28
- Biura BK, 28
Biura is a Dalit mother of three school-going sons from Nigale village. She was also 14 when her first baby was born, and felt her womb come out while collecting firewood soon after giving birth. She is in constant pain, and is worried that her husband will leave her because she cannot fulfill her husband’s physical wants.
Three months ago Buira’s pain became intolerable and she went to the district hospital in Gamgadi where the doctor told her that she had fourth degree prolapse, and referred her to the Karnali Zonal Hospital in Jumla. The government offered her Rs 1,500 transport allowance, but it would have cost her Rs 10,000 for transport and lodging costs for herself and a minder. So she never went.
Saraswoti Devi Thakur, 40
- Saraswoti Devi Thakur, 40
Saraswoti Devi is from Hariharpur of Dhanusa district, and has been living with a prolapsed uterus for the last 14 years after her second baby. She tells me in a whisper: "Till three years ago, I used to just tuck it back in and keep working in the fields, but now the womb does not go inside and it is painful to walk and work.” Feeding and nurturing the family was difficult enough with an alcoholic husband who drinks away the savings and beats her up at night, but the prolapsed uterus has made life infinitely more difficult.
She knows the hospital offers free treatment, but her husband doesn’t allow her to go, saying: “Who will do the work here if you go to hospital?” Saraswoti says: “I feel tired all the time, there is always a white discharge from my womb, I find it difficult to work. My husband doesn’t understand that I am in pain, no one does.”
- Ram Shakhi Mukhiya of Hariharpur and mother of six who had kept her condition hidden for 34 years. A friend told her she could get free treatment in Janakpur, and she asked her son repeatedly to take her there. Ram Shakhi was weeping when she told me: "My son and daughter-in-law said to me, why do you need to do it in this old age, don’t you feel ashamed?"
Her neighbor Piyariya Devi Mahato is 40 and she is one of the few women who has had surgery for her uterine prolapse. However, her right leg has gone completely numb and she cannot walk. It looked like the surgery was defective.
Uterine prolapse, a condition in which which afflicts one in every ten women in Nepal. It is caused by the weakening of the ligaments providing inadequate support for the uterus, which then slips out of the vagina.
A recent survey showed that despite the government free treatment scheme launched in 2008, only 20% of women with uterine prolapse have been reached. The rest, like Chukka Nepali and Biura BK in Mugu are still living with the degrading condition, facing additional ostracisation.
Uterine prolapse is more common in the remote mountains when women have to work hard from a very young age while giving birth and raising children. But it is also prevalent in the eastern Tarai.
Nepal’s entrenched patriarchy is the main reason the condition persists among mainly among the poor and uneducated. Experts say there is a clear correlation between areas of the country where the status of women is low with the prevalence of the condition. Uterine prolapse makes all the other risk factors, like malnutrition of teenage mothers, short-spaced births, hard physical work soon after childbirth and domestic violence, secondary.
After a U.N. report in 2006 showed the extent of the problem, the government announced free treatment for the estimated 200,000 women in need of immediate corrective surgery. However, after a survey showed surgeries in mobile health camps were not up to mark, the Ministry of Health restricted operations to district and zonal hospitals, and slashed the budget. Only 1,600 surgeries were performed in 2015.
Naresh Pratap KC of the Family Health Division explains that is because the estimates for women with uterine prolapse is exaggerated: “The numbers are much less, which is why very few women are coming for surgery that is why we reduced the budget.”
But the reality here in the rugged, arid mountains of Mugu is very different. It the village of Charapa alone there were six women with Stage 4 uterine prolapse. In the Tarai, there were eight women with the condition in the small village of Hariharpur alone.
Samita Pradhan of the group Centre for Agro-Ecology and Development (CAED) says uterine prolapse is a hidden problem and is much more widespread than reported: “We work in 20 districts and 1 in 4 every women who agree to talk with us has some form of prolapse.”
Treatment camps run by NGOs in Makwanpur recently found that out of 900 women examined, 200 had the condition. This could just be the tip of the iceberg because of the shame and fear of ostracisation.
The government allocates Rs12,000 for every surgery and Rs500 as transport allowance in the Tarai and Rs1,500 for mountain districts, which is inadequate. But there is no money for post-operative care, another reason patients do not see free surgery. The government’s free operation is mainly for the fourth stage of uterine prolapse, which means tens of thousands with less serious symptoms do not qualify for surgery.
Nurse Saroja Ghimire at the district hospital in Gamgadi says women come for treatment when the pain gets intolerable, and they often have to be referred to Karnali Zonal Hospital for surgery. “About 90% of the women go home dejected because they cannot afford to go to Jumla,” she says.
"The government’s free treatment is benefiting many women but it is not enough,” says Giulia Vallese of the United Nations Population Programme (UNFPA). “Also, free surgery alone is not enough we need to address the comprehensive needs.”
Happy to be rid of it
Shreebati Devi Mahato, 70, has lived in Lalvitti village of Dhanusa district all her life, and for most of her life she has had this thing hanging out of her. She gave birth to 11 children, seven are alive and four died at childbirth.
“I lived in hell for most of my life when my womb dropped, I had back pain, couldn’t walk,” says Shreebati who had free surgery at Janakpur Zonal Hospital six months ago. “Now I can walk, I am in heaven.”
HARD TO REACH
Total population of women in Nepal: 13.6 million
Proportion of women with uterine prolapse: 6.4%
Total number of women with condition: 870,000
Women who got free surgery: 20%
Source UNFPA 2016
Treating pain and shame, Mallika Aryal