Perspective (Spotlight Weekly)

Increasing Cases of Uteral Prolapse: Issues Related with Women's Right to Health

By Bipin Adhikari

For far too long, our government has ignored the unique needs of women's health care in the gender perspective. The increasing reports of prolapsed uterous in Nepal seems to be yet another serious issue which the government needs to look into more seriously. Many news reports, including that of the RSS and Kantipur, in recent months. have focussed on the plight of these women, yet there does not seem to be any official plan on how to deal with the situation.

Although there is no estimate on the number of women suffering from the problem of prolapsed uterus, the assumption is that their numbers are increasing day by day. The cases of uteral prolapse are common in the hills as well as plains. That means many women live in this country, depending on severity of their cases, with uninary tract infections, other uninary symptoms which occur due to the frequently associated cystocele, constipation, haemorrhoids, ulceration and infection. In addition, given the level of social awareness, the psychological stress that the patients go through is also not negligible.

The reasons why there are cases of prolapsed uterous seem to be clear. The uterus is normally supported by pelvic connective tissue and the pubococcygeus muscle, and held in position by special ligaments. Weakening of these tissues allows the uterus to descend into the vaginal canal. Tissue trauma sustained during childbirth, especially with large babies or difficult labor and delivery, is typically the cause of muscle weakness. It also can be related to diseases that cause increased pressure in the abdomen, such as obesity, respiratory problems with a long-lasting (chronic) cough, constipation, and pelvic organ cancers. Pelvic organ prolapse can occur after hysterectomy for another gynecological health problem, such as endometriosis, dysfunctional uterine bleeding, or uterine fibroids. The loss of muscle tone and the relaxation of muscles, which are both associated with normal aging and a reduction in the female hormone estrogen, are also thought to play an important role in the development of uterine prolapse. It is also said to be occurring most commonly in women who have had one or more vaginal births.

The April issue of Himal South Asian [www.himalmag.com/2003/april/analysis.htm] produced a brief analysis of B. Subba, D. Adhikari and T. Bhattarai on The Neglected Case of the Fallen Womb focusing on hundreds of thousands of women who live with a prolapsed uterus. The report states that for women, utero-vaginal prolapse is a matter of utmost discomfort, but social conditioning often deters them from seeking medical assistance even if it is available. Commonly, in the rural communities of Nepal, there is no medical support whatsoever; the health post, if at all accessible, is often manned by male attendants. So, according to the analysis, the affected woman will usually push the cervix back with her fingers, and continue to work on the fields, carry water and firewood, cook, clean and care, unwittingly worsening the condition. By the time of third degree prolapse, when the nature of the condition forces its identification, the report opines that there is nothing to be done for it but surgical removal — unaffordable treatment for the majority of women in that socio-economic category that is particularly vulnerable to uterine prolapse. Thus, an affected woman will often spend the better part of her adult life in unforgiving pain, often bleeding from ulcers, unable on bad days to even walk. Among other things, the report also highlights that "the burdens of patriarchy and feudal relations of production operate on these circumstances to exacerbate the demands on women. Typically, in underdeveloped countries, where most work is done manually, a household cannot spare a woman's labour for any substantial length of time. Thus, women must recover fast from any condition that constrains their output. In rural areas, where the requirements from labour are more physically demanding than in the cities, families cannot afford to let the women ëoff-duty' even at the time of childbirth, let alone once every month." The report maintains that "lifting heavy objects and bearing many children are most frequently attributed as causes of uterine prolapse. But there are others, such as the practice of pressing the woman's stomach to facilitate the expulsion of the placenta after giving birth, and the tying up of the belly to stop it from popping out after delivery, that raise the probability of prolapse. Intercourse before the female genital organs have recovered from delivery (2-3 months) can also cause it. In fact, such is the fragility during that period that even a harsh cough can contribute to the stress."

Individual health, subjective and intangible as this concept may be, is an important condition for one's well-being and dignity as a human being. We find the right to health in Article 25 of the Universal Declaration of Human Rights (1948), Article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR, 1966), Article 12 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW, 1979), and Article 24 of the Convention on the Rights of the Child (CRC, 1989). Obviously states cannot guarantee good health, but they are the entities best suited to create certain basic conditions under which the health of the individual is protected and possibly even enhanced. They give the state the responsibility of not only arranging health care, but also creating underlying preconditions for good health.

As the Himal South Asian news report suggests, the government which has published a handbook on uterine prolapse, with the help of the United Nations Population Fund and the German aid agency GTZ, must make them widely and easily available to women's groups as well as community health workers and even human rights activists all over the country. It must be right, as a matter of law and policy, however, to continue to insist on the faithful implementation by the Government of the legal obligations it has undertaken under treaties dealing with the right to health. A duty of care is owed by the government - even in the most difficult circumstances.

[Adhikari is a lawyer. He can be reached at human_rights_nepal@yahoo.co.uk]