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Project Description

In Nepal, over 25 % women in rural areas are estimated to be suffering from utero-vaginal prolapse (UVP). They have miserable, degraded life. Very few attempts have been made to decentralize provision of prolapse surgery to peripheral set-ups in remote hill districts to address this need.

There are no surgical services in the rural areas and the patients cannot afford to go to hospitals in the cities for economic reasons. Therefore, it is proposed that the curative surgical treatment will be provided on the spot to the patients with severe prolapse. A total of about 1,800 patients will benefit from this project in 3 years' time.

Project Description:

In Nepal, it is estimated that over 25 % women in rural areas are suffering from some degree of utero-vaginal prolapse (UVP). UVP is a problem where the genital organs along with the urinary bladder and the rectum come out from their original position. They have miserable, degraded life with genital prolapse. They have no sexual life for years due to prolapse. Their husbands desert them. Coital difficulties with the third-degree uterine prolapse and procedentia are obvious. A major degree of prolapse prevents penetration into the vagina. Husband brings in another wife basically for sex and going for other alternative ways of finding sex; falling prey to the commercial sex workers or having extramarital affairs. There are many heart-breaking stories. Prolapse is a curable condition and surgery is the mainstay of treatment.

Genital prolapse in Nepal:

Common health problems in the women of Nepal are anemia, pregnancy complications, unsafe abortions, genital prolapse, sexually transmitted diseases, genital infections, menstrual problems, cervical, breast and ovarian cancers and fertility problems. The incidence of prolapse rises in the elderly, constituting about 60% of one series of patients who underwent major gynecological surgery. In Kathmandu valley, surgery for prolapse is the second on the operation list of gynecological department of the major hospitals.

In countries like Nepal, a higher incidence and more severe degree of uterovaginal prolapse occurs in women who are delivered at home by dhai/sudenis (untrained birth attendants). This is because the patients are made to bear down before full dilatation of the cervix, when the bladder is not empty. Also, prolonged second stage of labour causes undue stretching of the pelvic floor muscles, as episiotomies is not employed by dhais. Many women develop minor degree of prolapse soon after childbirth. A raised intra-abdominal pressure due to mainly chronic bronchitis, large abdominal tumors or obesity tends to increase any degree of prolapse, which may previously be present. Smoking and chronic cough are the predisposing factors.

Circumstances force the poor rural woman to resume their heavy work soon after delivery without any rest or pelvic floor exercises. Congenital weakness of the pelvic floor muscle, instrumental delivery and rapid succession of pregnancies preclude proper postnatal rehabilitation; and there will be tendency to develop prolapse.

Prolapse or "the neglected tragedy" is still the leading cause of morbidity in woman of remote areas of Nepal. Exact numbers are difficult to obtain because women with prolapse often remain silent about their problem and do not report to heath care providers. In a small study, the prevalence of prolapse was found to be 16% - 35% in rural Nepal (Siraha, Gorkha and Nuwakot). Small survey of districts showed the prevalence is higher in hilly districts as compared to plain/urban districts.

Several international and national organizations working in rural Nepal recognized prolapse as a big problem in rural women and they have tried to address the problem by running programs to identify the cases (village surveys) and provide them with ring pessaries. Very few attempts have been made to decentralize provision of prolapse surgery to peripheral set-ups in remote hill districts to address this unmet need. The reason for this may be firstly the complexities to set-up a functioning major operation theatre in a remote and low- resource area, secondly the unwillingness of the medicos to leave their lucrative practice in an urban area and thirdly the expensive nature of the management of a major surgical camp in the hills. In the year 2003 and 2004, two such camps for operating on prolapse were successfully conducted in Sankhuwashabha and Ramechhap districts of Nepal. This author performed 40 major operations for prolapse without any untoward complications. Therefore, major surgeries for prolapse in rural Nepal can be done safely.

Justification:

Majority of women with prolapse in Nepal cannot make use of surgical services concentrated in or near large urban centers. There are no surgical services in the rural areas where the patients having prolapse reside and they cannot afford to go to Hospitals in the cities for economic reasons. This is why there is need for managing their problem of prolapse in the rural settings by organizing surgical camps.

Purpose:

An important contribution will be made to the ruined lives of women with genital prolapse in rural areas of the eastern hills of Nepal by providing surgical remedy for their problem at or near their home at no expenses. In addition, preventive measures for the prolapse and awareness about it will be an important focus during the camp period. Data of the patients with prolapse will be obtained in the selected remote districts and the major causes for the occurrence of prolapse will be identified.

Outputs:

Curative surgical treatment will be provided on the spot to the most needy patients with severe prolapse. A total of about 1,800 patients will benefit from this program in 3 years' time.

Magnitude of the problem (prevalence of prolapse) will be assessed objectively and baseline data regarding prolapse in the mentioned districts will be generated for future use for planning treatments or otherwise.

Preventive measures through health education will be encouraged to adopt to reduce the incidence of prolapse in women.

Activities:

The proposed project is for 3 years' duration. It will be implemented in the eastern hills of Nepal. A total of 11 districts will be covered in 3 years' time.

One week long surgical camp will be organized in a selected remote place to treat severe prolapses. About 25 major operations will be performed during the period and the in-patients' post-operative care will be provided to them accordingly for a week following the surgery. The total period of time for a camp in a place will thus be about two weeks including preparation for the camps, identification of the patients with prolapse, pre-operative evaluation of the patients, actual operation period and post-operative care and traveling time; to and fro from Kathmandu. Surgical operations for prolapse are generally carried out through vaginal rather than through the abdominal surgical route. Prolapse is usually treated with vaginal hysterectomy and pelvic floor repair (anterior and posterior colporrhaphy) or enterocele repair. Hence, two surgical camps will be organized in a month, totaling 24 in a year and 72 in 3 years' time. About 25 major surgeries will be performed in each camp. Thus, an estimate of 1,800 patients will be treated during the project period of 3 years. Blood will be arranged from Central Blood Bank at Kathmandu and transported to the camp-site.

Provision for health education regarding prolapse will be made to the concerned women at the Camp set-up. A great strain is put on the pelvic floor (supports uterus) during pregnancy because of hormonal influence, the weight of the developing fetus and the altered pelvic posture. It is important, therefore, to teach pregnant women pelvic floor exercises antenatally in order to maintain the tone of the muscle so they remain their functions. A focus will be put on other preventive measures as well.

Beneficiaries:

The immediate beneficiaries are the needy rural women (having genital prolapse) of the eastern hills of Nepal. All the women in the region will be benefited in the long run from such outreach camps due to the awareness and health education imparted during the camp period. Indirectly concerned family and the society, as a whole will be benefited because of the treatment the female member of the family.

Vaginal Hysterectomy set
Abdominal Hysterectomy set
Electro-surgical Unit (Cautery Machine)
Suction Machine
ECG Machine
Pulse Oxymeter
Oxygen Concentrator
Steel Drums
Autoclave Machine
Generator

Medical and Surgical Supplies: $30 per case of surgery
Total number of surgeries in 3 years = 1,800
Total cost of Supplies for all cases = $30 x 1,800 = $54,000

Contingency (5% of $396,330) = $19,817

Nepal In Figures:

Nepal is a landlocked country nestled in the foothills of the Himalayas. It occupies an area of 147,181 square
kilometers. It shares its northern border with the Tibetan Autonomous Region of the People's Republic of China and its eastern, southern, and western borders with India. The population is approximately 23.2 million and half of them are females.

Nepal is predominantly rural with only about 14% of the population living in urban areas (Central Bureau of Statistics, 2001). 42% of the population is below the poverty line. Population per doctor in Nepal is about 18,000. The average life expectancy is 59.5 years. Literacy in Nepal is 65% for males and 42% for females. 

Topographically, Nepal is divided into three distinct ecological zones. These are the mountains, hills and terai or plains with 7%, 44% and 49% population respectively. The transportation, communication and health facilities are very limited in mountains and hills because of the harsh terrain.

Eighty-nine percent of Nepalese live in rural areas with more than half the population deprived of basic and primary health care services. More than 60% of doctors have only worked in the Kathmandu valley and those posted in remote areas hardly spend a year.

The estimated per capita gross domestic product (GDP) for the year 1999/2000 is US $244. About 80% of the Nepalese population continues to rely on agriculture for their livelihood.

Women's Status in Nepal:

The maternal mortality ratio (MMR) of Nepal is one of the highest in the world and the fertility rate is also very high (4.1 births per woman in 1998-2000. Maternal death is 539 per 100,000 live births. Antenatal care, postnatal care and institutional deliveries are not common in Nepal. Less than one in ten births takes place in a health facility.

There is a wide gap between urban and rural areas in educational attainment, health facilities, transportation and communication facilities, and economic status. And women are always on the lower level in every aspect. Rural women have more than twice as many children (4.4) as urban women (2.1). The same applies to uneducated women. Marriage is almost universal in Nepal. The median age at marriage is 16.1 years for the women and rural women getting married one year earlier than the urban ones. The median age at first birth is about 20 years and one in five adolescent women age 15-19 are already mothers or pregnant with their first child.

The Nepal Family Health survey of 1996 indicates that 92% of all women deliver at home. The chances of Nepalese women suffering pregnancy complications are very high and consequently this risk increases as these women undergo multiple pregnancies during their reproductive age. 

Women in Nepal are generally less educated than men. Women in rural areas lack the financial means, adequate food, housing, health care, educational facilities, social status. Mostly they are exploited and excluded ones. Husbands in Nepal have a greater say in decision-making than wives. Usually the husband alone has a final say in
their health care.