Nama Devi Khadkha might have bled to death had there been no mobile clinic in Safebagar.
SAFEBAGAR, Accham District, Nepal —“May you live 100 years! You have given me my life back,” a beaming Guma Badela told the doctor and nurse examining her. She had come to a mobile health clinic for a post-surgery check-up and to express thanks.
During their previous visit to this remote valley in December the health team had identified Badela, 45, as a candidate for surgery. She suffered from a severe case of fallen womb, or uterine prolapse, a painful and debilitating condition that for three years had prevented her from walking or working normally. In February visiting surgeons in Dadeldhura operated successfully.
At the hospital in neighbouring Doti District, Nama Devi Khadkha was thankful to be alive. In her fourth month of pregnancy, the 31-year-old mother of two girls suffered an incomplete miscarriage. Khadkha might have bled to death if she had not been brought to the mobile clinic in Safebagar; she was taken in the team’s jeep to Silgadi, a two-hour drive, to receive lifesaving care.
Both women benefited from the recent agreement halting 10 years of civil conflict in Nepal. A ceasefire has made it possible to start restoring medical services in contested areas. Many health workers fled the fighting between government troops and Maoist rebels, and insecurity prevented residents from travelling to get needed treatment – including tens of thousands of women suffering from uterine prolapse and other complications stemming from unassisted labour.
Last November, a medical team from the Adventist Development and Relief Agency (ADRA Nepal) began a one-year tour of six conflict-affected mid-western and western districts, setting up camp for a few days at a time in remote towns and villages. They saw nearly 20,000 clients in the first four months.
The camps are organized by UNFPA, the United Nations Population Fund, with funding from the European Commission’s Humanitarian Aid department (ECHO), which supports relief activities for vulnerable people in crisis zones around the world. The focus is on reproductive health care – including family planning, prenatal exams, and treatment for sexually transmitted infections – but no one is turned away.
Women with prolapsed uteruses are a principal target group. An estimated 600,000 Nepalese women of reproductive age, one in ten, suffer from the condition to some degree. About two thirds of them need corrective surgery, but very few have access to it.
Uterine prolapse can result from prolonged labour, early pregnancy, improper delivery techniques, resuming work too soon after childbirth, or births too closely spaced. All of these conditions are common in rural Nepal, where child marriage is common, family planning use is low, women typically carry firewood and other heavy loads, and nine out of ten give birth at home without a skilled birth attendant.
Patients queue to see the gynaecologist.
When they first visited Accham, the ADRA team identified 59 women who were good candidates for surgery. About half of them were later operated on at the Team Hospital in Dadeldhura by surgeons brought from Kathmandu by the NGO Public Health Concern Trust (PHECT), with ECHO support.
Two and a half weeks after undergoing surgery, Badela was still recovering but looked forward to resuming her normal routine. “Soon I will be able to cut grass, fetch firewood and thresh wheat again without pain,” she said. “Without the operation I would have suffered my whole life.”
Badela was one of several post-surgery patients who came for follow-up at ADRA’s second camp in Safebagar in early March. But there were others less fortunate.
Kunta Nepali, 43, rode a tractor 10 hours to get to the camp. She had not been to the previous camp when surgical referrals were available. Nepali, suffers from third-degree uterine prolapse, the most severe type. Unaware of treatment options and with no means to travel, she has endured the condition for 22 years.
Married at 15, she was injured while giving birth for the fifth time at age 21.
“I am in pain everywhere from the neck down,” she complained. “My two sons work in India but they don’t send any money home. My husband and I are so poor we have to do everything. I can hardly walk, but I have to go to the forest to get wood, tend to the animals and carry manure to the fields.”
As a temporary measure, a nurse inserted a rubber ring – a ring pessary – to hold Nepali’s uterus inside her body, and gave her an extra one so her local health centre paramedics could repeat the procedure in three months’ time. The staff noted her address and said they would contact her the next time they came to select patients for surgery – but given the remoteness of her village this hardly seemed a sure thing.
Kokila Bista could not even be given a pessary, because her prolapsed uterus was infected – a common condition. She was given topical cream and antibiotics and told to seek care again when the infection clears. But she may never be eligible for surgery due to her poor health.
Like a startling number of women in this poor region, Bista, 32, is living with HIV. Her husband had migrated to India to work, as a majority of men here do. Before he died five years ago he brought home the virus, most likely acquired in the brothels of Mumbai. (Local people call AIDS the “Bombay disease”.)
Project director James Pradhan talks with staff during camp setup.
On their first day here, the ADRA-led team treated 180 residents for a wide variety of ailments. On the second day, after news of the camp spread throughout the area, 456 clients came, including about 250 gynaecology patients. Many were treated for reproductive tract infections; others had prenatal exams or pregnancy tests.
The ADRA mobile team of 12, including two doctors and two nurses, was assisted by about 20 district and local health workers.
In a small building, patients queued in front of three examination rooms, for general medicine, gynaecological care and family planning services. A nearby tent was used for laboratory work. Outside another, a crowd watched health education videos.
“Our biggest joy is when we a treat patient who has suffered for decades. That brings a big smile to our faces,” said James Pradhan, project manager of the ADRA camps.
The ECHO-supported camps can meet only a small fraction of the accumulated need for reproductive health services in Nepal’s impoverished far western and midwestern districts. The government-run health system is beset with crippling shortages of skilled personnel, medicine and equipment. Most villages rely on barely trained female community health volunteers for medical care.
Women who experience problems in labour, for instance, typically have to be transported for long distances over rough mountain roads to reach a health centre with a doctor and a blood supply. Only one facility in all of western Nepal, the privately run Team Hospital in Dadeldhura, offers Caesarean sections.
The reproductive health camps are addressing a deep need at a critical juncture in Nepal’s history. “Now that the war has stopped, communities have high expectations that there will be a peace dividend,” said Junko Sazaki, UNPFA Representative in Nepal. “They want to have quick access to basic services, including reproductive health care.”
“Before the conflict made the situation worse, it was already hard to reach remote areas or to keep doctors at health posts,” Pradhan explained. “Even after peace is restored, it will take decades to restore good facilities in places like this.”
Improving the capacity of government-run health services is a key goal of UN agencies working in Nepal and a central part of the new assistance programme now being formulated. ADRA Nepal collaborates with district health offices, and helps to build local know-how, by providing classes and hands-on training sessions for service providers from the areas the camps serve.
“When we leave, local health workers will be able to do follow-up,” said Pradhan. “We can teach them to do lab tests, counselling and family planning services.”
This month Japan agreed to give UNFPA $400,000 to provide additional reproductive health camps in conflict-affected areas of Nepal.
Last year the Government and Maoist insurgents agreed to end a civil war that had killed some 15,000 people and displaced over 100,000 others. In January the United Nations established a Political Mission in Nepal (UNMIN) to help implement the peace deal and support this year’s planned elections. UNFPA is working to ensure that women will be part of the post-conflict political process and reconstruction efforts, as called for by UN Security Council Resolution 1325.
— William A. Ryan
“May you live 100 years! You have given me my life back,” Guma Badela told the doctor and nurse examining her. She had come to a mobile health clinic for a post-surgery check-up and to express thanks. “Soon I will be able to cut grass, fetch firewood and thresh wheat again without pain. Without the operation I would have suffered my whole life.”
“I am in pain everywhere from the neck down,”said Kunta Nepali, who has endured uterine prolapse for 22 years. She was injured at the age of 21 while giving birth for the fifth time. “My two sons work in India but they don’t send any money home. My husband and I are so poor we have to do everything. I can hardly walk, but I have to go to the forest to get wood, tend to the animals and carry manure to the fields.”
Kokila Bista, 32, a widowed mother of three, suffers from a prolapsed uterus and finds it very difficult to work. Her husband died in India five years ago. When she went to India seeking treatment for her condition in 2005, Bista learned she had HIV. Because of her poor health, options for treating her uterine prolapse are limited.