By its origin, risk factors are directly related to the delivery of children and these are also strongly influenced by cultural, economic, and social conditions of women, especially in rural Nepal. Therefore, a maternal health programme could contribute to increase knowledge of women how to prevent POP, to recognise signs of POP and seek medical care for POP in an early stage. The learning’s about utilisation of health care facilities for maternity care by women and their barriers for attending based on extensive research, are also relevant for developing specific POP programmes.²

For POP prevention relevant elements of maternal health programme are:

Firstly, family planning may increase the woman’s age of the first pregnancy and may reduce the number of pregnancies. Both are important for lowering the risk for developing POP. The government’s Demographic and Health Survey of 2011 found that 50% of married women aged 15-49 used a form of contraception and that 43% of those used a “modern method”. This reflects an increase in using modern contraception methods compared to 26% in 1996 and 35% in 2001. In 2016 the percentage of married women using modern methods of contraception was still 43% and actually was not changed during past 10 years, underlining the need for extra efforts. The contraceptive prevalence rate (CPR) among married women varies with age, rising from 23% among women age 15-19, peaking at 69% of women age 35-44, and then slightly declining to 65% among women age 45-49. There are many women who do not use contraception but who do not want to get pregnant. Across Nepal, 27.5% of women had an “unmet need” for contraception. The effects of caste and ethnicity on maternal health revealed that up to 39% of Hill Janajati, Hill Dalit and Muslim women had an unmet need for contraception. However, these figures only reflect the responses of married women of reproductive age who are not using any form of contraception and who want to postpone their next pregnancy or stop childbearing, or pregnant women whose last delivery was “mistimed” or unwanted. They do not include unmarried, widowed, separated or divorced women; consequently the “unmet need” may be higher than these government data suggest.³

The government sector is serving 70% of modern contraception method users, what can be subdivided in 32% by hospitals, 20% by (sub)-health posts, 8% by mobile camps, 4% by primary health care centers and 3% by Female Community Health Volunteers (FCHV).

Secondly, giving birth at a “birthing center” assisted by skilled birth attendants instead of at home without any professional help, is also important for lowering the risk of developing POP. Only 7-14% women had access to supervised deliveries in 2000-2006.^4,5,6,7

In 2011, about 28% of all births took place at health facilities and 36% of all childbirths were conducted by a skilled birth attendant.⁸ According to the Demographic and Health Survey of 2011, 40% of women had delivered their last child in a health facility.⁹ In 2016, 60,9 % of women had given delivery in a health facility.¹⁶ Persistent inequities in coverage of maternal and newborn health services continue to pose a major challenge to the health-care system.²¹Large differences in access to skilled birth attendants are seen in different ethnic and caste groups. Women from the relatively advantaged Newari and Hill Brahmin groups were most likely to have a skilled person assist them (71% and 65% respectively). In sharp contrast only 22% of Terai Dalit women, a skilled birth attendant assisted 30% of Hill Dalit women, 28% of Hill and Terai Janajati women and 33% of Muslim women in the five years up to 2011.³

Thirdly, avoiding specific physical activities shortly after the delivery is thought to be a contribution in lowering the risk of developing POP. In a study in Bhaktapur district (1337 women aged 20 and above), the majority (64.3%) took rest for at least one month after delivery, but 26.73% started working in field in 2-3 weeks after delivery.⁶ Only 2.2% of women delivering at home received a home visit by a health professional in the first week after the delivery.¹⁰ Recently, a study was published about the potential role of physical labor during menstrual period: the authors conclude that lifting heavy loads during menstruation may increase the risk of stretching and injuring pelvic floor supportive tissues.²²

The government has set up nationwide maternal health services programmes and infrastructure to improve women’s and children’s health before and after delivery. Many socio-demographic variables, such as age of women, number of children born, level of education, ethnicity, place of residence and wealth index, are predicators of utilizing the maternal health services for most recent child.¹¹ Four levels of barriers to accessing reproductive health services have been identified: Firstly the family-related barriers, like women needing permission to leave the house; older women who had given birth without any healthcare viewing treatment as “unnecessary”; and families requiring women to work at the time the health facility was open. Secondly the community-related barriers, including religious or social requirements for women not to travel alone or mix with non-related men.

The distance to the health facility along with availability and cost of transport can be a barrier. Lastly for Dalits, caste based discrimination amongst health service providers was another barrier which resulted in not delivering services and discouraging them from trying to access services.³

Barriers to the recommended four antenatal care (4ANC) visits has been studied recently in eastern Nepal. Being from disadvantaged ethnicity, lower women’s autonomy, poor knowledge of maternal health service and incentive upon completion of ANC, less media exposure related to maternal health service, and lower wealth rank were significantly associated with fewer than the recommended 4 ANCvisits. Thus, maternal health programs need to address such socio-cultural barriers for effective health care utilization.^12,17,20 Possibilities to increase skilled birth attendant utilization have been studied as well.¹³

In conclusion: some important recommendations for the prevention of POP are increasing women’s empowerment, limiting frequent pregnancies and provision of educational material.¹⁴

WfWF Data

Counselling and teaching on all involved healthcare levels are the main activities of WfWF. Healthcare providers are trained by WfWF in identifying women with POP or who are at risk for POP. General information about nutrition and POP prevention is given and the importance of regular pregnancy checks and childbirth in a Birthing Center is emphasized.¹⁵

References

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2. Uterine prolapse and its impact on quality of life in the Jhaukhel-Duwakot Health Demographic Surveillance Site, Bhaktapur, Nepal. Shrestha B, Onta S, Choulagai B, Paudel R, Petzold M, Krettek A. Glob Health Act 2015,8:28771 http://dx.doi.org/10.3402/gha.v8.28771

3. National Alliance for pelvic Organ Prolapse Management – Nepal. Amnesty International Joint- Submission to the United Nations Committee on economic, social and cultural rights 53rd session, 10-28 November

4. Reducing morbidity from uterovaginal prolapse in Nepalese women through surgical camps; an ambitious approach. Rana A. N. J. Obstet. Gynaecol Vol. 1, No. 2, 1-3, 2006

5. Pelvic Organ prolapse, don’t forget developing countries.Gunasekera P Sazaki J, Walker G. www.thelancet.com Vol 369 May26, 2007

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9. Demographic and Health Survey Nepal Report 2011. Population Division Ministry of Health and Population Government of Nepal Kathmandu, Nepal New ERA Kathmandu, Nepal. March 2012

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13. A cluster randomized evaluation of an intervention to increase skilled birth attendant utilization in mid- and far western Nepal. Choulagai BP, Onta S, Bhatta DN, Shrestha B, Krettek A. Health Policy Plan. 2017 May 4. doi: 10.1093/heapol/czx045

14. Uterine Prolapse in Doti district of Nepal. A Research Report Prepared under the Regional Health Research Grant F/Y 2066/67 of Nepal Health Research Council.Submitted by Paneru DP July 2010

15. Annual Report WfWF 2004 - 2022

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17. Assessing knowledge and behavioural changes on maternal and newborn health among mothers following post-earthquake health promotion in Nepal. Dhital R, Silwal RC, Simkhada P, Teijlingen E, Jimba M. Https://doi.org/10371/journal.pone.0220191 July 25,2019

18. Prolapse related knowledge and attitude among married women of reproductive age. Khanal G, Ghimire P, Shrestha N,Koirala S. J of Chitwan Medical College 2020;10(31):14-18

19. Knowledge on uterine prolapse among married women of reproductive age in Nepal. Shrestha B, Devkota B,Khadka BB, Choulagai B, Pahari DP, Onta S, Petzold M, Krettek A. Int J Womens Health. 2014;6:771-779 https://doi.org/10.2147/IJWH.S65508

20. Sociodemographic correlates of antenatal care visits in Nepal: results from Nepal Demographic and Health Survey 2016. Adhikari M, chalice B, Bista B, Pandey AR, Upadhyaya DP. BMC Pregnancy and Childbirth 2020 20:513 https://doi.org/10.1186/s12884-020-03218-x

21. Intersectional (in) equities in contact coverage of maternal and newborn health services in Nepal: insights from a nationwide cross-sectional household survey.Khatri RB,Alemu Y,Protani MM, Karkee R,Durham J.BMC Public Health(2021) 21:1098

22. Potential role of physical labor and cultural views of menstruation in high incidence of pelvic organ prolapse in Nepalese women: a comparative study across the menstrual cycle. Biswokarma Y, Brandon K, Lohman E, Stafford R, Daher N, PetrofskyJ, Thapa U, Berk L, Hitchcock R, Hodges PW. Front. Med. 11:1265067