Better knowledge is very important for women to prevent POP, to recognise POP in an early stage and to seek medical advice at a health facility.Root causes are complex, and this should be recognised/ incorporated/ addressed in the health care offered to reduce the burden of women.
Currently, the availability of services for POP is increasing, and more women are becoming aware of the issue and are seeking help instead of keeping their prolapse a secret. Special attention is paid to the Female Community Health Volunteers (FCHV) as they play an important role in the communities of Nepal to inform women and to encourage them to seek medical health care at the health post.
The FCHV provide, after a short training from Government Nepal, some basic care and education in the villages, with the focus on mother- and childcare and contraception. Of great importance is the direct communication with all women in the own mother group of each FCHV.1
FCHVs provide information on causes, signs/symptoms of POP and can advise women to seek further health care at the peripheral health facility. The training curriculum for FCHVs (2010 revision) contains 20 substantial chapters with a huge amount of information. The one on POP defines the condition, the causes and ways to prevent it. Since 2003 volunteers should receive a five-day “refresher” training every five years. Anyhow volunteers told Amnesty International that their knowledge of uterine prolapse was not sufficient.2
The curriculum for training new FCHVs (2010 revision) defines POP and lists for its causes: pregnancy under 18, insufficient nutrition, giving birth every year, carrying loads after childbirth and lack of a skilled birth attendant. It informs the Volunteers that to prevent uterine prolapse, women should marry and have a baby after the age of 20, eat sufficient nutritious food, leave two years between children, avoid pressing the abdomen during labour, not carry loads and take sufficient rest after the delivery.2
Counselling in community settings/meetings is one of the main activities of WfWF. Local health care providers are trained by WfWF in identifying women with POP and those who are at risk for POP. The training is carried out by Nepalese partners of WfWF or by the regional government under the leadership/supervision of the Nepalese representative of WfWF. General information about nutrition and POP prevention is given and the importance of regular pregnancy checks and childbirth in a Birthing Center is emphasized.
The Female Community Health Volunteers are also trained and education materials are provided, as they play an important role for women health in the communities of Nepal. General information about nutrition and POP prevention is given and the importance of regular pregnancy checks and childbirth in a Birthing Center with professional help is emphasized.
In 2014 1659 households were visited in 5 VDCs in a hilly area.3 Most women were illiterate, 73% did agricultural work, the average age of marriage was 16.7 years, average age of first pregnancy 20.1 years, average number of children per marriage 3.8, > 90% delivered at home with the help of family or neighbours. Knowledge about POP was provided by FCHVs (53,3%) and in 30% through health camps. As cause of POP the women answered: hard work (74.7%), insufficient nutrition (52.4%), giving birth to many children (36.5%). Complaints of POP provided were: back pain and vaginal discharge (60.8%), bulging feeling in vagina (27.4%). Preventional activities: no more heavy lifting/ work (58.6%), nutritious diet (44.2%), marrying at a later age (33%).
In 2012 a group of 25 women attending a gynocamp were interviewed.4 Although the majority have little knowledge of the risk factors of POP, 70% consider it a health problem that can be prevented; 30% actually were taking preventive measures: less heavy work, wholesome diet and rest after pregnancy. Especially lower cast women like Dalit women marry young, are less developed and carry out heavy work, in particular when their husbands are working abroad.
A couple of recommendations were formulated based on the results: involve men more in mother and child care; provide information at school; provide suitable information (pictures instead of text), better access to health care.
A qualitative study in a hilly area of Parbat district has been carried out by Tribhuvan University in 2017 to understand the impacts of the gynocamp organised by WfWF in the preceding years, covering all aspects of prolapse care in practice and training/education of various people involved in prolapse care.5 The study was conducted aiming to get answer for the following specific objectives: I To quantify the impact of interventions on women from the selected locality; and II To explore whether and how it was possible to transfer required knowledge and skills to the concerned stakeholders at the local level and to government institution/staff. This qualitative study clearly showed that different categories of individuals and institutions benefitted from these gynocamps. Women having POP problems have clearly been benefited from this approach. Women from all age, caste/ethnicity and economic situations got different kinds of benefits. Especially women of marginal social and economic situations primarily benefitted from these gynocamps as they received the services in their vicinity and free of cost. Along with the improvement in the health situation of women, these gynocamps also contributed to the wellbeing of their respective family and of the whole community. Likewise, transfer of knowledge and skills to the local health workers made not only the recipients the direct beneficiaries, but also to the whole health care system and ultimately the women from the locality who may need such services in the days to come.
In 2015, an evaluation study was done by WFWFteam.6 In 8 villages in Dhading and Sindhupalchowk, health workers were interviewed to check what they remember of the training they received in the past. An attempt was also made to get a picture of how the process of 'increasing' awareness of POP was progressing among women and the general population. With this objective in mind, 4 VDCs were visited where a POP camp, including training, was held longer ago (> 3 years) and 4 VDC’s where this occurred just one year ago. In total 75 FCHVs and 23 HPWs were interviewed using a questionnaire and the spontaneous answers were noted.
Ten interviews in the form of discussions took place with staff in a higher position, including the District Health Personnel. The answers were very diverse. But in general, the training appears to be effective. Aspects/Areas for further improvement were also identified.
A problem is that there is a high turnover of health post personnel, so a considerable number of currently active health care people did not had received the WfWFtraining. The POP problem is not incorporated in the healthcare system as a distinct disease.
In 2010 and 2011 in total 14 health workers were interviewed.7 They all received at least one day of training. Result: they have gained knowledge about POP stages; cleaning pessaries; repositioning pessaries; more targeted referrals. They are not experienced in measuring and placing a new pessary and treatment of complications. Recommendation: more training sessions; stocking with white pessaries.
1. Female Community Health Volunteers in Community-Based Health Programs of Nepal: Future Perspective. Khatri RB, Mishra SR, Khanal V. Front. Public Health 5:181
2. 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
3. A Household Survey Report on Knowledge and Practice of Married Women with Children on Uterine Prolapse at working VDCs of RHEST in Dhading District, Nepal. RHEST, 2014
4. Prevention practices adopted by married Dalit women against pelvic organ prolapse in Dhading district. Submitted to the Kathmandu University Center for Development Studies, Kathmandu, Nepal. Bhattarai K, August 2012
5. A Study on the Impact of Women for Women Foundation’s Field Camps on Healthcare Workers and Inhabitants of a Community with a Focus on Women with Pelvic Organ Prolapse. An Evaluation Report. Dahal KB, Ph.D. 2018
6. Health Care Research, WfWF report.Dekker J, Tamminga C, Verdegaal M, Tamminga H. 2016
7. Uterovaginale prolaps bij de Nepalese vrouw. Een follow-up studie naar de effecten van de pessariumbehandeling en operatieve ingrepen in ruraal Nepal (jn Dutch, summary in English).Lammers H, 2012