Recovering Femininity

 

An effective and easily implementable
socio-medical project in the treatment of uterine prolapse,
a hidden Nepal’s national tragedy

 

PROJECT SUMMARY

Project title :

Recovering Femininity

Project specific objective:

To increase access and delivery of gynaecological services in remote and rural areas of Nepal.

Direct Beneficiaries:

8,000 women, who will be granted access to the 20 gynaecological camps; local medical and paramedic personnel, who will be granted training.

Project duration:

5 years

INTRODUCTION AND RATIONALE

Over 80% of Nepal's population lives in rural areas where geographical, economic and cultural barriers limit basic medical care. The recently suspended armed conflict exacerbated the lack of health workers, facilities and supplies, increasing the burden of the most common diseases. As of today, most Nepali hospitals are located in urban areas and most of the existing rural facilities lack funding, trained staff and medicines.

Individual approach to health care is also inadequate, as a consequence of scarce facilities and insufficient income. Villagers in fact tend to take prescribed drugs only until symptoms are relieved, unaware of the fact that incomplete drug treatments create micro-organism resistance, and frequently reach health posts when disorders are too advanced to be treated appropriately.

Furthermore, gender discrimination, added to the lack of medical assistance in the remote areas of Nepal, results in multiple exclusion and disadvantage and limits overall access to health care.

Amongst the needed health facilities, gynaecological services in particular represent an urgent necessity especially in those areas in which gender discrimination and misconception of disorders affecting the reproductive system are frequent and widespread.

Gender discrimination

Gender discrimination with regards to wellbeing affects the female condition directly, in limiting women access to health facilities, and indirectly, through cultural stereotypes mostly tied to gynaecological disorders.

Although the Government’s 1991 health policy includes a plan aiming at augmenting health facilities as well as female access to health services, compared to males Nepali females generally have lesser access to health care and, as a consequence of both discrimination and of scarce medical facilities, frequently are forced to live accepting, rather than curing, their illnesses.

By observing a few country statistical data, the urgency of RH services in Nepal along with their being a means of female empowerment, appears evident:

o   The average marriage age for women is 16

o   52% of women begin childbearing before 20 years of age

o   Maternal death rate is the highest in south Asia, accounting for an average of 539 yearly deaths per 100,000 women

o    Neonatal mortality rate registers 39 deaths for 1000 live births

o   70% women childbearing are anaemic

o   27% newborns are underweight

o   Only 53.4% women receive antenatal care

o   A mere 13% of overall deliveries are assisted by trained personnel (while 27% of female death is attributed to delivery)

o   46% maternal deaths are due to bleeding

Clinical Background on the Uterine Prolapse

It is estimated that 600,000 Nepali women in reproductive age suffer from a prolapsed uterus, an extremely serious pathology which not only causes physical pain and unbearable distress, but also inevitably leads to extended infection. In remote rural areas uterine prolapse is more widespread compared to urban centres and it is furthermore aggravated by a virtually absolute lack of gynaecological assistance as well as by gender discrimination.

Uterine prolapse occurs when the cervix and uterus fall from their normal anatomical position, as a consequence of weakened supportive ligaments. Among its causes, uterine prolapse includes excessive physically straining activities (such as lifting and carrying heavy objects) carried out during pregnancy and puerperium, multiple and frequent child bearings, unattended childbirth, malnourishment, pressing and tying the woman’s stomach after delivery to facilitate the expulsion of the placenta, and intercourse before the female genital organs have recovered from delivery.

The direct consequences of the disease are backache, abdominal pain, vaginal discharge, stress, incontinence, infection of the urinary tract, profuse menstrual bleeding, irregular vaginal bleeding, ulcerous sores, and vaginal infections.

Added to physical pain is deterioration of sexual life and stigmatization of being promiscuous, which for women already affected by gender discrimination undoubtedly resolves in a tremendous burden. As a consequence, affected females tend to ignore the disease, continue their working activities and unwillingly worsen their state.

In more economically developed countries, the most applied treatment for uterine prolapse is corrective surgical intervention (hysterectomy). This, in many Nepali areas, is a synonym of no treatment at all since sterile operation theatres are not always available and individuals do not dispose of the monetary means required for such a solution.

In alternative to surgery, it is possible to intervene on uterine prolapse through the use of pessaries, which consist in silicone or rubber rings, of variable sizes, frequently used for the treatment of pelvic organs’ prolapse.

The implantation of pessaries is very simple, and thus entails the expertise of a nurse (following a brief period of practical training held by a medical doctor), a simple clinic room, and quite limited money resources. All costs pertaining to anaesthesia, hospital admittance and stay, sterilisation of the operational theatres and surgical materials are not required.

The nature of the uterine prolapse, added to the general condition of too many local women, relentlessly determines a loss of female and personal dignity, which is definitely catastrophic for social righteous recognition. Granting women their health and allowing them to recover the pride of femininity is not merely a basis for economic development, it is first of all a fundamental human right.

Our Mission

This project is part of our broader mission of granting women their fundamental human rights and preventing female humiliation and discrimination.

It is intended to be a five year long pilot program designated for 8,000 women of the Targeted Areas affected by uterine prolapse. On the basis of the results obtained, we will extend the project to other Nepali geographical areas. 

 

EXAMPLE OF AN IMPLEMENTED SITE DESCRIPTION

Dhading District data

Targeted Areas is a plain area VDC (Municipality) located in Dhading District at the border with Gorkha Districts. The latter lie in the Bagmati and Gandaki areas and represent two of the least developed district of Nepal, respectively ranking 18th and 20th in terms of a composite index of development.

Targeted Areas is connected by highway, and joins Tipling, Sertung, Lapakhading, Jharlang and Ri VDCs. Despite government provisions relative to health post buildings, a strategic point throughout these VDCs is insufficient to meet requirements.

Having a very low socio-economic status, associated with poverty, starvation, famine, disease, and exploitation, these VDCs remain mostly deprived regions.

o   Total VDCs (Municipalities) in the territory: 50 (source: CBS, 2001)

o   POPULATION (source: CBS, 2001)

 

DATA

DAHADING DISTRICT

TARGETED AREAS

Total population

338, 658

7, 658

Total female population

172, 794

4079

Total male population

165,864

3,579

Total households

62, 759

1,458

Population growth rate

1.97%

 

 

o   HUMAN DEVELOPMENT in DHADING DISTRICT(source: NHDR, 2001)

Human Development Index: 0.410

Gender Development Index: 0.362

Social Empowerment Index: 0.318

Life expectancy at birth: 58.6

Human Poverty Index: 47.7

Infant mortality rate: 51 per 1000 live births

Women Empowerment Index: 0.3

Adult Literacy rate: 43.7%

           Male: 53.9%

           Female: 34%

 o   HEALTH in Dhading District (source: CBS, 2001)

Number of hospitals: 1

Number of nurses: 66

Number of primary health care centres: 2

Number of paramedical: 91

Number of health posts: 16

Expected pregnancies: 18,449

Number of doctors: 5

Live births: 3648

 

 

HELP/Nepal’s SPECIFIC EXPERIENCE
our latest experience in gynaecological service provision and treatment of uterine prolapse

1.  In April 2007 HELP/Nepal conducted with the Ramghat Health Centre, primarily based in Kathmandu and operative in various regions of Nepal,  two health camps, of the duration of two days each, in the Dhading District. The camps focused on gynaecology, dentistry and general medicine.

2.     In March 2007 HELP/Nepal implemented in Nepalgunj the pilot project for Recovering Femininity in collaboration with the governmental health centre Ramghat Health Centre and Saathi Banke NGO, based in Nepalgunj.

        The project focused on providing for treatment of the uterine prolapse through implantation of ring pessaries within the framework of an RH camp of five days duration. The designated beneficiaries were 184 women in Nepalgunj. Daily attendance and response to both the medical and family planning activities resulted impressive.

        The project is currently in its follow-up phase, consisting in check-up visits for the women treated with pessary implantation.

         A total of 30 pessaries for uterine prolapse of various degrees were implanted in the 5 days implementation phase. All patients to whom the pessary has been implanted were thoroughly informed on the basic hygienic notions relative to the pessary, and on the fact that a second visit, inclusive of pessary extraction, disinfection and re-implantation, was necessary after six months.

3.     In November 2007 HELP/Nepal implemented in Dailekh (Naumule VDC) a full filed project of Recovering Femininity in collaboration with the Australian Embassy. On 428 visits, of which 386 properly gynaecological, 109 pessaries have been implanted and 31 surgical operation are been performed.

A full detailed report is herewith:

 

No. of Gynecological Examinations

386

Total Number of Visiting Patients

428

  

Age of Patients

 

Children under 15

2

15-19

35

20-24

70

25-29

60

30-34

50

35-39

62

40-44

45

45-49

32

50-54

29

55-59

11

60-64

30

65-69

1

70-74

1

 

Patients’ Occupation

 

Agriculture/ domestic

418

Shopkeeper

5

Student

3

Social worker

1

Tailor

1

 

Number of Hours Work Per Day

 

1-4 hours

77

5-8 hours

163

9-12 hours

186

Not stated

2

 

Social Habits

 

Smoker and drinker

69

Smoker and non drinker

46

Drinker and non smoker

42

Non smoker and non drinker

162

Not stated

109

 

Age of First Menstruation

 

10

2

11

1

12

20

13

34

14

76

15

143

16

49

17

20

18

13

19

4

20

8

21

1

22

1

Total no. of ages registered

372

Average age of first menstruation

14.95

 

Age of Last Menstruation

 

27-29

1

30-32

3

33-35

9

36-38

3

39-41

5

42-44

7

47-47

15

48-50

13

51-53

7

54-55

4

57-59

4

Patient cannot remember exact age

1

Total no. undergone menopause

72

Total no. still menstruating

300

 

Menstrual Cycle

 

Regular

184

Irregular

77

Stopped for an unknown reason

8

Stopped due to preg/recent delivery

44

Menopause

72

Not stated

43

 

Contraceptive Use

 

Depo Provera injection

35

Condoms

10

The Pill

5

Husband underwent vasectomy

35

Norplant family planning

1

Minilab

2

Total no. using contraception

88

Total no. not using contraception

340

Medical History

 

Previous hospitalisation

159

Hospitalised for uterine prolapse

54

Pessary implanted-still in place

6

Pessary implanted but came out

22

Hospitalised for:

 

Gynecological complaints

60

Rectum prolapse

2

Gastric problems

13

Body pain

11

Hysterectomy

10

Pelvic Inflammatory Disease

2

Infertility test

2

Kidney X-ray

1

Abortion

1

Loss of appetite

1

Breast abscess

1

 

Pregnancy Conditions

 

No. of women having been pregnant

381

Deliveries at home

364

Deliveries at hospital

15

Deliveries at home w/health worker

2

No. of women with miscarriage

49

No. of women with baby die at birth

83

No. of women with child die from illness

31

No. of women undergone abortion

8

 

Number of Pregnancies Per Patient

 

1

43

2

52

3

50

4

54

5

35

6

34

7

26

8

23

9

8

10

8

11

9

12

5

13

1

14

0

15

1

Total no. of pregnancies

1597

Ave. no. of pregnancies per patient

4.2

 

Number of children per patient

 

1

44

2

76

3

52

4

62

5

41

6

31

7

15

8

12

9

4

10

0

11

1

Ave. no. of children per patient

3.25

 

Doctor's Diagnosis

 

1st degree uterine prolapse

62

2nd degree uterine prolapse

18

3rd degree uterine prolapse

30

1st degree cystocele

57

2nd degree cystocele

37

3rd degree cystocele

11

1st degree rectum prolapse

17

2nd degree rectum prolapse

12

3rd degree rectum prolapse

1

Total prolapse

3

Change of previous pessary

4

Primary infertility

10

Secondary infertility

4

Cervicitis

8

Cystitis

3

Gastritis

23

Bronchitis

9

Incontinence

2

Dysmenorrhea

9

Otitis

2

Heart murmur

1

Conjunctivitis

1

G.E.R.D.

1

Pelvic Inflammatory Disease

1

Bacterial infection

1

 

Treatment Prescribed

 

Pessary implanted

109

Pessary suggested after pregnancy

5

Pelvic exercises suggested

93

Further medical examination suggested

27

Amoxicillin

14

Diclofenac

7

Nava Jeevan

30

Paracetamol

16

Ranitidine

26

Operation to remove mass

2

Erythromycin

7

Ciprofloxacin

9

Buscopan

1

 

 

Number of women refusing pessary

13

 

 

Complimentary medicines dispensed

 

Fluconazole

428

Wormex

428

Vitamin tablets

428

OBJECTIVES

BROAD OBJECTIVES

Objective One

Providing for a better community-level health environment by augmenting access to gynaecological services to women in Nepal.

Objective Two

Empowering women in Nepal by arousing awareness on their right to access health services and to accept and cure gynaecological disorders.

Objective Three

Contributing to local capacity building in the field of health services.

SPECIFIC OBJECTIVE

Improve the diagnosis and treatment of gynaecological disorders in general and, specifically, of uterine prolapse, in the Targeted Areas.

 PROJECT TARGET SITES

Please note that, at the moment, the sites are listed in alphabetical order.

1)      BANKE District

a)      KANTHIPUR VDC

b)      KARKADO VDC

c)      KARMUNANA VDC

d)      KHAJURA VDC

e)      PARSHAPUR VDC

2)      BARDIYA District

a)      GULERIYA (Municipality)

b)      KHAIRAPUR VDC

c)      MAMPTUR VDC

d)      MATHURA HARIDUWAR (Half Municipality)

e)      TARATAL VDC

3)      DAILEKH District

a)      BALUWATAR VDC

b)      DUWARI VDC

c)      KALIKA VDC

d)      NAUMULE VDC

e)      TOLI VDC

4)      JHAPA District

a)      DAMAK (Municipality)

b)      DHARMPUR VDC

c)      SATASHI VDC

d)      SHIVAJUNG VDC

e)      TOPGACHI VDC

PROJECT BENEFICIARIES

DIRECT BENEFICIARIES

a)      Around 1,600 Women of different Districts per year (total of 8,000)

b)      20 local female nurses

INDIRECT BENEFICIARIES

a)      The local female community as a whole

b)      Local population  

IMPLEMENTATION STRATEGY

In order to achieve the objectives, the following strategy will be implemented:

1.      Conducting four ten-days gynaecological camp per year in Targeted Areas (total of 20 camps), in which an average of 400 women each will be provided gynaecological assistance, consisting in diagnosis and treatment of gynaecological disorders and in gynaecological counselling.

Targeted Areas has been identified as strongly lacking RH services and easily approachable from major VDCs and clusters, so as to attract the most possible affluence from adjacent areas.

2.     Providing special attention to uterine prolapse within the frame of gynaecological check-ups held at each gynaecological camp. All cases (most probably around 200) of uterine prolapse will be treated through pessary implantation and some expected 80 cases of severe Level II and Level III prolapse will be treated through corrective surgery.

3.     Training and updating two female nurses on general RH services and gynaecology and providing the nurses with essential supplies for the provision of gynaecological treatment and uterine prolapse treatment.

The training will occur through Direct knowledge transfer on gynaecological diagnosis and cure, during operational assistance on the patients on behalf of the project’s medical and paramedic staff.

The gynaecological training provided will focus on:

4.      Providing for follow-up on the patients treated within the camp through two 3-day follow-up camps conducted after three months and after six months in the target area, and through follow-up visits conducted by the trained nurses. The follow-up will include pessary substitution and post-operational check-up, and will be conducted by the project’s medical staff and the two local nurses. All further follow-up will be provided by the trained local nurses.

All Reproductive Heath Services provided will be in line with National Medical Guidelines and Standards.

Collaboration relative to the provision of medical services will be provided by one of the most prestigious faculties of Medicine in Italy, the Department of Medicine and Surgery of the University of Bologna. Staff from the University will provide direct medical assistance on the RH camps and will participate to the know-how and expertise transfer to local personnel.

ACTIVITIES

Activity One – Assess the camp’s specific requirements

o         Identify an appropriate site within Targeted Areas in which to conduct the gynaecological camp.

o         Identify all requirements for the camp. The evaluation will include a detailed assessment of the required supplies (drugs and medical materials) needed for :

-         The health services which will be provided within the camp

-         The training of the two local nurses

-         Local capacity building through provision of drugs and medical materials to be used following the camp’s conduction.

o         Conduct a two-day orientation on gynaecological camps to the local nurses.

Activity Two – Conduct an advertisement and mobilisation campaign

o         Organise a three-day advertisement campaign in Targeted Areas, intended for awareness on the upcoming camp, three days prior to the camp’s conduction.

The campaign will mainly comprise:

-         distribution of paper leaflets, which, considering the elevated level of illiteracy in the target territories, will be construed in the form of cartoon strips

-         radio announcements.

Activity Three – Identify and assess local personnel

o         Inform local entities on the upcoming gynaecological camp and on the requirement of two nurses.

o         Assess interested female personnel

o         Identify two nurses qualified and interested in the training, and committed to pursue gynaecological services in the territory.

Activity Four – Conduct the gynaecological camp

o         Provide for the following gynaecological services:

o         Gynaecological check-up and referral services

o         Implantation of ring pessaries on all consenting patients affected by any level of uterine prolapse.

o         STI/RTI syndromic case management

o         Obstetric services for high risk ante-natal cases

o         General Health care services

o         Identify, amongst the 400 patients who receive gynaecological services within the camps, those affected by uterine prolapse. About 200 patients are expected to present the pathology.

o         Identify cases of advanced level II and level III uterine prolapse to be treated through corrective surgery.

Activity Five – Provide for correctional surgery (hysterectomy) on level III uterine prolapse

o         Provide for transport of the identified patients to Kathmandu, in partnership with Nesa.

o         Provide for hysterectomy on the 80 identified cases of level III uterine prolapse within the Manhoman Memorial Hospital and/or Nepal Medical college. Surgery will be performed by the project’s medical personnel, assisted by the project’s paramedical personnel.

 Activity Six – Conduct two follow-up gynaecological camps in the target territory

o         Inform all patients treated within the camp on the importance of maintaining appropriate hygienic habits for the correct preservation of the treatment.

o         Inform all patients treated with ring pessaries that the latter must be substituted within six months.

o         Perform two follow-up gynaecological camps providing for gynaecological check-up visits to the patients treated within the gynaecological camps.

Activity Seven – Provide for on site coaching on gynaecology, including diagnosis and intervention on uterine prolapse, to local personnel

o         Coach the two nurses in gynaecological treatment throughout the duration of the gynaecological camp.

Activity Eight – Provide the local trained nurses with essential supplies

o         Administer to the two nurses any supplies essential to RH activities which have been identified as necessary during the preliminary camp assessment

o         Provide the nurses with essential drugs

o         Provide the nurses with 100 pessaries  

OUTPUTS

Output One

400 women of Targeted Areas and bordering VDCs granted with gynaecological assistance per camp (total of 1,600 per year, 8,000 grand total).

Output two

200 target beneficiaries received treatment for uterine prolapse, through implantation of ring pessaries per camp (total of 800 per year, 4,000 grand total).

Output two

80 women affected by advanced level II and level III uterine prolapse successfully treated through hysterectomy per camp (total of 320 per year, 1,600 grand total)..

Output Three

Local capacity in the provision of medical gynaecological services augmented.

Output Four

Awareness amongst local female population regarding the nature, symptoms and treatment of gynaecological disorders sensibly augmented.

Output Five

Access to Health services in general and to gynaecological services specifically evidently increased.

Output Six

Gender equality and equity in health service provision successfully promoted.

SUSTAINABILITY

Recovering Femininity is part of a broader project which comprises various programs focused on the conduction of RH and gynaecological camps countrywide. Implementation is enabled through established and maintained relations with project partners, who guarantee required staff and facilities and contribute to the activities’ funding.

Financial sustainability

Sustainability for Recovering Femininity has been till now granted through HELP/Nepal staff, facilities and funds and thanks to a contribution of Australian Embassy in Nepal..

Fundraising for future sustainability of other Recovering Femininity programs is already active. Where private funding should not be sufficient, HELP/Nepal will guarantee autonomously for project costs through a series of projects currently in implementation and aiming at providing for the NGO’s sustainability.

Territorial sustainability

Territorial sustainability within Targeted Areas shall be granted through training of local personnel and conduction of the gynaecological camp within a site that may perdure as a medical/gynaecological post to be conducted by the trained personnel.

Support to the trained nurses shall be provide, when sought, on behalf of HELP/Nepal,

Through defined agreements, hysterectomy will occur within the Manhoman Memorial Hospital in Kathmandu and/or Nepal Medical College. With both institutions a MoU has been already signed.

 MONITORING AND EVALUATION

The project includes a monitoring and evaluation team which shall perform regular assessments of the activities, achievement of the expected outputs, audit and effective budget expenditures as part of a lesson-learning process.

All monitoring activities will focus primarily upon the Beneficiaries’ actual attendance of the identified gynaecological camp and upon their response to the medical treatment provided.

Monitoring and evaluation shall be carried out as follows:

1.      Monitoring and follow up

General monitoring shall be conducted by project staff within the framework of the follow-up camps, in collaboration with project partners.

A Progress Report, following the first follow-up camp shall be defined by the monitoring team, who shall conduct a one-day monitoring visit to the camp for the purpose.

Sentinel monitoring conducted through intermittent but constant data collection from project partners.

2.      Internal Evaluation

o   Evaluation reporting performed five months from project inception and containing:

-         Assessment of progress and performance

-         Evaluation summary

-         Impact evaluation

3.      External Evaluation

o   Meetings and interviews with project partners and the two local trained nurses

o   Review, analyses and quality control of relevant project documentation of the internal evaluation reports

STAFF

1.      1 project manager

2.      2 project coordinators

3.      5 medical doctors

4.      2 medical officers

5.      5 health assistants

6.      5 staff nurses

7.      3 surgeons

8.      5 support staff