Nepal: Widespread gender discrimination has triggered sexual and reproductive rights crisis

Source: Amnesty

Widespread and systemic gender discrimination in Nepal has led to hundreds of thousands of women suffering from a reproductive health condition that leaves them in great pain, unable to carry out daily tasks and often ostracized from their families and communities, Amnesty International said in a new report today.

Uterine prolapse – a debilitating condition where the uterus descends from its normal position into the vagina - is rooted in discrimination that has severely limited the ability of women and girls to make decisions about their sexual and reproductive lives. Harsh working environments, early marriages and having too many children all contribute to the condition.

“This is an urgent human rights issue. Widespread uterine prolapse in Nepal goes back to the ingrained discrimination against women and girls that successive governments have failed to tackle adequately,” said Madhu Malhotra, Director of Amnesty International’s Gender, Sexuality and Identity Programme.

“Hundreds of thousands of women are suffering needlessly in Nepal today. Governments have only taken token steps to address the condition, and not followed up with concrete action to reduce risk factors for women and girls.”

The report, Unnecessary Burden: Gender discrimination and uterine prolapse in Nepal, is based on extensive field research in Nepal, including interviews with women, girls and men, women rights activists, medical experts and government officials.

Uterine prolapse is a global health problem but particularly prevalent in countries like Nepal where gender discrimination is high and access to healthcare limited. A UN estimate suggests that 10 per cent of Nepal’s 13.6 million women are affected, and this figure could be much higher in some regions.

Unlike in the rest of the world where uterine prolapse is most common among older women, many Nepali women develop the condition in their 20s.

Uterine prolapse causes great pain, with many women unable to do the heavy physical labour or carry heavy loads they are often compelled to, or even to sit comfortably or walk.

There is also considerable social stigma around the condition. Sometimes women are ostracized or described as “lazy” by families and communities when they are in too much pain to do the work expected of them. Amnesty International's research found that often women are unable or reluctant to seek healthcare, or to even talk about their pain.

Kopila, a 30-year old from western Nepal, had her first child at age 18, and has lived with the condition since the birth of her fourth child when she was 24. She has been prevented from seeking healthcare by her husband, and forced to do hard physical labour during and after pregnancy.

“[When I first developed uterine prolapse] I started feeling back pain and stomach pain and I couldn’t stand straight or sit or do work. I feel pain in my lower abdomen and generally I have back pain when I work hard. When I sneeze my uterus comes out,” Kopila said.

There are many causes for uterine prolapse, including giving birth at a young age, having many children within a short space of time, inadequate nutrition, lack of access to skilled health workers during labour and being forced to do physical work during or soon after pregnancy.

But at the heart of the problem is persistent discrimination against women and girls that has gone unaddressed by successive Nepali governments.

Women and girls are in essence denied control of their own bodies and lives. Many are unable to decide if or when to marry or have children, whether to use contraception or how many children to have. Ensuring they are able to access quality healthcare during pregnancy is often out of women’s own hands.

Discrimination also puts women and girls at risk of domestic violence, including marital rape. Uterine prolapse frequently makes sexual intercourse painful but men and women described to Amnesty International how women are unable to refuse to have sex with their husband.

Nepali civil society organisations, especially women rights groups, have worked for years to bring the issue to the attention of the government. This led to a 2008 Supreme Court ruling that the high rate of uterine prolapse in the country is a violation of reproductive rights and ordering the government to tackle the situation.

To date, however, successive Nepali governments’ efforts to address uterine prolapse prevention and gender discrimination have fallen far short of what is needed.

Existing policies on reproductive and maternal health do not address all the risk factors and are ineffective in addressing the underlying discrimination. Those policies that do exist are hardly implemented, if at all.

There is a complete lack of an overall strategy to prevent uterine prolapse prevention. A draft strategy, which included some elements of prevention, has been pending adoption by the government since 2008 – an indication of an appalling lack of official attention.

This delay and lack of urgency reflects a lack of coordination and political will amongst relevant ministries in Nepal, who were all unwilling to take full responsibility for uterine prolapse prevention in interviews with Amnesty International.

Governments’ efforts have mostly focused on providing surgery (predominantly hysterectomies) for late stage cases – a limited approach that does not do what is required to prevent the condition.

“Nepal urgently needs a comprehensive plan to prevent uterine prolapse so fewer women and girls have to suffer through this condition. Ministries have to stop passing the buck and instead take responsibility for something affecting hundreds of thousands,” said Madhu Malhotra.

“Nepal has gone through a protracted political crisis but that can’t be an excuse for inaction. The new government under Prime Minister Sushil Koirala now has an opportunity to give uterine prolapse the attention it requires. The first step is to publically recognise it as a human rights issue.

“Any prevention plan must include effective measures to tackle gender discrimination, and ensure that women and girls know about uterine prolapse and are empowered to make decisions about their own lives. Denied control over their bodies, health and lives, women and girls in Nepal are ready for change”