The silence and shame surrounding reproductive health in Nepalis killing the nation's women.Continuing a series on Nepal's women, Siobhan Tanner reports on reproductive rights in the country.

Shame nearly killed Kalawati Gupta. In the end it was poverty and €160-cost of a hysterectomy-that prevented her from going to hospital. But it was shame that kept her suffering in silence for 22 years, as her womb gradually slipped out of her birth canal.

''I first noticed something was wrong after the birth of my second child,'' Kalawati, tells The Irish Catholic through a translator in a mobile health clinic in Kusma village, located in the western Terai region of Nepal.

She was 26-years-old at the time and told only her mother who prescribed a herbal remedy for the pain. Within a week, Kalawati had returned to the paddy fields, hefting loads of cut grass and sticks, straining the muscles of her weakened uterus. ''We should normally take a rest for 20 days and neighbours and sisters come to help with the housework but at that time of my second child there was no-one to help, I couldn't take a rest.'' The pain persisted through a third labour and during the birth of her fourth child, Kalawati's womb dropped fully out of her body. ''The midwife pushed it back in, it was very painful, there was more blood than usual,'' she says.

From then on, she had difficulty lifting, sitting and standing and suffered from constant backache. Of the other prolapse symptoms - abdominal cramps, burning urine, incontinence and the foul-smelling white discharge of inevitable infection - she says nothing.

Uterine prolapse affects an estimated 700,000 women in Nepal with 200,000 requiring immediate surgery. The condition is caused when the weakened uterus slips into the birth canal causing a painful bulge. At this stage, a small rubber ring can hold the womb in place but the majority of Nepalese women that eventually arrive at hospitals are severe cases needing emergency hysterectomies.

In Nepal where women make up 70 per cent of the agricultural workforce, extensive physical labour during and after pregnancy coupled with malnutrition is the main cause of prolapse. A 2007 study found that average weight of women being treated for prolapse in a Kathmandu hospital was just 45 kilos.

In paddy fields surrounding around Kusma there are three times as many women as men to be seen working in the fields. A gynaecological camp visiting the area in 2004 found that more than 70 per cent of women attending suffered from prolapse.

In Ireland, as in the rest of the developed world, cases of stage three uterine prolapse are extremely rare and never fatal but extreme neglect in Nepal has led to the death of hundreds of women from infection and cervical erosion.

After the country's first democratic election in 2008, the then Prime Minister, Pushpa Kamal Dahal in his inaugural speech committed to rid the country of the scourge of prolapse and last year's budget included the allocations to cover the €160-cost of 12,000 operations.

Attitudes

Following the announcement, CARE Nepal, a women's organisation, set up a camp in the village of Kusma. Here for the first time Kalawati Gupta saw a doctor and was finally referred for an operation, 20 years after her womb first began slipping.

The stethoscope hanging around the neck of government health nurse Sita Shrestha and a green screen divider are the only indicators that the room is a health clinic. The majority of her patients are women and the majority of problems are reproductive.

Six years of advocacy by CARE Nepal in the area have had their effect. Shrestha who has been visiting the area for the past 15 years sees ''more and more cases of prolapse every day''. But, ''these are the cases of the past, there are hardly any new cases anymore''. She sees a change in women's attitudes and their willingness to discuss reproductive rights. ''Before women were ashamed to speak of sex in front of others but now only 50 per cent will not discuss it.''

Sitting forward underneath a poster of a cartoon depiction of a mother giving birth in hospital, Bhagmani Jeiswal falls into this category. She doesn't know her age, she guesses 59, though she looks closer to 70 - she is on the waiting list for the government subsidised surgery after her uterus dropped out of her body about a year ago. Bhagmani didn't tell anybody until she heard three women in the village had gotten a free operation. ''I was too embarrassed,'' she says. Is it painful? She shakes her head, ''No'' and unconsciously shifts her weight in the plastic chair.

Less than a kilometre away, Mannet Nessa gestures to the dirty floor of her mud hut where she gave birth to her second youngest with only the help of her 10-year-old daughter. One goat is tethered in the corner beside the sleeping form of her eldest son and flies buzz around a pile of tin bowls. Although the hospital is only 40 kilometres away in the town of Parsai, Mannet has given birth to her nine children in this hut, the norm for a country where 90 per cent of infants are delivered in homes without the help of trained nurses.

Mannet (pictured) is one of the luckier mothers around here - she has no health complications and only one of her nine children has died of diarrhoea. Less fortunate Bhagmani Jeiswal has buried four of her seven children, three dying from severe diarrhoea before reaching the age of five and Kalawati too lost an infant to pneumonia.

Almost every woman here has a similar tragedy to tell.

In 2006, a Red Cross report labelled Nepal ''the deadliest place in the world to give birth, outside Afghanistan and a clutch of countries in sub-Saharan Africa''.

According to the report 6,000 women and 30,000 infants in Nepal die annually because of unsafe childbirth and neonatal practices. It concluded that woefully inadequate facilities are at the root of the problem. There are 1,300 doctors, 90,000 under-trained health workers, 87 hospitals and fewer than 1,000 health centres for Nepal's 26 million people and many of the country's 4,000 villages have no health centre.

Government efforts to lower the mortality rate have focused on improving health facilities and cite the country's mountainous geography as the main obstacle to progress. The Himalayas which make Nepal a destination for 500,000 tourists every year also keeps the majority of the population cut off from healthcare.

But neither the lack of health facilities nor the geography explain why the flat lands of the Terai, the most accessible of Nepal's three topographies, has one of the highest level of uterine prolapse and maternal deaths in the country.

In 2008, the extensive Maternity and Mortality study yielded a result that shocked the country and gave an insight into the darker reasons behind the death statistics.

The first of its kind in a decade, the study surveyed eight districts - consisting of 12 per cent of the population - over a one year period. It too found that inadequate facilities and lack of doctors were contributing factors in maternal deaths in hospitals but more significantly noted the fact that 80 per cent of women arrived at the facility in a critical condition and died within the first hour ''indicates that delays in deciding to seek care was an important contributory factor.''

It is on the social causes of this fatal delay that CARE Nepal and NGOs like them have focussed its efforts.

Obstacles

Iman Sunar who led the organisation's project in the western Terai, says women's own fatalism and embarrassment were the first obstacles to change. They found that women did not want to go to hospital as there were no female health workers and believed that prolapse was the result of a sin in a previous birth. ''The root of this problem is social, it is a question of mentality and the power relation in the family,'' says Sunar.

In the Terai, where the ultra conservative Madhesi ethnicity dominate, cultural traditions such as child marriages aggravate the stats as the immature uteruses of child brides are more susceptible to prolapse.

Beliefs such as the one that women and their newborns are ''unclean'' and should be confined in a shed for 11 days still exist in parts untouched by the advocacy effort.

Moreover, Sunar and his team found an underlying belief that head of the family and husband regarded treatment for women a waste of money.

In Nepal, a 5-year-old girl is more likely to die than a boy of the same age. While no national health survey has identified the gender disparity, local studies have repeatedly found that girls, especially in poorer larger families, receive lower quality and less food than boys. With malnutrition being the largest contributing factor to child deaths, this practice alone could explain the biological anomaly.

The preference for sons was starkly illustrated following the legalisation of abortion in 2002 when clinicians reported the incidence of sex-selective abortion. In a country where 50 per cent of the population are below the poverty line of a $1-a-day, the lack of economic return from a daughter is a deciding factor in investing in her welfare. A daughter carries the burden of a dowry while a son carries the promise of one and in Hindu culture only the son can perform the parent's last rites. Added to which a daughter is a 'temporary member' of her maternal family as once married she becomes an extended member of her husband's family.

''HIV/AIDS has got everybody's attention because it affects everybody but uterus prolapse only affects women that is why the government are not paying full attention,'' accuses Iman Sumar.

''It's not enough to subsidise operations, that will never solve the problem, to improve woman's health we need to counsel the women, the husband and the mother-in-law, we need to change the whole mentality.''

The Maternity and Mortality study showed a drop in the number of women of a reproductive age dying from pregnancy complications - from 21 per cent in 1998 to 11 per cent in 2008.

From a high of 539 deaths per 100,000 live births in 1998 when it was the leading cause to 229 in 2009, the data showed Nepal is likely to meet the Millennium Development Goal of reducing the ration to 134 by 2015.

But the good news was overshadowed by another, less expected result. More Nepalese women were killing themselves - suicide had replaced maternal reasons as the number one cause of death of women aged between 15 and 50 - jumping from 10 per cent to 16 per cent.

There was another apparently unrelated finding: one of the main reasons that women did not go to a health facility was laaj. Translated to English laaj means shame.

Journalist Siobhan Tanner and photographer Hu O'Reilly travelled to Nepal with the aid of the Simon Cumbers Bursary fund.