December 22008KathmanduNepal: Birma Pariyar has lived for more than 20 years with her uterus slowly falling out. She struggles to walksitand work. The pain in her back and abdomen is so intense it sometimes feels like she is in labor. But until recently Ms Pariyar had never told anyonenot even her husbandabout her condition.

Ms Pariyar is one of an estimated 600,000 women in Nepal suffering from uterine prolapsea debilitating condition in which the muscles supporting the uterus weakencausing it to descend into the vaginal canal. Some of the women live for years with the uterus completely outside of the body. A third need immediate hysterectomies.

The combination of pain and shame drives those afflicted to desperation: "Sometimes they apply mud or pieces of flip-flops... they cut a piece of slipper and put it in the vagina just to hold their falling wombbecause they have been suffering from so much pain," said Samita Pradhan, Secretary of the Uterine Prolapse Alliance (UPA)a network of women's organizations and partner of The Advocacy Project (AP). "There have been cases of women applying cement inside their vaginas just to hold their uterus."

After years of suffering in silencewomen like Birma Pariyar are beginning to speak out. Their advocateslike the UPAare also taking heart and seeking international support. This summerAP sent two Peace FellowsNicole Farkouh and Libby Abbott, to volunteer with the UPA. Ms Farkouh recently gave a briefing to experts in women's health and population at USAID in Washington.

The publicity is starting to have an effect. In Septemberthe Nepali government pledged funding for 12,000 surgeriesa three-fold increase over last year. But much remains to be doneand the UPA is calling for a major campaign in Nepal and abroad.

In supportAP has posted new web pages that include profiles of 22 womenincluding Ms Pariyarand video interviews with Ms Pradhan and the two AP Fellows. The profiles are organized around ten risk factors that render women like Ms Pariyar vulnerable to prolapse. 

Prolapse is a consequence of social exclusionignoranceand abusive cultural taboos. According to Ms Pradhanwomen in Western Nepal are considered unclean during menstruation and after childbirth. Often, they are forced to live in a cowshed and denied dairy products and other nutritious food. Birma Pariyar herself married at the age of 15 and returned to work in the fields a week after giving birthputting enormous strain on her uterus. She was also beaten by her husband.

"Women are loaded with heavy work even during pregnancy and immediately after child delivery," Ms Pradhan said. "In additionthey do not have access to health facilities for safe delivery. (This) is not a mere medical problem. It is interwoven with many social causesincluding gender discrimination. We need to change the whole patriarchal society."

She added that many women who suffer from prolapse are ostracized. Some end up as servants in their former home if their husbands take on a new wife.

Little research has been done into the prevalence of prolapse because the condition is not considered life-threatening. But Ms Farkouh encountered one woman in a village whose uterus had rotted away and who later diedmost likely from an infection caused by prolapse. Such cases underscore the need for both government intervention and more research.

At the same timeadvocates also agree that prolapse should not take money away from other efforts to make motherhood safer and reduce maternal mortality. Insteadthey hope to use prolapse to lobby for increased investment in women's health.

Meanwhilemuch can be done at little or no expense. Women can be taught exercises which help to tighten the pelvic muscles. Local health centers can also provide inexpensive rubber pessary rings that hold the uterus in place and alleviate the painful symptoms.

The Uterine Prolapse Alliancea sub-committee of the Safe Motherhood Federation of Nepalcomprises 20 Nepali organizations, and is now looking abroad to promote its message and pressure the Nepali government for change. The Advocacy Project has pledged to help by recruiting Peace Fellowssupporting the Alliance's advocacyand by organizing outreach events at universities in the United States.AP welcomes offers of support.