Savitri Joshi was determined to tame the cow.

It was snowing, in her home village of Nagthat, in Uttarakhand’s Dehradun district. And she had given birth only eight days earlier. But when her mother and sister-in-law told her that they were unable to tether her cow, she knew she had to help. So she stepped out in the freezing February cold, making her way towards the scared animal, which was wandering on a road facing white Himalayan peaks. As she approached it, she decided to avoid a longer route, and jumped over a fence.

Suddenly, she felt a sharp pain in her vagina. She fought it down and managed to tie up the cow.

When Joshi’s mother realised she was in pain, she rushed her back inside the home, laid her down on a cot, and administered hot fomentation therapy to her. She fed her some hot baadi, made with flour and ghee, to comfort her, but the pain did not recede.

Three months passed by, and the pain persisted. Something was wrong.

Joshi’s family then took her to a hospital in Vikasnagar, around 45 km from her home. There, doctors told her that her uterus had slipped down from its normal position. She had a condition called pelvic organ prolapse.

In medical terms, “prolapse” refers to the drooping of organs. In the case of pelvic organ prolapse, the pelvic floor muscles weaken or collapse as a result of trauma, and one or more organs in the pelvic region, like the uterus, the bladder, or the rectum, descend towards the vagina. They may also bulge out of the vagina, and sometimes cause urinary or faecal incontinence.

Joshi said she didn’t have a bulging as such, but that “if you look carefully, it is slightly visible”. She felt terrible pain during urination, as well as during her periods. And when she worked on the farms, bent all day over the potatoes, peppers and beans that the family grows, mostly for its own consumption, she felt like she was in labour all over again.

Globally, the prevalence rate of pelvic organ prolapse has been reported to be around 9%. But in low-income, developing countries, it can be close to 20%.

“I won’t be able to give you the exact number, but we see about four patients with POP during every outpatient department session,” said Anupama Bahadur, a professor and the unit head at the department of obstetrics and gynaecology at the All India Institute of Medical Sciences in Rishikesh. While doctors in cities like Delhi and Gurgaon told me that they primarily see patients over the age of 50, in some villages of Uttarakhand, I also met women as young as 30 who were struggling with the condition.

Bahadur explained that while the condition may be prevalent in both urban and rural areas, it is primarily women from lower socioeconomic backgrounds, like Joshi, who are more vulnerable.

“If you look at the conditions that cause pelvic organ prolapse, you will see that it’s mostly the women from these communities who are likely to get it,” she said, “These are the women lifting heavy weights, working on the fields, and not getting enough rest after delivery.”

Bahadur and other doctors I spoke to also explained that early pregnancy, a high number of thinly spaced vaginal deliveries and home deliveries under the supervision of untrained healthcare workers were some of the reasons behind pelvic organ prolapse in rural areas. Chronic constipation and cough can also increase a woman’s vulnerability to the condition.

Savitri Joshi, of Nagthat village, suffered from pelvic organ prolapse after an incident in which she jumped over a fence. Despite this, she continues to do hard labour regularly. Photo: Sanna Irshad Mattoo

In 2021, Bahadur and her colleagues at AIIMS Rishikesh worked on a report on women’s experiences dealing with pelvic organ prolapse – the report’s primary author was the veteran doctor Shashi Prateek, who passed away that year. The report studied 45 cases of women in Uttarakhand who had pelvic organ prolapse, and found that 80% of them were from rural areas. It noted that nearly all the subjects were involved in daily hard labour, such as “carrying heavy weights like buckets of water, bundles of grass and wood for household purposes”.

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The problems that women face as a result of pelvic organ prolapses are exacerbated by their reluctance to seek help for it.

“A woman comes to us when she has a feeling that something is coming out of her vagina, or has heaviness in the perineal region,” Bahadur said. “They are unable to walk or do their day-to-day household activities, like going to the field, which bothers them a lot. They also find it difficult to get intimate with their partner. But by the time they approach us, it’s very late.”

The AIIMS report found that the length of delay in seeking treatment among the subjects ranged from one year to 40 years. A major reason for these delays was shame: 56% of the women did not seek treatment out of embarrassment and fear that it could result in a loss of social value. Other reasons included poor transport facilities, financial constraints, and a lack of family support.

“They suffer in silence,” Bahadur said. “A woman is normally neglected in the household. She doesn’t have a voice.” Further, she noted, if a woman “comes to get evaluated and admitted for a condition like prolapse, which takes time to recover from, it can hamper her day-to-day activities. That also prevents her from seeking treatment.”

In Sumitra Devi’s case, a lack of awareness about the problem was a key reason she delayed seeking treatment. “I suffered alone for 20 years,” Devi said. “I never knew that it was a disease.” (Devi’s name was changed for this story at her request.)

She recounted that the problem likely began after the birth of her eldest child, and has since grown so severe that she can’t wear panties.

“There’s this watery discharge nowadays,” she said, sitting in a dimly lit room of her house in Sila village of Dehradun district’s Kalsi town. “And the itch, it drives me crazy. It burns. Sometimes I end up hurting myself while itching, but what to do? It’s so painful.”

She has also been struggling with the problem of the smell of the discharge. “I only wear loose salwars,” the 40-year-old said. “And by the next day, I need to change them due to the smell.”

Like with Joshi, Devi’s uterus protrudes from her vagina. She feels extreme pain during sex. Engaging in manual work is also painful, but she said she can’t avoid everyday chores like working on the farms, or fetching water, firewood and grass for the cattle and the household.

When we met, she had just finished cooking a lunch of dal and rice for her husband and their four children – but there was still a lot of work to be done.

“I will have to do something about it now,” Sumitra Devi said. “I am in too much pain. What if it gets worse?”

The reluctance to seek treatment isn’t limited to women in rural areas.

Amita Jain, a urogynaecologist and senior consultant at Medanta – the Medicity Hospital in Gurugram, noted that even upper class women in urban areas tend to neglect the condition until it has developed to an advanced stage. “They mostly come to us when they have developed ulcers or are experiencing difficulty passing urine,” she said. “They might think that it’s a normal part of ageing, or they feel ashamed about it, especially those women who don’t have a husband and find it difficult to talk to their sons.”

Sumitra Devi of Sila village was unaware that prolapse was a medical condition, and delayed seeking treatment for 20 years. The problem even affected the clothes she could wear. Photo: Sanna Irshad Mattoo

But women in rural areas do tend to find themselves in more physically risky situations – such as in Joshi’s case, when she pursued her cow.

For Kalavati Goswami, who lives in Roshila village of Haldwani, in Nainital district, it was a near-fatal trip to the jungle one day that pushed her to see a doctor. “I had gone there as usual to get firewood and grass but on that day, I passed out,” the 70-year-old said over the phone. “I had been experiencing the bulging, pain, and bleeding for a long time, but I was so young. And so scared to tell others.”

Tragically, even when women do find the courage to ask for help, their concerns are often dismissed.

Thirty-year-old Geeta Tomar in Dehradun’s Laccha village told her husband and mother-in-law when she noticed the symptoms of pelvic organ prolapse after the birth of her first child in 2012. “But they said that you are so young. And the child is young too. We will look into it later,” she recounted.

Part of the reason for this hesitation is that families fear the possibility that the woman may need a hysterectomy, noted Rajeev Prasad Bijalwan, a researcher and deputy manager at Dehradun’s Rural Development Institute. Bijalwan and his team studied the social conditions that impact women with pelvic organ prolapse in the town of Chakrata, also in Dehradun, in 2015. “If a woman tells the family that she needs to undergo a hysterectomy, they might not agree,” Bijalwan said. “Because who will give birth to the babies then?”

Tomar said that she suffered for seven years before she could finally get treatment. During this period, she had another child and continued with her regular household chores.

“I have suffered a lot,” she said.

“Did your husband support you?” I asked.

“See, in a village setting like ours, you have to ask the elders of the house – the mother-in-law, the father-in-law,” she said. “Whether you want to see a doctor or visit a market. If they don’t allow it, we can’t do it.”

Doctors say that the treatment for pelvic organ prolapse depends on its stage and severity. Meenakshi Ahuja, director of the obstetrics and gynaecology department at Fortis La Femme hospital in New Delhi, explained that there are four stages of uterine prolapse. “The first stage is when the uterus descends from the normal position, the second is when it reaches the vulva, the third is when it’s coming out, and the fourth is when the uterus is completely out,” she said. “The lax muscles can also cause the anterior and posterior vaginal walls to prolapse. So the bladder, the rectum, or the anal canal can also come down.”

While some degree of prolapse is common among women, Jain said, conservative management, which refers to treatment that avoids invasive procedures, can fix a lot of cases. If the prolapse is detected at an early stage, for instance, doctors can recommend exercises to tone up the pelvic muscles so that the tissue can be held up, Anupama Bahadur noted.

Ahuja explained that post-menopausal women are particularly vulnerable to pelvic organ prolapse. “Laxity of muscles is usually linked to childbirth, but after menopause, when the tone of the muscle goes down further, the uterus is bound to come out,” she said. She added that exercises like Kegel’s exercises, particularly around periods of childbirth, could help with the problem. Further, she explained, taking care to avoid chronic constipation and cough, and prolonged labour, could also help reduce the risk, as could avoiding the use during delivery of forceps and other instruments, which can damage the pelvic floor.

But if the problem reaches the third stage, surgery might be necessary. “Normally, if a woman is medically fit for anaesthesia, we go ahead with a vaginal hysterectomy,” Bahadur said.

But she added that other factors might make hysterectomy an unviable option. “We have to consider a lot of factors, like whether she has completed her family and would like to retain her menstruation function,” she said.

She noted that there were other surgical options, which involved excising some tissue and reattaching the rest, or using a device to support loose tissue – but added that many women are unable to access these treatments due to poor transport facilities and local health infrastructure.

Amita Jain emphasised the importance of educating young people about pelvic health starting right at the school level. “Young women and girls need to understand this very important part of the body so at the time of pregnancy, they can ask for pelvic floor exercises,” she said, adding that, in India, pelvic floor physiotherapy is a neglected subject.

But even when a woman has the information she needs, she might struggle to follow through on medical recommendations.

When Joshi came back from the Vikasnagar hospital, she had a prescription and clear instructions from the doctors: avoid hard manual labour, like washing clothes or working on the farms. They recommended that if she couldn’t avoid the work, she wear a waistband to support her pelvic floor muscles.

“They advised me to not carry heavy loads and take rest. But can you really rest?” the 45-year-old said, sitting in the backyard of her friend’s house, overlooking rugged Himalayan peaks. Her hands were busy knitting with pink wool. She added that she had, however, reduced the weights of loads she carried.

“How much load do you carry at a time now?” I asked.

“Not a lot. Thirty kilograms,” she said.

“And that’s not a lot?” I said.

“For someone who used to carry over 60 kilograms, it’s nothing,” she replied.

Women of Dehradun's Laccha village. Doctors often hesitate to suggest treatments such as hysterectomies, because women or their families may wish for them to continue menstruating. Photo: Sanna Irshad Mattoo

Her friend Leela Devi agreed – she, too, suffered from pelvic organ prolapse. “You have to do everything in these mountains, babu,” she said, adjusting a bright green spool of wool on her lap.

“We have a major water issue here,” she continued. “We don’t get water in taps. It has to be brought in.” There were several large vessels and cans around the house, which the women filled from a community tap a few hundred metres away. The tap supplied water for about three hours every day, normally between 3 pm and 6 pm, in which the women had to get all the water they needed – for household use, cattle and domestic work. Leela Devi doesn’t know how many trips she has to make every day. “Maybe six or seven? Maybe more?” she said.

According to data from the Indian government’s Har Ghar Jal scheme, 84% of households in Dehradun district have a tap water connection. But Nagthat’s residents say that while they have taps, they have no water.

“Women in these regions spend about 30% time of their day carrying water,” said Bijalwan. He explained that the problem with water affected them in three ways. “First, they have to carry it from far-away places,” he said. “Second, the scarcity makes it difficult for them to maintain personal hygiene, which becomes a source of infection. Third, with already scarce water, the men of the house take precedence in consuming it, and women do not get to drink enough water, which can lead to severe constipation. And when you have constipation, you have higher chances of getting POP.”

The problem can also take a toll on women’s mental health. According to the AIIMS Rishikesh report, 84.44% women “had started to feel bad about their body as a result of prolapse”, which had “even resulted in their depressive and irritable mood”. Their inability to travel, do household chores, and be sexually intimate with their partner compounded their problems, the report found.

I described some symptoms of depression to Leela Devi and Joshi – frequent sad spells, mood swings, an inability to work. Both said they had experienced these after suffering from prolapse. “You keep thinking, ‘What is this? What is happening to me?’ And you can’t even share it with anyone due to shame,” Leela Devi said.

But Joshi explained that for her it wasn’t a problem of embarrassment. “The thing is that men don’t understand,” she said.

Leela Devi nodded. A man’s clothes, hanging on a clothesline over her head, cast a shadow on her face.

“They tell us that it’s no big deal and that we are feigning pain to avoid work,” she said. “It’s a woman’s pain. We suffer every day. How would they understand?”

This reminded me of Kalavati Goswami, who said that her husband forced her to resume work four days after she delivered one of her babies – when she tried to refuse, he beat her up. “If our husbands were better, we won’t be in this condition,” she said.

She wants to get help but doesn’t have the money. “My bladder keeps slipping out of the vagina when I walk,” she said. “But I can’t seek treatment.”

Bijalwan argued that pelvic organ prolapse should be called a “sociobiological” condition. “When we met the women, we found that many of them have almost zero presence in sociocultural activities due to the bad smell, recurrent infections, etc,” he said. “They even fear sitting down because the uterus might come out.”

This was in keeping with the experience of Roshni Devi, a resident of Lacchha village, who started experiencing abdominal pain and heavy bleeding after the birth of her sixth child, around 20 years ago. “I could not stand in anyone’s presence,” she said. “I couldn’t go anywhere. On my son’s wedding, I had to change my clothes three times within three hours. I was too embarrassed to talk to anyone.”

“How did it affect your relationship with your husband?” I asked.

“For a year, it felt like I was lying in a pool of water,” she said. “Nothing happened.”

For many of these women, the risks and complications of pelvic organ prolapse are compounded by the lack of access to good medical care.

“What can you really do about it?” 66-year-old Jullo Devi Chauhan asked me at Laccha village. “Look at these women. So many of them had had the child pulled out of them by force during labour. There’s no doctor, no nurse, no healthcare facility here.”

She was sitting on a wide terrace with around ten other women, most of whom at some point had had pelvic organ prolapse.

“They have built such a nice hospital in Nagthat but there are no doctors,” Chauhan continued. “What to do? We go to them, share our details, request them to bring doctors, and then nothing. Nothing happens. No political leader, no one from the administration ever comes to help. We have been demanding healthcare for years! Those who have the money can get themselves treated elsewhere, but what about us?”

The Nagthat hospital that Chauhan mentioned is run by the Indian Red Cross Society. When I visited in December 2021, I found that the wards lay empty – the only personnel present were three female healthcare workers and a security guard.

It wasn’t always like that. There used to be doctors, the workers said, but hiring hadn’t been carried out in years. “On our own, we can’t take patients,” one worker said, requesting anonymity. “We just do the basic check-up and help those with minor injuries.”

MS Ansari, the general secretary of the Uttarakhand Red Cross Society confirmed over the phone that hiring for the hospital was indeed stopped in 2008. “Actually, the hospital was started by the International Red Cross Society years ago as part of a project,” he said. “But then they stopped funding us. The doctors working there retired and now we don’t have anyone there. We have been trying to revive it, but on our own, we are unable to fund the entire operation.” He added that the society is considering collaborating with another organisation that could potentially fund the hospital. “I understand people are in pain, but we are helpless,” he said.

A representative of the Indian Red Cross Society in New Delhi did not comment on the residents’ health challenges. Replying over email, they said only that the Uttarakhand Red Cross Society is responsible for running the hospital.

A hospital in Nagthat that is not staffed by any doctors. The problems that women in Uttarakhnd's villages face are exacerbated by the lack d by the lack of accessible medical care. Photo: Sanna Irshad Mattoo

Understandably, Chauhan is miffed. “Nobody does anything for us. If it weren’t for Nirmala, many of us would have been dead. She is our god.”

Chauhan was referring to Nirmala Bijalwan, who runs a one-woman healthcare centre of the Himalayan Institute Hospital Trust in the hills of Nagthat. For many women, and even men, in several nearby villages, she is the first and sometimes the only point of contact for medical problems, ranging from fevers to fibroids.

“I live here,” the 38-year-old said, pointing to another room adjacent to her office. “I have been here since 2007.” Her office is filled with dozens of papers, posters and pamphlets about the region’s geography, administration, and the health campaigns she has run.

Every morning, Bijalwan, with a mask across her face and a bag on a shoulder, walks down to the neighbouring villages, talking to women about their health concerns and suggesting treatment. “I don’t have a vehicle. It’s very difficult,” she said.

Bijalwan also faces other kinds of challenges. A few years ago, when a woman from a neighbouring village told her that something was protruding from her vagina, Bijalwan took her to doctors in Dehradun and ensured that she had a surgery. But after that, the woman’s family came to the centre to fight with Bijalwan. “Her husband accosted me and said, ‘How dare you take her to the hospital?’” Bijalwan recounted.

But the treatment had been crucial. “She had been in depression,” Bijalwan said. “It was so bad that she broke down before the doctor. And here, her family was upset because she won’t be able to work for two months after the surgery.

“You have to take such risks. It’s a part of my job.”

We were sitting outside her office in a small patio-like space. It was late in the afternoon by the time Bijalwan finished recounting this story and she had to leave to fetch water. “As a single woman, I can still manage with the scarce water, but what about those with a family?” she said, gathering two vessels and a bucket. “Many people come to the village and make many promises about many different things. The government says they are making development but where is it?”