"KNOWLEDGE REGARDING CAUSATIVE FACTORS OF UTERINE PROLAPSE

AMONG 20 – 60YEARS OF MARRIED WOMEN AT BHUTANESE REFUGEE CAMP, DAMAK”

A RESEARCH PROPOSAL SUBMITTED FOR

THE PARTIAL FULFILLMENT OF REQUIREMANT FOR

POST BASIC BACHELOR IN NURSING

BY

DEEPIKA BHATTARAI

TO

DEPARTMENT OF NURSING

ASIAN COLLEGE OF ADVANCE STUDIES

SATDOBATO, LALITPUR

(AFFILIATED TO PURBANCHAL UNIVERSITY)

2067B.S (2010 AD)

TABLE OF CONTENTS
 CHAPTER I: PAGE NO.
INTRODUCTION: -
1.1 BACKGROUND OF THE STUDY……………………………………………..1-2

1.2 RATIONAL AND JUSTIFICATION……………………………………………………….2

1.3OBJECTIVES OF THE RESEARCH STUDY……………………………………………3

1.3.1 General objective………………………………………………………………………..

1.3.2 Specific objective………………………………………………………………………..

1.4 VARIABLES OF THE STUDY………………………………………………………………3

1.4.1 Independent variables…………………………………………………………………

1.4.2 Dependent variables…………………………………………………………………….

1.5 CONCEPTUAL FRAMEWORK…………………………………………………………….4

1.6 OPERATIONAL DEFINITION……………………………………………………………4-5

1.7 RESEARCH QUESTIONS…………………………………………………………………...5

1.8 SIGNIFICANT OF THE STUDY……………………………………………………………..5

1.9 LIMITATION OF THE STUDY………………………………………………………………6

Chapter II
REVIEW OF LITERATURE
2.1 LITERATURE REVIEW RELATED TO STUDY VARIABLES………………….7-10

2.2 SUMMARY OF THE LITERATURE REVIEW………………………………………10

CHAPTER 3:
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RESEARCH METHODOLOGY:
3.1 RESEARCH DESIGN……………………………………………………………..11

3.2 POPULATION OF THE STUDY……………………………………………….11

3.3 STUDY AREA……………………………………………………………………….11

3.4 SAMPLE SIZE……………………………………………………………………….11

3.5 SAMPLING TECHNIQUE……………………………………………………….11

3.6 INCLUSIVE CRITERIA……………………………………………………………11

3.7 PRE-TESTING OF THE INSTRUMENT……………………………………..12

3.8 METHOD OF DATA COLLECTION………………………………………….12

3.9 DATA COLLECTION TOOL………………………………………………..……12

3.10 DEVELOPMENT OF INSTRUMENT……………………………………….12

3.11 VALIDITY AND RELIABILITY…………………………………………………12

3.12 ETHICAL CONSIDERATION…………………………………………………12-13

3.13 BUDGET……………………………………………………………………………..13

3.14 MEASURE TO REDUCE BIAS IN THE STUDY………………………….13

3.15 DATA ANALYSIS………………………………………………………………….13

CHAPTER-I

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INTRODUCTION
1.1 Background of the study:

Nepal is a developing country with marginal living standard political instability, low
education, and low productivity in most of the sectors leading to insufficiency fulfilled
basic needs of the people. The health care need of the people is increasing with
increasing total number of population 28,809,526 – source (2008- World Bank, world
development indicators) but the health personnel and health centers are limited only in
urban area. Every people can’t take health services easily.

Approximately, 90% of the population sectors and more than 80% of the total industrial
materials depend on forestry products. Political instability, increasing unemployment,
increasing population, lack of awareness and impact of western culture also influence on
economic status. Socio-economic status comprises not only income but also education,
balance diet, the status of women and other factors as well. All these socio-economic
and cultural factors directly or indirectly influenced to women’s health depend
economically on the agriculture.

The health situation of Nepali women leaves much to be desired. Women's health, and in
particular their reproductive health, is severely affected by their low familial and social
status, patriarchal perspectives, traditional values, illiteracy, poverty, etc. Among the
health problems faced by women related to reproductive health, Uterine Prolapse is a
complex condition that is often kept in secret because of the shame of the condition
affecting a sensitive part of the woman’s body. Many women fear condemnation from
their communities and families and until today, discussion and debate surrounding the
disease does not openly occur within the family and society. Women who suffer from
Uterine Prolapse continue to remain silent on the matter.

Most of societies have patriarchal family. Almost all decision- making power is on man’s
hand. So every family gives more value to the male person and neglect female baby. In
Nepal, culture from childhood period, daughter must do extra work than same age of
boy in that family. But they can’t get more nutritious food. Women eat at last after every
male member eaten. From childhood period to aging they must perform household and
fieldwork. Due to more exhaustion, lack of nutritious food, rest, low female literacy rate
(42.8% according to 2001 census) can occur lots of health problems. Among these
health problems, reproductive problem is the major problems.

It is well known that, Bhutanese refugees are originally from Bhutan, due to some
political conflict they become Refugee from 1991, they are residing in seven different
refugee camp located in Jhapa and Morang. Among them 6 camps (Beldangi, ii, ii
extension, Goldhap, Timai, Khudunabari) are located in jhapa where as Sanischare camp
is in Morang.

Total populations of this Bhutanese refugee is 81,701 in which male are 41,554 and
female are 40,147 among them 16,340 (20%) are of reproductive age(15-49 years).Out
of which approximately 18,000 population are living in Beldangi II, which is my research
center.

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1.2 Rational and justification of the study:-

Uterine prolapsed is a very common morbid condition in Nepal among women during
reproductive age So that good management in labour and pueperium, delivered by
trained skilled personnel, nutritious diet, birth spacing, treatment of chronic disease can
prevent uterine Prolapse.

The incidence of UP is difficult to determine as many women does not seek medical
advise. The recent studies shown that 1:10 women of reproductive age is suffering from
uterine prolapsed (National strategy of uterine prolapse 2007)

Uterine Prolapsed is not only gynecological problem but also a major social and maternal
problem found in Nepal. Occupation, education, age of marriage, age of first pregnancy
helps to identify the cause of uterine Prolapse. Having this condition also predisposed the
women to STI, HIV, /AIDS due to open decubitus ulcer. Prevention is better than cure.
Thus this small-scale study will help to know the status of married women(20-60 years)
of Bhutanese refugee camp ,Damak and suggest some intervention to identify the cause
of uterine Prolapse.

Uterine prolapsed impairs the quality of life of women in Nepal and has been largely
neglected at each level starting from family, individual to the policy.

It is the clear indicator of women and gender based violence (GBV) and failure to ensure
human rights of women by the states. The ICPD plan of action has recognized the
reproductive rights as well as women empowerments and gender equality. In the context
of Nepal the government has initiated free operative surgeries to the women with uterine
prolapsed.

Taking about Bhutanese refugee, they reside in the huts that are made up of bamboo.
They have to stay in very congested area in each hut there are about 8-9 people living.
In this camp there is a regulation of early marriage, multi-parity, early pregnancy and
improper and inadequate rest in pueperium for daily wedges.

So with this all circumstances the refugee camp could be the best place to have research
on the uterine prolapse.

By knowing the causative factors of uterine prolapse it helps to prevent and manage in
time .So knowledge of uterine prolapse is important to prevent, control and treat the
patient in time.

1.3 objective of the study

1.3.1 The general objective

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  To assess the knowledge regarding causative factors of uterine prolapsed
among 20-60years married women.

1.3.2 The specific objective

TO;
 Find out the knowledge of causative factors of uterine prolapsed.

 Explore the socio-demographic characteristics of respondents.

 Find out the type of delivery.

 Find out the age of marriage.

 Identify the age during 1st delivery.

 Find out the place of last delivery.

1.4 variables of the study

1.5.1 Independent variables:

 Age

 Religion

 Ethnicity

 Economic status

- Occupation

 Education

 Number of children

 Age of first delivery

 Birthing place of last delivery

 Types of last delivery

1.5.2 Dependent variables:

 Knowledge of causative factors Uterine Prolapsed

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1.6 conceptual Framework:
 Age

 Religion
Source of information
 ethnicity
-Health education
given by health staffs.  Occupation
-Radio
 Education
-Television
 Family support
-Newspaper
 No of children.

Knowledge of causative
factors of uterine prolapsed

1.7 Operational Definition

Uterine Prolapse:-

Uterine Prolapse means - uterus protrudes through the pelvic floor operation
genital hiatus. OR

Uterine prolapse is the descent of the uterus through the vagina due to
stretching or weakling of the transverse cervical ligaments.

Terms which were used in this study have different meaning elsewhere but in
this study the terms given below means as follows:

Protrude: - Extension beyond the usual limits, or coming outside

Descends: - Go downward from its normal position

Menopause: - Cessation of menstruation

Chronic cough: - Cough occurring more than 1 month

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Prolapse: The falling down, or downward displacement, of a part or viscous.

Herniation: Abnormal protrusion of an organ or other body structure through a defect

or natural opening in a covering, membrane, muscles or bone.

Obesity: - overweight according to body mass index

Knowledge: The knowledge of causative factors of uterine prolapse will be measure on

the question No.18

If the respondent can mark

0 Option =no knowledge

1-2 option= some knowledge

3-4 option=moderate knowledge

>4 option= Good knowledge.

Literate: - who can read and write.

Illiterate: - who cannot read and write.

Education: Clients were able or not to read or write.

Reproductive age: Female whose reproductive organ is anatomically and functionally

developed. Age between 15-49years.

Information source: radio, television, newspaper etc.

1.8 Research questions

 What are of knowledge regarding the causative factors of uterine Prolapse among 20-
60years married women at Bhutanese Refugee camp,Damak?

1.9 significance of study

This study help to give knowledge regarding causative factors of Uterine Prolapse and
make people aware about uterine Prolapse; It help to find out and analysis existing
situation of 20-60 years married women of Bhutanese refugee camp,Damak and help
other researcher to take this book as reference and compare the fact of present and
past.

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1.9 limitation of the study

There may be bias in generalization because of limited sample size taken and
convenience of study area and geographical location choose. The accuracy of the
information would depend upon the willingness of the respondents to reply

Only married women of age between 20-60years are taken.

The information for this study is based on Bhutanese refugee camp (Beldangi ii) Damak.

This study will be conducted for 5 weeks.

Sample size is 100 populations.

Descriptive study based in questionnaire and face to face interview.

Researcher self sponsoring this research.

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 CHAPTER II

2.1 LITERATURE REVIEW:-

A uterine prolapsed is a very common morbid condition in women. It is most common in

reproductive age and after menopausal age. Uterine prolapsed means the uterus
protrudes through the pelvic floor. It is also called genital hiatus or genital prolapsed.

Reproductive age and after menopause due to mismanagement in labor and pueperium
period. Usually vaginal delivery increases the risk of this problem. Uterine prolapsed
most often occur in multiparous women due to injuries to the muscles and fascia of the
pelvic floor. Women without any children may also have this problem due to obesity,
ascitis, uterine or ovarian tumors, chronic coughing and constipation etc. uterine
prolapsed usually develops gradually, suggesting that the effect of aging play a major
role. Due to reduce some connective tissue support then vaginal wall relaxed and more
chances to herniate the uterus.

The global prevalence of genital Prolapse is estimated to be 2–20% in women under age
45 years. Genital Prolapse is mainly due to insufficiency of the pelvic floor and consists
of a Herniation of an adjacent pelvic organ into the vagina. More than 1 million of Nepali
women suffer from uterine Prolapse, and the majority of these patients are of
reproductive age. Cited by “Unveiling the veil” by the Center for Agro-Ecology and
development (CAED 2007 march 1).

Among 2,268 women in Siraha and Saptari Districts in Nepal, 37% of women have
uterine Prolapse. Another report from Nepal revealed that 40% of women with uterine
Prolapse are of reproductive age having given birth to their first child (RH morbidity
conducted in FWD of Nepal).

UNFPA reveal that there are more than six-hundred thousand women affected by the
disease, out of which two hundred thousand require immediate treatment. Uterine
Prolapse is widespread across the country and has affected women in the mountains,
hills, plains and the valleys of Nepal. In addition, Uterine Prolapse makes no distinction
between young and old women, and women as old as eighty have been found to be
among the sufferers. In a study of admitted gynecological cases in TUTH in the period
from April 1993 to 2000, 12-17% of cases were genital prolapse.

In Nepal, uterine Prolapse appears to be widespread, but little published evidence exists.
“Bonetti et al” examined 2,072 women in West Nepal and detected that one in four of
these women had genital Prolapse. The most commonly perceived cause of Prolapse is
lifting heavy loads, including in the postpartum period. Most reports describe heavy

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household and farm working during pregnancy, as well as pre- and post delivery, as the
main causes and risk factors for this problem in Nepal.

The pregnancy is not uncommon in 1 st degree uterine prolapse with cystocele rectocele.
Pregnancy is however unlikely where the cervix remains outside the introitus and
continuation of pregnancy, cited by Dutta DC (1997).

In the total number of gynecological problem, the uterine prolapse rate is high than
other gynecological problem due to low female literacy rate (42.81%) high fertility rate
(3.1) and delivered by trained personnel rate is low(29.7%) according to 2006/2007
annual reports.

Degree of uterine prolapse

I) 1st Degree: - The cervix and the uterus body descends but remain within the
vagina.

II) 2nd Degree: - Cervix can be seen outside the introitus but the body of the
uterus still lies within the vagina.

III) 3rd Degree:- The uterus lies almost completely outside the introitus the vagina
is completely inverted.

Cited by, DUTTA D.C (4th edition)

Cause of uterine prolapse

i) Perineal tear during delivery.

ii) Multiparous women.

iii) Delivered by untrained personnel.

iv) Lack of nutritious diet in post-natal period.

v) Lifting of heavy load and doing vigorous type of exercise in pueperium.

vi) Pregnancy in quick succession.

Sign and symptoms of uterine prolapse

i) Feeling of something coming out per vagina.

ii) Backache or dragging pain in pelvis.

iii) White vaginal discharge.

iv) Difficulty in walking

v) Frequency of micturaton.

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 Management

CONSERVATIVE PROCEDURE

-Reposition and pessary application to reduce edema and reduce the venous
congestion which in turn heals the decubitus ulcer.

-Pelvic floor exercise like Kegel’s.

-Improvement of nutrition.

SURGERY

-vaginal hysterectomy with pelvic floor repair.

-Total abdominal hysterectomy.

Cited by (ELSEVIER comprehensive guide to PGMEE-4th volume)

Fact sheet about Uterine Prolapse

Uterine Prolapse is a disease that affects the reproductive health of women.

 At present, 6, 00,000 women are affected by the disease; and among them 2,
00,000 require immediate treatment (WHO, UNFPA & TU Teaching Hospital). A
2004 study of field-based health camps in 10 districts of Nepal conducted by the
Safe Motherhood Network revealed the following statistics about women afflicted
by Uterine Prolapse:
 Among the 415 patients who came for health check-ups, 70 percent represented
women from the hilly region and 30 percent represented women from the plains;

 Fifty-eight percent were Brahmin/Chettris, while the rest were from indigenous
groups and Dalits; ·Although the disease is usually detected among Nepali women
aged 25 to 50 years,  the study found that a 16 year-old girl and 80 year old
woman were also among the patients;

 86 percent of the women were already married by the age of nineteen and among
these women, 31 percent were women between the ages of 20 and 24 and 19
percent were women between the ages of 15 and 19;

 Ninety-five percent of the women had carried large and heavy loads within 45
days of child birth;  

 Sixty-one percent of the women had between three and five children;

 Among the women who visited the health camps, 40 percent had one child while
22 percent had two children;

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  Among the 2900 women who went through a health check-up, 10 percent were
affected by the disease; (Medical Study Institution, 2006)

 Uterine Prolapse was more prevalent among women who were deprived of
general health services;

 Generally Uterine Prolapse occurred because of a lack of nutritious food,

appropriate rest, and health services and care; and

Lack of health education was also one factor for the cause of uterine Prolapse.

2.2 summary of the literature review:-

All these studies and literature were use by the investigator in developing concept and
nature of the present study. Most of these literature describes the uterine Prolapse is the
common genital Prolapse. The studies highlights the mother need to be educated on the
women’s health about the proper exercise of the pelvic floor muscles, rest during
pueperium period, avoid lifting heavy load, birth spacing, discourage early marriage and
early pregnancy, and health education on treatment of disease associated with
reproductive health.

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 CHAPTER III

3: Research Design and methodology:

This chapter includes the research methodology and procedure, which is the most
important part in the research. This chapter includes the details of methodology selected
for this study. It includes the research design, area of study, and population of study,
sample of the study, inclusive criteria, variables, and data gathering tools, data
collection procedure and ethical consideration.

3.1 Research design

The study was carried out by using small scale descriptive research design.

3.2 population of the study

The study populations were 20-60 years married women of Bhutanese refugee camp,
Damak.

3.3 Area of study

The study was carry out in Bhutanese Refugee camp (Beldangi II), Damak.

3.4 sample size

The sample size was 100 populations.

3.5 sampling technique

Non-probability, purposive sampling technique was adopted for the study.

3.6 Inclusive Criteria

The clients who were willing to participate in the study.

Married women of age between 20-60years were taken.

Women of Beldangi-ii were only included.

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3.7 Pre-testing of the instrument

Before actual data collection the instrument was pre-tested of 10% of the sample size
among married women of Bhutanese Refugee camp (Beldangi II, Extansion) Damak.

Data collected from the pre-test is not included in the study report and some require
modification were done in actual data collection questionnaires after pre-test. After
consult with research guide.

3.8 Method of Data collection

 Formal permission letter was taken from the college.

 Informal Verbal consent was taken from CMO (camp medical officer) of Beldangi II,
PHCP.

 Field visit was done to collect the data.

 10-20 cases were visited each day.

 Each case was interviewed individually with the structured questionnaire.

3.9 Data collection tool

Structured Questionnaire was used as data collection tool.

3.10 Development of instrument:-

Close-ended questionnaire was developed in three categories:

a. Demographic data of respondent.

b. Obstetric history of the respondent.

c. Knowledge on uterine prolapse of respondent.

3.11 Validity and reliability of tools:-

The content validity was done through the review of literature, expertise opinion taken
from the subject teacher and other teachers.

3.12 Ethical consideration

 Ethical approval letter was taken from collage.

 Informal verbal consent was taken from CMO of Beldangi II, PHCP.

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 Confidentiality was maintained.

 The Respondent were not forced to participate in the interview.

3.13 Budget

The research was conducted on self finance.

3.14 Measure to reduce bias in the study

There was no any discrimination in ethnicity, religion, educational status, occupation of

the respondents.

Close-ended questionnaire was used to take interview.

Respondents were not forced to participate in the study.

3.15 Data analysis

 Filled up question was checked on the spot.

 Collected information was edited with coding manually soon after the interview to
facilitate further work.

 Standard general statistical method such as percentage were applied in computer.

 Analysis was prepared by pie chart, bar graph and tabulation.

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