Menstrual Hygiene Management

Menstruation is a natural process. However, in most parts of the world, it remains a taboo and is rarely talked about (HOUSE et al. 2012).

Many cultures have beliefs, myths and taboos relating to menstruation. Almost always, there are social norms or unwritten rules and practices about managing menstruation and interacting with menstruating women. Some of these are helpful but others have potentially harmful implications. For example, in some cultures, women and girls are told that during their menstrual cycle they should not bathe (or they will become infertile), touch a cow (or it will become infertile), look in a mirror (or it will lose its brightness), or touch a plant (or it will die) (HOUSE et al. 2012).

Cultural norms and religious taboos on menstruation are often compounded by traditional associations with evil spirits, shame and embarrassment surrounding sexual reproduction. For example, in Tanzania, some believe that if a menstrual cloth is seen by others, the owner of the cloth may be cursed (HOUSE et al. 2012).

Most striking is the restricted control which many women and girls have over their mobility and behaviour due to their ‘impurity’ during menstruation, including the myths, misconceptions, superstitions and (cultural and/or religious) taboos concerning menstrual blood and menstrual hygiene (TEN 2007). The figure below details examples of these restrictions in several Asian countries. Similar restrictions are practised in other countries around the world.

Having said this, it is important to recognise the potential for intra-cultural variations in the interpretation of meanings of menstruation, and how ‘taboos’ may in fact serve the interests of women, even if at first glance they appear to be negative. For example, women may appreciate the ‘banishment’ to menstrual huts as they are given a rest period from the normal intensity of daily chores (KIRK & SOMMER 2006).

Remarkable is also that the education by parents concerning reproductive health, sexuality and all related issues is considered almost everywhere as a “no-go” area (TEN 2007). It appears that in much of Asia and Sub-Saharan Africa, girls’ level of knowledge and understanding of puberty, menstruation and reproductive health are very low (KIRK & SOMMER 2006).

The taboo of menstruation helps to inflict indignity upon millions of women and girls, but it also does worse: The grave lack of facilities and appropriate sanitary products can push menstruating girls out of school, temporarily and sometimes permanently (see also water sanitation and gender).

Stigma around menstruation and menstrual hygiene is a violation of several human rights, most importantly of the right to human dignity, but also the right to non-discrimination, equality, bodily integrity, health, privacy and the right to freedom from inhumane and degrading treatment from abuse and violence (WSSCC 2013).

Actually, there is a relation between menstrual hygiene and school drop-out of girls from the higher forms (grade four and five) of primary and secondary education (see also water sanitation and gender). Research confirms that the onset of puberty leads to significant changes in school participation among girls. In spite of the fact that Millennium Development Goal (MDG) 2 (achieve universal primary education) has been accomplished in the lower forms of primary education in many developing countries, the participation of girls, in particular in Africa and Asia, lags far behind the participation of boys in the higher forms of primary and secondary education. Besides the fact that girls are married off at an early age in some cultures, many girls are kept at home when they start menstruating, either permanently (drop-out) or temporarily during the days they menstruate. When girls get left behind this can eventually also lead to school drop-out (TEN 2007).

The monthly menstruation period also creates obstacles for female teachers. They either report themselves sick or go home after lessons as fast as possible and do not have enough time to give extra attention to children who need it. The gender–unfriendly school culture and infrastructure and the lack of adequate menstrual protection alternatives and/or clean, safe and private sanitation facilities for female teachers and girls undermine the right of privacy, resultingin a fundamental infringement of the human rights of female teachers and girls. Consequently, girls and women get left behind and there is no equal opportunity. Due to this obstacle, MDG 3 (promote gender equality and empower women) cannot be achieved either (TEN 2007).

Adapted from HOUSE et al. (2012) and KIRK & SOMMER (2006)

There are also health issues to consider apart from the above-mentioned social issues. Poor protection and inadequate washing facilities may increase susceptibility to infection, with the odour of menstrual blood putting girls at risk of being stigmatised (see also water sanitation and health. In communities where female genital cutting is practiced, multiple health risks exist. Where the vaginal aperture is inadequate for menstrual flow, a blockage and build-up of blood clots is created behind the infibulated area. This can be a cause for protracted and painful period, increased odour, discomfort and the potential for additional infections (KIRK & SOMMER 2006).

It is assumed that the risk of infection (including sexually transmitted infection) is higher than normal during menstruation because the blood coming out of the body creates a pathway for bacteria to travel back into the uterus. Certain practices are more likely to increase the risk of infection (see figure below). Using unclean rags for example, especially if they are inserted into the vagina, can introduce or support the growth of unwanted bacteria that could lead to infection.

As an example, findings from Bangladesh, where 80% of factory workers are women, show that 60% of them were using rags from the factory floor for menstrual cloths. These are highly chemically charged and often freshly dyed. Infections are common, leading to 73% of women missing work for on average six days a month. Women had no safe place either to purchase cloth or pads or to change/dispose of them. When women are paid by piece, those six days away present a huge economic damage to them but also to the business supply chain (WSSCC 2013).

Infrequently mentioned in studies conducted in developing countries are the simple discomforts, such as lower back pain, bloating, cramping, mood swings, and other symptoms related to menstruation that have been well documented in Western literature. Whereas girls in developed countries generally have access to a range of general – and specific – painkillers and other pharmacological products, girls experiencing similar symptoms in sub-Saharan Africa and Asia do not have access to such ‘luxuries’.

Sanitary Protection Materials and Disposal

The choice of sanitary protection is very much a personal decision based on cultural acceptability. It is often influenced by a woman’s or girl’s environment and access to funds, water supply and affordable options. It is critical that any programme aiming to support women or girls with sanitary protection materials involves them in the planning discussions and decisions about the options to be supported (see also deciding with the community and planning with the community).

Disposable sanitary towels are the most frequently used methods of managing menstruation. In resource-poor settings they are often prohibitively expensive, bulky to transport and difficult to dispose of. Many women and adolescent girls from poor families cannot afford to buy these hygienic towels (APHRC 2010). Some girls may even be led to trade sex for small amounts of money in order to purchase sanitary protection materials (KIRK & SOMMER 2006). But sanitary pads reduce the barriers for girls to stay in school, which are multiple: fear of soiling, fear of odour, and even if there are WASH facilities at school, fear of leaving visible blood in the latrine or toilet (WSSCC 2013).

Cloths or cloth pads may be a sustainable sanitary option, but it must be hygienically washed and dried in the sunlight. Sunlight is a natural steriliser and drying the cloth pads on sunlight sterilises them for future use. They also need to be stored in a clean dry place for reuse. Girls who do not know what menstruation is can have little hope of managing it safely or hygienically, as a workshop participant demonstrated when she shared her own experience of growing up in Sierra Leone: “Me and my sisters all hid our sanitary cloths under the bed to dry, out of shame.” Her experience is common worldwide: many participants shared anecdotes from field studies and interviews of girls and women who attempt to dry their cloths out of sight. In practice, this means hiding them in a damp and unhygienic place (UNICEF 2008; WSSCC 2013).

The menstrual cup may be an appropriate new technology for poor women and girls. It is a cup made of medical silicone rubber that is inserted into the vagina to collect menstrual blood. It needs to be removed and emptied less frequently than sanitary pads. That reduces the problems young women face in lacking privacy and facilities to change and dispose of sanitary products in schools and other contexts. This technology may offer a sustainable, practical and cost-effective alternative. It is recommended that when using the menstrual cup one needs to maintain a high standard of hygiene especially during insertion, removal and general cleaning. Although water shortages could present challenges for its use, the amount of water required when using the menstrual cup is minimal compared to other methods (APHRC 2010). Offering menstrual cups can be a social business opportunity for the private sector, as shown by experiences from Kenya (RUBY CUP 2013).

The table below compares the advantages and disadvantages of further sanitary materials (HOUSE et al. 2012).

Advantages and disadvantages of different sanitary protection materials. Adapted from HOUSE et al. (2012)

Sanitary Infrastructure

Adapted from KIRK & SOMMER (2006)

From a very practical perspective, girls who lack adequate sanitary materials may miss school each month during their period (see also water sanitation and gender). If girls attend schools which lack adequate latrines and water supplies to comfortably change sanitary materials and wash themselves in privacy, they may be unable to remain comfortably in class during their menstrual cycle (see also sater sanitation and dignity. The absence of clean and private sanitation facilities that allow for menstrual hygiene may discourage girls from attending school when they menstruate. UNICEF (2005) estimates that about 1 in 10 school-age African girls do not attend school during menstruation or drop out at puberty because of the lack of clean and private sanitation facilities in schools.

Poor sanitary facilities in schools also affect women teachers’ experiences. Given the unavailability of substitute teachers due to teacher shortages all over the developing world, this leads to reduced teachers’ instruction time by 10-20% (WORLD BANK 2005).

Where girls are able or determined to attend school throughout menstruation, insufficient facilities and sanitary protection may nevertheless create discomfort in the classroom and an inability to participate. For example, menstruating girls may hesitate to go up to the front of the class to write on the board, or to stand up as is often required for answering teachers’ questions, due to fear of having an ‘accident’ and staining their uniforms.

To manage menstruation hygienically, it is essential that women and girls have access to water and sanitation (see also access to water and sanitation. They need a safe, private space to change sanitary materials; clean water for washing their hands and used cloths; and facilities for safely disposing used materials or a place to dry them if reusable.

Disposal

Last but not least, good management of menstrual hygiene should obviously include safe and sanitary disposal. This is widely lacking. Where do girls and women dispose of their sanitary products and cloths? Wherever they can do so secretly and easily. In practice, this means the nearest open defecation field, river or garbage dump. This applies to both commercial and home-made sanitary materials (WSSCC 2013). In developing countries, which frequently have poor waste management infrastructure, this type of waste will certainly produce larger problems (see also health risk management). For this reason, encouraging menstrual hygiene in developing countries must be accompanied with calculated waste management strategies (TEN 2007).

Neglecting menstrual hygiene in WASH programmes could also have a negative effect on sustainability. Failing to provide disposal facilities for used sanitary materials can result in blocked latrines becoming blocked and quickly filling pits (HOUSE et al. 2012).

Yet, adequate facilities and sanitary protection materials are only part of the solution. In addition, it is necessary to go beyond the practical issues of menstrual management in schools and workplaces, and to use the vehicle of education. Education and information (in combination with hygiene and sex education) empowers women and girls with factual information about their bodies and how to look after them (KIRK & SOMMER 2006) (for example through invalid link or part of invalid link). Presently, teachers are rarely trained in teaching menstrual hygiene and consequently rarely teach it. Male teachers may feel cultural norms forbid them from discussing such topics with young girls. As a result, MHM is either taught late or not at all (WSSCC 2013).

Empowering women and girls is also necessary so that their voices are heard and their menstrual hygiene needs are taken into account (see also awareness raising). Because a lack of factual information compounded by the prevalence of myths means that girls’ practical needs related to managing menstruation are often not appreciated or appropriately addressed (KIRK & SOMMER 2006) (see also invalid link).

Community wide approaches (see also planning with the community), which specifically involve boys and men, are promising ways of improving MHM. Physical barriers to girls and women because of inadequate sanitary means are often connected to social barriers like taboos and stigmas and need to be considered together.

Another software tool to improve women’s dignity are days off work whilst having their monthly periods. In Zambia, for example, every working woman is entitled by law to one day off work each month to ensure that women function at their best. This day is referred to as „Mother’s day“. Although there are no specifics, it is a silent belief that it was set up to accord a woman a day’s relief whilst having her monthly periods (MYWAGE 2013). A day off work must not mean less economic performance for a business as women may regenerate more energy to outweigh the day off.