Menstruation Matters
Sanitary pads are very hard to buy because the economy is high. Mum cannot give you the money to buy. Not everybody can even get enough money to buy a cotton wool or tissue paper and using a cloth we always fear because it may fall off while with friends.
— Anonymous (15 years old, Kasese, Uganda)
Menstruation is a natural and healthy process, and globally, every day 3-400 million people menstruate. Traditional ways have been developed to manage menstruation, but traditional is not necessarily ideal: using products such as corn cobs or old newspaper, or using practices such as isolating menstruators in ‘menstruation huts’. This has many, inter-related implications for reaching the Sustainable Development Goals.
POVERTY
Menstrual products can be costly, and inaccessible especially to the poor:
- In Kenya, one study found that 10% of 15-year old school girls engage in transactional sex in order to earn money to buy pads[1].
- In some societies, menarche is associated with being ready for marriage, especially for girls from poor households, whereby the financial responsibility for taking care of the girl passes to the husband. While the way menarche is perceived seems to be associated with early marriage, some reports from Zimbabwe and Uganda also suggest that the high cost of dealing with MHM, including buying menstrual products, may also increase the risk of early marriage, as parents want to pass on the expenditure[2].
- In the UK, the government has begun providing free products to address ‘period poverty’, which is seen to keep girls out of class[3].
EDUCATION
Inadequate Menstrual Health Management (MHM) causes girls to miss school. The extent of the problem found varies greatly in different contexts. For example, some research and pilot studies in Uganda indicate:
- Attendance: in Uganda, one study showed that female students miss school on 28% of period-days, in comparison with 7% of non-period days. Findings also highlight that girls’ education was not only influenced by absence from school but also absence from class[4].
- Participation: Another study from Uganda showed that girls participate less in school activities during menstruation. For example, during their period nearly 70% experienced shame and insecurity, and more than half avoided standing in class to answer questions[5].
HEALTH
Inadequate MHM also poses health risks, e.g. greater risk of sexually transmitted infections such as HIV. For example:
- A review of 81 studies from Low and Middle Income countries showed that girls were so ashamed by menstruation that they did not dare seek medical care and instead engaged in self-medication[6].
- A study from Kenya found that prevalence of sexually transmitted infections was lower amongst girls who received free MHM products than those who did not, supporting the theory that girls engaged in transactional sex to buy MHM products. Girls who were provided with menstrual cups had lower rates of yeast infections than those who received disposable pads, supporting the theory that they washed and reused the pads before they were dry [7].
GENDER AND AGENCY
There is strong evidence that menstruators have strong feelings of shame and fear related to MHM. One review of 81 studies from low-and middle-income countries found consistent evidence that girls lack knowledge of menstruation before reaching menarche although levels vary. When they are menstruating, they feel ashamed, afraid, socially restricted, and that their mobility is reduced (e.g. they cannot ride a bike). They feel ashamed to visit the doctor for medical problems if they are menstruating[8].
REFUGEES and DISPLACED
Key groups such as the displaced face unique challenges with regard to MHM. Challenges vary in short-term response to something like an earthquake in Nepal as opposed to longer term settings, such as in Uganda, where refugees have lived in settlements for 10-20 years. Humanitarian agencies may provide MHM products only for 3-6 months, after which menstruators are expected to go back to ‘usual practice’[9]. For example:
- In the Nakivale refugee settlement in Uganda, 78% of menstruating girls had access to disposable pads, but only for an average of six months after they arrived. Pads were sometimes shared with other female family members, reflecting insufficient supply.[10]
- In the Imvepi refugee settlement in Uganda, where CARE and WoMena have been working together, Harriet, a trainer of trainees, notes that “some women will sell their (food) rations but you can only get about 4 USD from that. You then spend 1.4 USD of that on pads alone and now you only have 2.6 USD left. You are also now hungry because you have sold all your food.[11]”
[1] Phillips-Howard, P.A., Otieno, G., Burmen, B., Otieno, F., Odongo, F., Odour, C., Nyothach, E., Amek, N., Zielinski-Gutierrez, E., Odhiambo, F. and Zeh, C., 2015. Menstrual needs and associations with sexual and reproductive risks in rural Kenyan females: a cross-sectional behavioral survey linked with HIV prevalence. Journal of women’s health, 24(10), pp.801-811.
[2] Tellier S, Hyttel M, WoMena.2018. Menstrual Health Management in East and Southern Africa Region – a Review Paper. Johannesburg: UNFPA. Available from: https://womena.dk/wp-content/uploads/2018/06/UNFPA-Review-Menstrual-Health-Management-Final-04-June-2018.pdf
[3] George,A. 2019. ‘Girls are still missing school because of period poverty. There is an answer’, The Guardian, 8 Jan. Available from: https://www.theguardian.com/commentisfree/2019/jan/08/girls-school-period-poverty-scotland-free-menstrual-products-england-campaign
[4] Miiro, G., Rutakumwa, R., Nakiyingi-Miiro, J., Nakuya, K., Musoke, S., Namakula, J., Francis, S., Torondel, B., Gibson, L.J., Ross, D.A. and Weiss, H.A., 2018. Menstrual health and school absenteeism among adolescent girls in Uganda (MENISCUS): a feasibility study. BMC women’s health, 18(1), p.4.
[5] Hennegan, J., Dolan, C., Wu, M., Scott, L. and Montgomery, P., 2016. Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda. BMJ open, 6(12), p.e012596.
[6] Chandra-Mouli, V. and Patel, S.V., 2017. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low-and middle-income countries. Reproductive health, 14(1), p.30.
[7] Phillips-Howard, P.A., Otieno, G., Burmen, B., Otieno, F., Odongo, F., Odour, C., Nyothach, E., Amek, N., Zielinski-Gutierrez, E., Odhiambo, F. and Zeh, C., 2015. Menstrual needs and associations with sexual and reproductive risks in rural Kenyan females: a cross-sectional behavioral survey linked with HIV prevalence. Journal of women’s health, 24(10), pp.801-811.
[8] Chandra-Mouli, V. and Patel, S.V., 2017. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low-and middle-income countries. Reproductive health, 14(1), p.30.
[9] Parker, A.H., Smith, J.A., Verdemato, T., Cooke, J., Webster, J. and Carter, R.C., 2014. Menstrual management: a neglected aspect of hygiene interventions. Disaster Prevention and Management.
[10] Ivanova, O., Rai, M., Mlahagwa, W., Tumuhairwe, J., Bakuli, A., Nyakato, V.N. and Kemigisha, E., 2019. A cross-sectional mixed-methods study of sexual and reproductive health knowledge, experiences and access to services among refugee adolescent girls in the Nakivale refugee settlement, Uganda. Reproductive health, 16(1), p.35.
[11] CARE International and WoMena Uganda., 2018. Ruby Cups: Girls in Imvepi Refugee Settlement Taking Control. Available from: https://womena.dk/wp-content/uploads/2018/12/Ruby-Cups-Girls-in-Imvepi-Refugee-Settlement-Taking-Control-03.12.18-Final-report.pdf
Use these facts to start a conversation about menstruation.
“I hate menstruation because I have to miss school during those days and I love my school. There are no facilities where I can change and dispose menstrual waste which is why my mother always makes me stay home.”
— Kishori (Bettiah, India)
The Good News
1. Sustainable solutions to menstrual management such as menstrual cups are proving to be successful for young women in Uganda; the majority of a pilot study group found Ruby Cup to be an acceptable alternative to what they currently use.
2. Girls reported feeling more ‘happy and comfortable’ whilst menstruating after using reusable sanitary pads and learning about menstrual health at school.
3. A Ghanian study found that girls’ attendance increased substantially after receiving free sanitary pads and puberty education.
4. Many NGOs & social businesses are making enormous progress on delivering menstrual health education, like designing fun and games-based curricula that engages both boys and girls.
References: 1) Tellier M, Hyttel M, Gad M (2012). Pilot study report, WoMena Ltd: Assessing acceptability and hygienic safety of menstrual cups as menstrual management method for vulnerable young women in Uganda Red Cross Society’s LifePlanning Skills Project. Kampala, Uganda. 2) Irise International (2012) INSPIRES : INvestigating a reusable Sanitary Pad Intervention in a Rural Educational Setting Pilot Study : Evaluating the acceptability and short [online]. Available from: http:// eprints.whiterose.ac.uk/43906/. 3) Montgomery et al., Sanitary Pad Interventions for Girls’ Education in Ghana, 2012. 4) See www.menstrualhygieneday.org/partner
Reasons to use a menstrual cup
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- Economy — Menstrual cups can last up to 10 years. However, some brands recommend to replace menstrual cups each year. The initial cost for a cup is higher than for traditional hygiene device, but the cost is absorbed with each consecutive use.
- Environmental consciousness — With reusable cups, only menstrual blood is disposed of and there is nothing to be thrown away, which contributes to less landfill. The cotton used for most major brands of tampons and pads is also bleached, which is seen as harmful to the environment and leaves traces of dioxin in the cotton, which may be a carcinogen. As well, cotton itself is a very environmentally destructive crop as it uses more chemicals per acre than almost any other crop, as well as vast quantities of water.
- Portability — When traveling, the user can choose to carry only a single reusable menstrual cup, rather than multiple pads or tampons. However, some menstrual cup users use a form of back-up protection, such as pads, in addition to their cup.
- Comfort — As the menstrual cup is worn entirely within the body, it avoids the bulky or damp feeling of pads. It avoids the string of tampons, which may get wet after urination. Additionally, cups avoid the issue of over-absorption and dryness that tampons may cause. Cups can be worn before menstruation begins, which may appeal to women with irregular cycles.
- Convenience — Menstrual cups can hold more liquid than tampons for heavy flow, which may allow less frequent trips to the bathroom
The SDGs
