Menstrual Hygiene Among Adolescent Girls in Developing Countries: An Issue of Education and Access

Presented by Heather Jordan and Janna Knight April 14, 2009 CHSC 614, Tulane SPHTM

Outline
• • • • • • Social-Ecological Framework Scope – hygiene, absenteeism Important studies/data Biases and gaps in the literature Legislation/policy issues Advantages/disadvantages of products • Interventions

Social Ecological Framework
• Research and interventions around water/sanitation leave out menstruation Public Policy Community Institutional Factors Interpersonal • Lack of latrines in Schools • Sex ed after menarche Intrapersonal • Mothers don’t talk about menstruation before the fact • Men in family don’t want to see menstrual rags • Social construction of “shame” around menstruation • Separation during menstruation

• Poverty • Rural vs. urban • Education

Menstrual Hygiene
 Menstrual hygiene:  bacterial vaginosis (BV)  reproductive tract infections (RTI)  Toxic Shock Syndrome  odor  stains on clothes  important for girls’ selfesteem
Dasgupta & Sarkar, 2008 Photo, Lakshimi Murthy/Vikalpdesign

Absenteeism from School
“Of the 113 million children currently not enrolled in school, 60% are girls.” (Water Aid and Tearfund as cited by Bharadwai et al, 2004)  When girls miss a few days every month due to menstruation, the lost class time compounds and often leads to drop-out. FAWE names menstruation as the most important factor associated with school-drop among girls. A combination of poverty, cultural traditions and taboos in relation to menstruation are cited as causes.
EEPA, 2007

Why do girls stay home from school?
General Reasons:

   

high school fees household chores sexual harassment pregnancy

Menstrual-related Reasons:

 lack of latrines  lack of water  cultural restrictions on menstruating women  embarassment
UNICEF, 2001

A School Latrine in Malawi

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www.concernuniversal.org

Menstrual Myths and Taboos
Saudi Arabia  Bathing with cold water will prolong the bleeding (El-Gilany
et al, 2005)

 Menstruating women must refrain from eating eggs and chicken (Moawed, 2001) India  Hindu women are not supposed to cook or worship at a temple while menstruating (Bharadwai et al, 2004)  Menstruating women are not supposed to touch others’ food or have sex. Sanitary pads are usually set to dry in a “dark corner” so that men can not see them. (Murthy, 2000) In Islam  Muslim women are not supposed to pray, fast, touch a Koran or have sex (Bharadwai, 2004)

Menstrual Myths and Taboos
In Africa
Uganda  Menstruating women are not allowed to drink milk because of the belief that it will affect the cow’s ability to produce milk  Menstruating women are not allowed to plant certain crops Southern Africa  Menstrual blood can be used in witchcraft  Menstrual blood can affect the fertility of men, cattle and crops

The Gambia
Context: Women in sub-Saharan Africa have higher rates of BV than women in industrialized nations: 37% the Gambia 51% Uganda 52% South Africa 24% Tanzania 11% the United States 5% Italy
Morison, L., et al. “Bacterial vaginosis in relation to menstrual cycle, menstrual protection method, and sexual intercourse in rural Gambian women.” MRC Tropical Epidemiology Group, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. 81(3):242-7: 2005.

Hypothesis: The use of modern, disposable menstrual protection should lower the prevalence of BV. Method: Gambian women were taught to take their own vaginal swabs during menstruation. The swabs were tested for BV. The women alternated months using traditional cloth and disposable pads provided by the study team. The women served as their own controls. Results: “Our data do not support hypotheses that menstrual hygiene materials might explain the high prevalences of BV found in sub-Saharan Africa compared to industrialised countries.” The study team suggests further study on the role of hormones in BV is

Egypt
El-Gilany, A., Badawi, K., & El-Fedawy, S. (2005). Menstrual Hygiene among Adolescent Schoolgirls in Mansoura, Egypt. Reproductive Health Matters, 13(26), 147-152.

 Pop. and Method: 664 secondary school girls from various schools/regions, 14-18 yrs. Self-administered questionnaire.  Some Findings: Sanitary pads: 66.8% disposable, 15.9% re-usable cloth 6.7% changed pads at school 97% said they had no privacy at school for hygienic care Sources of information: 92.2% mass media 92.2% mother, 45% older sisters 18.1% school  Recommendations: Comprehensive health ed in schools, more info for girls about hygiene and bathing during menstruation. Use mass media and NGOs. Make sanitary more

Saudi Arabia
Moawed, S. (2001). Indigenous Practices of Saudi Girls in Riyadh During Their Menstrual Period. Eastern Mediterranean Health Journal, 7(1-2), 197-203.

 Pop. and Methods: 600 Saudi girls from outpatient clinics, 11-18 yrs. Interviews and questionnaires.  Findings:  Absenteeism – 61.7% did not attend school or work during menstruation  80.5% believed menstrual blood to be “unclean and unnecessary”  62.3% abstained from bathing  43.7% had NO information about menstruation before menarche  Other issues: self-prescription of medication, avoidance of protein and vitamin-C rich foods Recommendations: More and better health education for girls and women.

Bias in the Literature
 “After 3 years…the practice of using ready-made pads increased significantly from 5% to 25% and reuse of cloth declined from 85% to 57%. The trend analysis showed that adolescent girls perceived a positive change in their behavior and level of awareness.” (Dongre et al, 2007)  “Modern methods of menstrual hygiene protection…were not associated with a lower frequency of BV relative to traditional methods, supplying no evidence for the hypothesis that traditional methods of menstrual hygiene could explain the high prevalence of BV observed in sub-Saharan Africa.” (Morison et al, 2005)  From: Menstrual Hygiene: How Hygienic is the Adolescent Girl? “This study shows that majority of the girls preferred cloth pieces rather than sanitary pads as menstrual absorbent. Only 11.25% girls used sanitary pads during menstruation. Apparently, poverty, high cost of disposable sanitary pads and to some extent ignorance dissuaded the study population from using the

Gaps in the Literature
 Despite bias against cloth pads, there is no evidence they are less sanitary than disposable pads.  Most information came from reports by the EEPA and UNICEF. There were very few academic studies addressing menstruation as a health issue related to girls in education.  Just one academic report on the “Protecting Futures” intervention; no academic studies were found on the efficacy of smaller, grass-roots interventions.  Several studies have neglected to consider the effects of:  poor hygiene practices  limited access to clean water  the impact of cultural taboos

Legislation and Policy
“Overall the absence of MHM in the policy debate and hence in investments and action, is striking. This, points to a glaring need to highlight this issue in the policy debate together with practical work on what adolescent girls and women require to manage their menstrual needs in terms of materials, education and facilities for management and disposal.” – Bharadwaj, S., and Patkar, A., 2004 “…responding to menstrual hygiene needs has received limited attention in the water and sanitation (WatSan) sector, in terms of research and interventions. It has been relatively ignored in emergency relief and, perhaps more so, in development.” – Cooke, J.,
2006

What do girls and women use?

Reusable Cloth Pads
Advantages: • Reusable • Sustainable • Affordable for most, especially when hand-made

Reusable Cloth Pads
Disadvantages: • Must be washed with soap and water, not always easily accessible • If not washed and dried correctly, can cause infections
Juntunen et al, 2000 EEPA, 2007

Disposable Pads
Advantages:  More convenient than cloth  They don’t have to be washed

Disposable Pads
Disadvantages:  Not environmentally or economically sustainable  Often taxed as luxury products in the developing world- not affordable

EEPA, 2007

Disposable Tampons
Advantages:  Give women increased mobility (swimming)
Disadvantages:  Not environmentally or economically sustainable  Often taxed as luxury products in the developing world- or not sold at all  Can put women at risk for infections  Not appropriate for all

Reusable Menstrual Cups:
The Keeper, The Diva Cup, The Moon Cup, Advantages: Lunette,

 Reusable  Similar benefits of a tampon: increased mobility  Cost effective: less expensive than disposable pads or tampons at the end of the year. www.divacup.com

Reusable Menstrual Cups
Disadvantages:  High initial investment: price $ 20 – 40  Not appropriate for all cultures  Not appropriate for the developing world, Why?

EEPA, 2007 www.divacup.com

The Protecting Futures In 2007, Proctor&Gamble began a largeIntervention
scale intervention in several African countries called “Protecting Futures” to combat school absenteeism due to menstrual issues. The intervention includes:

 the donation of millions of sanitary pads to African students  the building of latrines in partner schools  the building of water systems in partner schools  education for students about menstruation http://

Callister, 2008

he Protecting Futures Intervention
Criticism of Protecting Futures:

Praise for Protecting Futures:

New York Times, 2007 Callister, 2008

he Protecting Futures Intervention
Criticism of Protecting Futures:

Praise for Protecting Futures:  UN Global Leadership Award, 2007 Partnerships with UNICEF and FAWE legitimize P&G’s plan  Data supports P&G’s efforts to improve menstrual education, latrines and water access at schools

New York Times, 2007 Callister, 2008

he Protecting Futures Intervention
Criticism of Protecting Futures:  Data does not support use of disposable pads over cloth use.  How will students afford the pads once they graduate?  What will the students do with all the waste?  Is an intervention spearheaded by a for-profit company in the best interest of African girls and women?

Praise for Protecting Futures:  UN Global Leadership Award, 2007  Partnerships with UNICEF and FAWE legitimize P&G’s plan  Data supports P&G’s efforts to improve menstrual education, latrines and water access at schools

New York Times, 2007

An Alternative Intervention: Lakshmi Murthy in Rajasthan,In 2000, MacArthur Fellow India
Lakshmi Murthy began an intervention to teach adolescent girls to make their own sanitary pads.

Cooke, 2006 www.mum.org

She taught girls: to not to be ashamed of their cycle  to use only cotton, not polyester cloth  to use lightly colored cloth, to easily see possible abnormalities to change pads three times a day to dry pads in the sun,

Other Organizations Promoting Cloth Pads:

Visit lunapads.com for more stories about grassroots efforts to get reusable pads to the

Conclusions
 Social-Ecological approach needed  Access to products - clean water, soap  Gender appropriate latrines in schools  Education for girls and boys  Community awareness building Need for UNICEF, WHO to support grassroots efforts  Prioritize menstrual health in policy for girls and women, and in water/sanitation Need for more research in menstrual hygiene in developing countries  Cloth vs. disposable pads, and causes of BV

Questions?

References
Bharadwai, Sowmyaa and Patkar ,Archana. (2004) Menstrual Hygiene and Management in the Developing World: Taking Stock.Junction Social; Social Development Consultants. Mumbai, India. Callister, Lynn Clark. “Always Stay in School.” Global Health and Nursing, 33(3): 2008. Cooke, J. (2006). Practical Interventions to Meet the Menstrual Hygiene Needs of Schoolgirls: A Case Study from Katakwi, Uganda. Thesis, Cranfield University. Dasgupta, A. and Sarkar, M. Menstrual Hygiene: How Hygienic is the Adolescent Girl? Indian Journal of Community Medicine, Kolkata, India. 33(2) 2008. Deutsch, Claudia. (November 12, 2007) “A Not-so-Simple Pan to Keep Africa Girls in School.” The New York Times. Dongre, A.R., Deshmukh P.R and Garg, B.S. “The Effect of Community-Based Health Education Intervention on Management of Menstrual Hygiene among Rural Indian Adolescent Girls.” World Health & Population. 9 (33) 2007. El-Gilany, AH, Badawi K, El-Fedawy S. “Menstrual hygiene among adolescent schoolgirls in Mansoura, Egypt.” Community Medicine Department, Faculty of Medicine, University of Mansoura, Mansoura, Egypt. (26):147-52: 2005. Europe External Policy Advisors. (2007) “Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goals.” Zoetermeer, Holland. Dr. Varina Tjon A Ten. Juntunen, A., Nikkonen, M. and Janhonen, S. “Utilising the Concept of Protection in Health Maintenance among the Bena in Tanzania.” Journal of Transcultural Nursing. 11(174): 2000. Moawed, S. (2001). Indigenous Practices of Saudi Girls in Riyadh During Their Menstrual Period. Eastern Mediterranean Health Journal, 7(1-2), 197-203. Morison L, Ekpo G, West B,Demba E, Mayaud P, Coleman R,Bailey R, Walraven G. “Bacterial vaginosis in relation to menstrual cycle, menstrual protection method, and sexual intercourse in rural Gambian women.” MRC Tropical Epidemiology Group, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. 81(3):242-7:

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