Menstrual hygiene management

Menstrual hygiene management (MHM) or menstrual health and hygiene (MHH) refers to access to menstrual hygiene products to absorb or collect menstrual blood, privacy to change the materials, and access to facilities to dispose of used menstrual management materials. It can also include the "broader systemic factors that link menstruation with health, well-being, gender equality, education, equity, empowerment, and rights".[1] Menstrual hygiene management can be particularly challenging for girls and women in developing countries, where clean water and toilet facilities are often inadequate. Menstrual waste is largely ignored in schools in developing countries, despite it being a significant problem. Menstruation can be a barrier to education for many girls, as a lack of effective sanitary products restricts girls' involvement in educational and social activities.

Reading in the book "Growth and change" about menstruation and puberty (Tanzania)

Menstrual Hygiene Day creates an occasion for publicizing information about menstrual hygiene management issues in the media. The day offers an opportunity to actively advocate for the integration of menstrual hygiene management into global, national and local policies and programmes.

Terminology

An accepted definition of menstrual hygiene management (MHM) is:

  • "Women and adolescent girls use a clean material to absorb or collect menstrual blood, and this material can be changed in privacy as often as necessary for the duration of menstruation.
  • MHM also includes using soap and water for washing the body as required; and having access to facilities to dispose of used menstrual management materials."[2]

The "value chain" related to menstrual hygiene management includes four aspects: awareness, access, use as well as waste management.[3]

The term “menstrual health” is broader than menstrual hygiene. It encompasses both the menstrual hygiene management practices and the broader systemic factors that link menstruation with health, well-being, gender, education, equity, empowerment, and human rights (in particular the human right to water and sanitation).[4] UNICEF now (since 2019) uses the term MHH for "menstrual health and hygiene".[1]

These systematic factors include accurate and timely knowledge, available, safe, and affordable materials, informed and comfortable professionals, referral and access to health services, sanitation and washing facilities, positive social norms, safe and hygienic disposal and advocacy and policy.[1]

Challenges
Celebration of Menstrual Hygiene Day in Amra Padatik, India

Menstrual hygiene management can be particularly challenging for girls and women in developing countries, where clean water and toilet facilities are often inadequate. In addition, traditional cultures make it difficult to discuss menstruation openly. This limits women's and adolescent girls’ access to relevant and important information about the normal functions of their own body. This directly affects their health, education and dignity. Access to information can be considered a human right.[5][6]

Currently there are about 3.73 billion women in the world. According to the World Health Organization (WHO), 52%, or 1.9 billion, of those women are of reproductive age, thus menstruating (WHO, 2018).[7] Women at some point in their life will go thru the reproductive age and thus, will experience menstruation. In 2016, Loughnan, Libbet C., Rob Bain, Rosemary Rop, Marni Sommer, and Tom Slaymaker discussed findings by the Water Supply and Sanitation Council (WSSCC) having estimated that daily 300 million women are menstruating.[8] On average, according to the WSSCC, a women will spend about 3,500 days during her life menstruating.

Many young girls and women of menstruating age live in poor socio-economic environments. WIlber, Torondel, Hameed, Mahon and Kuper (2019)[9] state that 663 million people lack basic access to safe water, and 2.4 billion people lack adequate access to basic sanitary conditions. For women and girls, the lack of safe, accessible water, sanitation and hygiene (WASH) is particularly troubling during menstruation and childbirth. According to data collected and reported on, Loughnan (2017)[10] points out that half a billion (or 13%) of women lacked a place to defecate, have little to no privacy for menstrual hygiene management, and 3/4 of those lacked access to soap and water.

In a 2014 study conducted in India, the researchers found that as many as 42% of women who participated in the study did not know about sanitary pads or from where in their anatomy menstruation originated, and that "most of them were scared or worried on first menstruation."[11] Worldwide, in 2018, one in three women did not have access to a working toilet at all.[12] Menstrual hygiene management issues have been ignored by professionals in the WASH sector, as well as in the health and education sectors.[13][14]

School toilets for girls in Tanzania, if they exist, often have no facilities to dispose of pads.

Health and psycho-social aspects

Poor MHM may affect the reproductive tract, but the specific infections, the strength of effect, and the route of transmission remain unclear.[14] In India, a majority of girls are at risk for reproductive tract infections (RTI) because of poor MHM. RTI can lead to various disabilities if not treated early on[15] and are the cause of 30–50% of prenatal infection.[16] Due to prejudices surrounding the issue, some women in India do not eat or take showers during their menstruation.[17]

Girls' self-image may be negatively impacted by adverse attitudes towards menstruation.[18][19]

Sanitation facilities at schools

The onset of menstruation is challenging for school-aged girls in low-income settings. Impacts can include school absenteeism, missed class time, reduced participation, teasing, fear and shame, and risky adaptive behaviours.[20] Further challenges that menstruating school girls face are a lack of knowledge, communication, and practical guidance prior to menarche and during menstruation; inadequate water, sanitation, and hygiene (WASH) facilities; and ineffective or unavailable menstrual management materials.[20]

In many parts of sub-Saharan Africa, girls can miss up to 5 days of school a month or drop out entirely due to insufficient access to water, sanitation and hygiene (WASH) facilities and menstrual hygiene products.[21][22] Improving access to WASH facilities can actually increase girls' attendance at school. A program for school sanitation in Bangladesh increased girls' enrollment at school by 11%.[23]

Menstrual waste is largely ignored in schools in developing countries, despite it being a significant problem. Girls' access to water and sanitation at school is only available at 47% and 46% of all schools globally.[5] Often, school toilets for girls (if they even exist) are missing bins for menstrual waste collection with the result that pads may be spread all around the school compound area.[24] This pollutes the environment and also causes embarrassment for the school girls.

In the United States, among other countries, girls who are unable to afford feminine hygiene products may miss school in order "to avoid the embarrassment of staining their clothes".[25]

Access to materials

In low-income countries, girls’ choices of menstrual hygiene materials are often limited by the costs, availability and social norms.[26][27]

A lack of affordable hygiene products means inadequate, unhygienic alternatives are used, which can present a serious health risk.[28][29] Menstrual cups offer a long-term solution compared to some other feminine hygiene products because they do not need to be replaced monthly. The quality of the material also makes them a reliable and healthy menstrual hygiene solution, as long as there is access to clean water for washing them.

Girls and women in the workplace often miss work because they don't have access to sanitary materials and places of employment in some countries do not provide resources for women or even have "proper toilets".[19] Women in Bangladesh who work in factories have reported that due to the cost of sanitary products for menstruation which they could not afford, they have resorted to using "factory-floor rags in place of pads and tampons, leading to dangerous infections and missed work."[30]

Menstruation can be a barrier to education for many girls, as a lack of effective sanitary products restricts girls' involvement in educational and social activities.[31][32] Often they do not attend school due to fear of leaking, shame or embarrassment, period pain or inadequate sanitation facilities that do not allow them to wash or change in privacy.[33] This applies mainly to schoolgirls from low-income families, since disposable hygiene products are a monthly expense that many females simply cannot afford.[34]

Adequate sanitation facilities and access to menstrual hygiene products are just one part of the solution to menstrual taboos that impede women's progress in many developing countries. Knowledge is critical for girls to feel comfortable with menstruation and to gain a positive awareness of their bodies.[35]

US and UK

Many low-income and/or homeless girls and women in the inner cities of the United States cannot afford sanitary supplies.[25][36] Food banks in New York report that feminine hygiene products are in high demand.[25] Homeless women in the United States may face the challenge of not being able to shower or use the communal toilet in homeless shelters as often as they need to in cases where there are restrictions on toilet usage.[36] In New York, proposals to help lower income women access menstrual sanitary supplies includes proposals to remove the sales tax on feminine hygiene products and "distributing free tampons in public schools."[25] Sales tax are levied on menstrual supplies in 36 states.[37] On May 1, 2018, the National Diaper Bank Network, which provides millions of diapers to poor and low income parents and advocates for policy change around basic needs, launched the Alliance for Period Supplies and began distributing free period products through allied organizations across the U.S.[38] Homeless women in other industrialized countries, such as the United Kingdom, face problems affording tampons and sanitary napkins.[39]

Disposal of used materials

A review in 2018 found that disposal of menstrual waste is often neglected in sanitation systems. This leads to improper disposal and negative impacts on users, the sanitation systems and the environment.[40]

Taboos
Main article: Culture and menstruation

Despite the fact that menstruation is a healthy biological process, it is approached with hesitance and misinformation because of deeply-rooted cultural taboos surrounding menstruation.

Cultural, religious and traditional beliefs — particularly in developing countries — can lead to restrictions that women or girls face during their period. In some societies, women do not wash their bodies, shower or bathe during menstruation. They may not be allowed to use water sources during menstruation. Even if they have access to toilets, they might not use them because of the fear of staining the toilet bowls (in the case of dry toilets or flush toilets where the flush is not powerful).[34] This impairs the use of menstrual cups compared to pads as the cups are normally emptied into toilets.

Expanding the discussion to include consideration of waste management is part of the attempt to "normalize" conversations about menstruation.[3]

Approaches for improvements

MHM in schools should not be a stand-alone programme but should be integrated with existing programmes on WASH in schools, school health and nutrition programmes, puberty education programmes, and emergencies.[41]

In rural Bolivia a menstrual hygiene management game was developed for school girls that stimulated detailed responses, and diversified participatory activities in focus group discussions. The board game helped to ease girls’ discomfort discussing menstruation.[20]

See also

References
  1. UNICEF (2019). Guidance on Menstrual Health and Hygiene. UNICEF, New York, USA
  2. UNICEF, Columbia University (2012). WASH in Schools - Empowers Girls' Education - Proceedings of Menstrual Hygiene Management in Schools Virtual Conferences. UNICEF and Columbia University, USA, p. 2
  3. "Normalizing Menstruation: Pushing the Boundaries of the MHM dialogue in India" (PDF).
  4. Keith, B. (2016). Girls’ and women’s right to menstrual health: Evidence and opportunities - Outlook on reproductive health. PATH, Seattle, USA, ISSN 0737-3732
  5. Sommer, Marni; Hirsch, Jennifer; Nathanson, Constance; Parker, Richard G. (July 2015). "Comfortably, Safely, and Without Shame: Defining Menstrual Hygiene Management as a Public Health Issue". American Journal of Public Health. 105 (7): 1302–1311=. doi:10.2105/AJPH.2014.302525. PMC 4463372. PMID 25973831.
  6. Imran, Myra (29 May 2015). "World Menstrual Hygiene Day Observed". The International News. Retrieved 29 June 2015.
  7. World Health Organization. (2018). Retrieved from:http://www.euro.who.int/en/health- topics/Life-stages/sexual-and-reproductive-health/news/news/2018/11/tackling- the-taboo-of-menstrual-hygiene-in-the-european-region
  8. Loughnan, Libbet C., Rob Bain, Rosemary Rop, Marni Sommer, and Tom Slaymaker. "What Can Existing Data on Water and Sanitation Tell Us About Menstrual Hygiene Management?" Waterlines 35.3 (2016): 228-44. Web.
  9. Wilbur, Jane; Torondel, Belen; Hameed, Shaffa; Mahon, Thérèse; Kuper, Hannah (2019). "Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people". PLOS ONE. 14 (2): e0210974. Bibcode:2019PLoSO..1410974W. doi:10.1371/journal.pone.0210974. PMC 6365059. PMID 30726254.
  10. Loughnan, Libbet. (2017, April ,17). Retrieved from: https://blogs.worldbank.org/water/lack-access- toilet-and-handwashing-materials-hits-women-and-girls-hardest-especially-when
  11. Arumugam, Balaji; Nagalingam, Saranya; Varman, Priyadharshini Mahendra; Ravi, Preethi; Ganesan, Roshni (2014). "Menstrual Hygiene Practices: Is it Practically Impractical?". International Journal of Medicine and Public Health. 4 (4): 472–476. doi:10.4103/2230-8598.144120.
  12. Bax, Tahmeena (28 May 2014). "Menstruation Misery for Schoolgirls as Sanitation Woes Hit Hopes for the Future". The Guardian. Retrieved 29 June 2015.
  13. House, S., Mahon, T., Cavill, S. (2012). Menstrual hygiene matters - A resource for improving menstrual hygiene around the world. Wateraid, UK, p.8
  14. Sumpter, Colin; Torondel, Belen; RezaBaradaran, Hamid (26 April 2013). "A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management". PLOS ONE. 8 (4): e62004. Bibcode:2013PLoSO...862004S. doi:10.1371/journal.pone.0062004. PMC 3637379. PMID 23637945.
  15. Juyal, R.; Kandpal, S.D.; Semwal, J. (April 2014). "Menstrual Hygiene and Reproductive Morbidity in Adolescent Girls in Dehradun, India". Bangladesh Journal of Medical Science. 13 (2): 170–174. doi:10.3329/bjms.v13i2.14257.
  16. Garg, R.; Goyal, S.; Gupta, S. (2012). "India Moves Towards Menstrual Hygiene: Subsidized Sanitary Napkins for Rural Adolescent Girls—Issues and Challenges" (PDF). Maternal and Child Health Journal. 16 (4): 170–174. doi:10.1007/s10995-011-0798-5. PMID 21505773. S2CID 7324914. Retrieved 30 March 2017.
  17. Tomar, Shruti (31 May 2015). "The Periodic Misogyny of Tribal Madhya Pradesh". Hindustan Times. Retrieved 29 June 2015 – via Newspaper Source.
  18. Gultie, Teklemariam; Hailu, Desta; Workineh, Yinager (30 September 2014). "Age of Menarche and Knowledge about Menstrual Hygiene Management among Adolescent School Girls in Amhara Province, Ethiopia: Implication to Health Care Workers & School Teachers". PLOS ONE. 9 (9): e108644. Bibcode:2014PLoSO...9j8644G. doi:10.1371/journal.pone.0108644. PMC 4182550. PMID 25268708.
  19. Sadeque, Syeda Samira (31 May 2015). "Talking Menstruation: About Time?". Dhaka Tribune. Retrieved 29 May 2015.
  20. Long, Jeanne; Caruso, Bethany; Freeman, Matthew; Mamani, Maribel; Camacho, Gladys; Vancraeynest, Koenraad (2015). Sahin, Murat (ed.). "Developing games as a qualitative method for researching menstrual hygiene management in rural Bolivia". Waterlines. 34 (1): 68–78. doi:10.3362/1756-3488.2015.007. ISSN 0262-8104.
  21. Bosco, Ijoo (29 May 2014). "E. Equatoria Marks Global Menstrual Hygiene Day". Sudan Tribune. Retrieved 29 June 2015 – via Newspaper Source.
  22. Amme, Grace (28 May 2015). "Uganda Celebrates Menstrual Hygiene Day". Uganda Radio Network. Retrieved 29 June 2015.
  23. Domestos; WaterAid; WSSCC. We Can't Wait: A Report on Sanitation and Hygiene for Women and Girls (PDF). World Toilet Day. p. 7. Archived from the original (PDF) on 2015-10-10. Retrieved 2019-06-13.
  24. Kjellén, M., Pensulo, C., Nordqvist, P., Fogde, M. (2012). Global review of sanitation systems trends and interactions with menstrual management practices - Report for the menstrual management and sanitation systems project. Stockholm Environment Institute (SEI), Stockholm, Sweden, p. 25
  25. De Bode, Lisa (17 June 2015). "New York City Wants to Provide Free Tampons to Address Menstruation Stigma". Al Jazeera America. Retrieved 1 July 2015.
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  27. Kaur, Rajanbir; Kaur, Kanwaljit; Kaur, Rajinder (2018). "Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries". Journal of Environmental and Public Health. 2018: 1730964. doi:10.1155/2018/1730964. ISSN 1687-9805. PMC 5838436. PMID 29675047.
  28. African Population and Health Research Center (APHRC). Experiences and Problems with Menstruation Among Poor Women and Schoolgirls in Nairobi. In: Policy Brief No. 20. Nairobi, Kenya: APHRC, 2010.
  29. Obiria M. Kenyan students could solve sanitary problem with banana-fibre pad. The Guardian. https://www.theguardian.com/global-development/2014/sep/26/kenyan-girls-sanitary-problem-banana-fibre-pad. 26 Sep 2014.
  30. Cowan, Samantha (28 May 2015). "Ditch the Euphemisms: Menstrual Hygiene Day Calls Out Period Taboos". TakePart. Retrieved 29 June 2015.
  31. UNESCO (2014). Puberty education & menstrual hygiene management - good policy and practice in health education - Booklet 9. Paris, France: United Nations Educational, Scientific and Cultural Organization (UNESCO).
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  33. Crofts, T. (2012). Menstruation hygiene management for schoolgirls in low-income countries. Loughborough: Water, Engineering and Development Center (WEDC), Loughborough University.
  34. House, S.; Mahon, T.; Cavill, S. (2012). "Menstrual hygiene matters. A resource for improving menstrual hygiene around the world". London: WaterAid.
  35. Kirk, J.; Sommer, M. (2006): Menstruation and Body Awareness. Linking Girls Health With Girls Education Archived 2015-02-26 at the Wayback Machine. Royal Tropical Institute (KIT), Amsterdam
  36. Goldberg, Eleanor (14 January 2015). "For Homeless Women, Getting Their Period Is One of the Difficult Challenges". The Huffington Post. Retrieved 1 July 2015.
  37. "More States Move To End 'Tampon Tax' That's Seen As Discriminating Against Women". NPR.org. Retrieved 2018-05-22.
  38. Pollitt, Katha (2018-05-10). "Are We Finally Getting Over the Belief That Periods Are Embarrassing?". The Nation. ISSN 0027-8378. Retrieved 2018-05-22.
  39. Isaac, Anna (5 June 2015). "The Homeless Period: It Doesn't Bear Thinking About and That's the Problem". The Guardian. Retrieved 29 May 2015.
  40. Elledge, Myles; Muralidharan, Arundati; Parker, Alison; Ravndal, Kristin; Siddiqui, Mariam; Toolaram, Anju; Woodward, Katherine (2018-11-15). "Menstrual Hygiene Management and Waste Disposal in Low and Middle Income Countries—A Review of the Literature". International Journal of Environmental Research and Public Health. 15 (11): 2562. doi:10.3390/ijerph15112562. ISSN 1660-4601. PMC 6266558. PMID 30445767.
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