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
• Social
• Research and construction of
Public Policy “shame” around
interventions
around menstruation
water/sanitation • Separation
Community
leave out during
menstruation menstruation
Institutional Factors

Interpersonal

• Lack of Intrapersonal
latrines in
• Mothers don’t
Schools
• Sex ed after talk about
menstruation
menarche
before the fact
• Poverty • Men in family
• Rural vs. urban don’t want to see
• Education menstrual rags
 Menstrual Hygiene

 Menstrual hygiene:
 bacterial vaginosis (BV)
 reproductive tract
infections (RTI)
 Toxic Shock Syndrome
 odor
 stains on clothes
 important for girls’ self-
esteem
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

ddddsfdd

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
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.
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

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
“…responding toPatkar,
menstrual
A., 2004 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,
Lunette, Advantages:

 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, EEPA,
Why? 2007
www.divacup.com
 The Protecting Futures
InIntervention
2007, Proctor&Gamble began a large-
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, New York Times, 2007
latrines and water access at Callister, 2008
schools
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?
Praise for Protecting  Is an intervention spearheaded by a
Futures: for-profit company in the best interest
of African girls and women?
 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, New York Times,
latrines and water access at 2007
schools
 An Alternative Intervention: Lakshmi
Murthy
in Rajasthan,InIndia
2000, MacArthur Fellow
Lakshmi Murthy began an
intervention to teach
adolescent girls to make
their own sanitary pads.

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
Cooke, 2006 times a day
www.mum.org 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: