February 2016

Outloo on reproductive health

Girls’ and women’s right to menstrual health: Evidence and opportunities

Menstruation is a natural and regular occurrence experienced by nearly all women of reproductive age. The average woman will have about 450 menstrual cycles over approximately 38 years of her life; this translates to managing for roughly 6.25 years.1,2 The ability to manage one’s menstrual health with adequate knowledge, safety, and dignity and without stigma is an essential human right.3 However, hundreds of millions of girls and women in low-resource settings are not well prepared when menstruation begins. They lack access to information, products, and infrastructure needed to comfortably manage menstruation. Girls’ and women’s health, well-being, and rights are compromised when they must isolate themselves from their families; avoid work, community activities, or school; and face risks to their physical safety because of their basic biology.4 Adolescent girls are especially vulnerable to negative outcomes related to menstruation, including efects on their overall self-esteem and confidence. This issue of Outlook establishes menstrual health as a sexual and reproductive health and rights issue; presents the obstacles to and the consequences of not promoting and protecting menstrual health; and highlights opportunities to improve menstrual health in low-resource settings.

MENSTRUATION: HEALTH, RIGHTS, AND BEYOND The Programme of Action from the 1994 International Conference on Population and Development defines sexual and reproductive health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.”5 Menstruation, a key function of the reproductive system, is fundamental to sexual and reproductive health and rights (see box on page 2 for a description of menstrual health). PATH/Eric Becker

1 Menstruation: Health, rights, 3 Negative outcomes: What do and beyond we know? 2 Obstacles to attaining 6 Opportunities to improve menstrual

INSIDE menstrual health health in low-resource settings What is menstrual health?

Most eforts to address menstruation in low-resource • Informed and comfortable professionals settings use the term menstrual hygiene management • Referral and access to health services (MHM). The United Nations Children’s Foundation (UNICEF) and the World Health Organization define a state of “good” • Sanitation and washing facilities MHM when girls and women use clean material to absorb or • Positive social norms collect menstrual blood; can change this material in privacy; and have access to soap, water, and disposal facilities for • Safe and hygienic disposal used materials (e.g., sanitary pads).6 The United Nations • Advocacy and policy Educational, Scientific and Cultural Organization (UNESCO) goes further and summarizes systemic factors that facilitate This issue of Outlook uses the term “menstrual health” to healthy menstrual management:7 encompass both the MHM practices and the broader systemic factors that link menstruation with health, well-being, gender, • Accurate and timely knowledge education, equity, empowerment, and rights. • Available, safe, and afordable materials

The right to information about sexual young adolescents can address puberty, is considered a time of cleansing and and reproductive health presents an fertility, gender, hygiene, safety, is celebrated.12,25 ideal opportunity for strengthening and communication (see the Grow Many cultures consider menstrual linkages with menstrual health, and Know and the GrowUp Smart blood and menstruating females to be especially for adolescents. Preparing programs for two strong examples). dirty and impure,12,18,22,25 which leads adolescent girls for menarche—the Menstrual health is also closely linked girls and women to be embarrassed initial onset of menstruation—can set to sectors beyond health, including about menstruation. This seems an important foundation for overall water, sanitation, and hygiene (WASH), particularly true for adolescent reproductive health and well-being. as well as education.20 Menstrual girls, negatively afecting their self- Globally, there are 1.8 billion young health crosscuts a number of the esteem and their outlook on puberty people between the ages of 10 and Sustainable Development Goals (SDGs; and growing up.11,14,18,26 In addition, 24 years old.8 Adolescents in many see box on page 3), and achieving some norms require girls and countries often lack basic knowledge the SDGs will require cooperative women to alter daily routines while about puberty and reproductive action and integrated programs. 21 menstruating. For example, women physiology, not to mention Coordinated interventions may in India and Nepal may be required comprehensive information about present ideal opportunities to test to avoid cooking, religious practices, sexuality. As a result, many young girls development models that include bathing, and sexual intercourse while are uninformed or misinformed about attention to menstrual health. menstruating.9,12,22 menstruation before puberty and are alarmed at menarche.9-17 Research in OBSTACLES TO ATTAINING five African countries found that, on Limited access to information MENSTRUAL HEALTH average, 66 percent of respondents and supplies were unaware of menstruation before Materials and supplies enable girls they experienced menarche.18 Cultural taboos and restrictions and women to manage menstrual Improving girls’ and boys’ access In many countries and cultures, blood. In many low-resource settings, to quality education on puberty menstruation is a taboo subject that girls and women cannot access and menstrual health provides is rarely discussed. As a result, girls or aford commercial menstrual opportunities to discuss other aspects and women experience shame and management supplies such as of sexual and reproductive health fear that interfere with their ability disposable or reusable sanitary (including contraception). Life to manage menstrual health and can pads, , or menstrual cups.* 7,12, 22-24 skills education can take place over impact their overall well-being. time and at appropriate ages with The barriers discussed here do not * Menstrual cups are reusable, flexible devices adolescents, as well as their parents exist in all low-resource settings, of inserted into the to collect menstrual 17, 19 course. In some places, menstruation blood. Women empty the cup as needed, usually or caregivers. Discussions with after 4 to 12 hours.

2 OUTLOOK Disposable sanitary pads are widely Lack of infrastructure separate latrines for girls, with doors preferred to traditional cloth—the and locks, clean water sources close by In many low-resource settings, girls more common management that also have soap, a mechanism to and women lack access to appropriate method.12,18,22,24,26,27 More than 70 privately dispose of sanitary materials, infrastructure and systems to support percent of girls interviewed for a and supplies on hand to keep menstrual health. When menstrual five-country study in sub-Saharan latrines clean.18,26,29 For example, an cloths are used they are often cleaned Africa stated that cost was the assessment of 62 primary schools in and reused. Ideally, used cloths would primary reason they were not using rural found that only 23 percent be washed with soap and clean water commercial sanitary products (e.g., of latrines had locks on the doors.29 and then dried and aerated in the sun. USD $1 to $2 for a pack of disposable Furthermore, schools rarely have However, girls and women will often sanitary pads).18 Some girls and sanitary products available, and if they attempt to dry cloths in hidden spaces, women lack access to clean cloth and do, it is often through small-scale and which may not allow them to fully dry have to adapt less clean cloth or other unsustainable donations.18,29 and may facilitate growth of harmful materials for absorbing menstrual .12,14,16 Moreover, many girls and Many challenges found in schools blood, including grass, leaves, cotton women do not have access to soap and also are relevant to girls out of school wool, and tissue.4,9,12,18 Leakage and water, particularly if they aim to clean and women in the workplace. For odor are more likely with products their supplies in secret.12,14 example, a needs assessment in not designed for menstrual blood Bangladesh found that female factory absorption. Lack of infrastructure is particularly workers used contraceptive pills to challenging for girls in school who Commercial menstrual health avoid menstruating so they would not must manage menstruation during supplies are made more expensive need to manage menstruation in the the school day. In a 2014 manual, by import and sales taxes, efectively factory’s inadequate toilet facilities.30 UNESCO states that menstrual health taxing women for their physiology.25 requires comprehensive puberty In 2011, Kenya eliminated import NEGATIVE OUTCOMES: WHAT education, menstrual management taxes on menstrual products, reducing DO WE KNOW? materials, safe and private latrines, costs by about 18 percent.28 These water and soap, and adequate disposal products may also be considered an Research on menstrual health is options.7 Unfortunately, many schools unnecessary expense at the policy, limited and of inconsistent quality, in low-resource settings do not have community, or household level, making it difcult to draw clear such supportive environments.10,18,29 particularly when finances are limited conclusions (see Table 1 on page 4 for Research indicates few schools have and/or controlled by men.13,15,22 an overview).

Menstrual health and the Sustainable Development Goals (SDGs)

While not mentioned explicitly in the 2030 Agenda for Goal 5: Achieve gender equality and empower all women Sustainable Development, menstrual health is relevant to and girls. at least 5 of the 17 SDGs and multiple targets, including: • Target 5.1: End all forms of discrimination against all Goal 3: Ensure healthy lives and promote well-being at women and girls everywhere. all ages. Goal 6: Ensure availability and sustainable management of • Target 3.7: By 2030, ensure universal access to sexual and water and sanitation for all. reproductive health-care services, including for family planning, information and education, and the integration • Target 6.2: By 2030, achieve access to adequate and of reproductive health into national strategies and equitable sanitation and hygiene for all and end open programmes. defecation, paying special attention to the needs of women and girls and those in vulnerable situations. Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. Goal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment, and • Target 4.a: Build and upgrade education facilities that decent work for all. are child, disability and gender sensitive and provide safe, non-violent, inclusive and efective learning environments For more information on the SDGs, visit www.un.org/ for all. sustainabledevelopment/sustainable-development-goals/.

FEBRUARY 2016 3 Menstrual health and sexual and self-reported RTI symptoms among health and reproductive health reproductive health women.31 This study used case-control outcomes concluded that “…there methodology and lab-confirmed is an initial indication that [poor Links to infection diagnosis, and it controlled for a menstrual health] may be associated Some research has linked poor number of potential confounding with an increased risk of RTI but menstrual health to reproductive factors such as income, religion, and the strength and route of infection tract infections (RTIs),** with the water and sanitation in the home. is not known.”23 The majority of most recent evidence identifying The researchers concluded that the 14 studies reviewed found an a link between reusable menstrual women using reusable cloths were association between poor menstrual cloths and RTIs, specifically bacterial significantly more likely to self-report management—primarily the use of vaginosis (BV) and urinary tract symptoms of urogenital infection (e.g., unsanitary absorbent material—and infections (UTIs).31 Menstrual abnormal vaginal discharge, burning RTIs; however, the research included health practices that may transmit or itching while urinating) than limited control for confounding bacteria to the reproductive tract women using disposable products. factors and relied on self-reported and and contribute to infections include Furthermore, women using reusable observational data. use of improperly washed and dried cloths were also more likely to be Links to high-risk sexual behavior? cloths; use of absorbent alternatives diagnosed with either BV or UTIs. (e.g., grass or tissue); extended use of The fact that some adolescent girls This study also highlighted the absorbent material; and poor general and women engage in transactional influence of socioeconomic and hygiene due to limited access to sex to obtain money for basic living contextual factors on reproductive soap and water.13,23 If left untreated, expenses is well understood. Evidence health outcomes. The authors found some RTIs can lead to increased from Kenya, South Sudan, Tanzania, that women with the ability to change susceptibility to HIV and other STIs, and Uganda indicates that some absorbent materials privately indoors which can in turn lead to secondary adolescent girls may specifically and those with higher incomes were infertility and/or adverse pregnancy engage in transactional sex to obtain less likely to have BV.31 Women with outcomes.13,23 commercial sanitary products.4,14,18,24,26 limited education were three times Research among 2,721 sexually active A rigorous 2015 study in Odisha, India, more likely than higher-educated menstruating women under 30 years found strong associations between women to have a UTI. of age in rural Kenya found that, reusable menstrual cloths and Although this recent study while overall prevalence of reported suggests a link between menstrual transactional sex for commercial ** This issue of Outlook refers specifically to management and RTIs, other sanitary pads was only 1.3 percent, it endogenous reproductive tract infections caused evidence is inconclusive. A 2013 was much higher among adolescent by overgrowth of organisms normally present in the genital tracts of healthy women, such as review of published evidence on girls, with 10 percent of sexually or vulvovaginal candidiasis. correlations between menstrual active 15-year-old girls confirming

Table 1. Outcomes: What do we know about menstrual health and...

…sexual and reproductive health? • Use of reusable menstrual cloths or absorbent alternatives may increase women’s risk of reproductive tract infections (RTIs), although that link needs to be further confirmed.

• Evidence suggests some young girls in East Africa are engaging in transactional sex in exchange for money for commercial sanitary products.

…education? • Some girls miss school due to menstruation, but the association is very complex to study. There is limited evidence consistently linking menstruation to educational outcomes.

• Interventions that focus on health and puberty more broadly, rather than those focused more narrowly on menstrual product availability, may be more or equally likely to improve girls’ school attendance and participation.

…gender-based violence? • Girls and women are more vulnerable to violence when they have limited access to WASH facilities; this exposure is increased when menstruating.

4 OUTLOOK this practice.4 Transactional sex, assigned girls to receive either school attendance and education even if relatively infrequent, places puberty education alone or puberty outcomes.13,14,18,24,36 For example, adolescent girls at significant risk education plus disposable sanitary studies in Kenya found that girls of HIV, other STIs, and pregnancy, pads.36 While it took slightly longer were unable to focus on the teacher underscoring the inequities and for the education-only group, girls because they were concerned about vulnerabilities faced by girls and in both intervention groups saw blood leaking on their clothes24 and, women. significant and similar improvements similarly, were afraid of standing up in school attendance (approximately to answer questions in case blood had Menstrual health and education 9 percent increase) by five months. seeped onto their uniforms.14 These findings indicate that provision Research suggests that menstrual of commercial sanitary pads with Menstrual health and gender- health challenges can lead girls to stay puberty education may improve based violence home from school while menstruating. school attendance at a faster rate, but The precise impact of menstruation that puberty education alone has It is well documented that girls and on girls’ school attendance and other a positive influence on attendance women are highly vulnerable to educational outcomes, however, is less in the communities studied. The gender-based violence, including clear. Studies have identified several assessment in Nepal found that the harassment, physical assault, and/or possible reasons for absences: lack of rape; this vulnerability is exacerbated provision of menstrual cups had 37 sanitary supplies, pain associated with limited impact on school attendance, by limited access to WASH facilities. menstruation, lack of appropriate although school attendance rates in A 2015 literature review noted sanitation and hygiene facilities in girls’ and women’s experiences of 11,14,16,18 the study sites were already relatively the school, and fear or shame. It high.27 While self-reported adoption rape when using toilets, taking a is also not clear how absenteeism due of the menstrual cup was fairly good bath, or collecting water, as well as to menstruation compares with girls’ in the treatment group, the efect on when they leave their communities absence or withdrawal from school for at night to defecate in private—a school attendance was minimal— 37 other reasons. menstrual cup use improved school common sociocultural norm. It follows that girls and women are International institutions consider attendance by 0.5 days of school per at increased risk of gender-based that menstruation does impact year at most. The study found that violence while menstruating, due to school attendance. Data from UNICEF many other menstrual factors had the need for increased access to WASH indicate that one out of ten school-age an efect on girls’ school attendance, facilities, desire to hide evidence of girls in Africa are absent from school including cramps, tiredness, having menstruation, and lack of sanitation when menstruating.32 Specific studies to change and wash clothes, and in homes. For example, Dalit women have produced a wide range of results, difculty walking and sitting. The in India have reported facing sexual however. A survey of five African authors noted that low-cost schooling harassment when using communal countries found that, on average, 49 and overall health improvements latrines.37,38 percent of girls interviewed missed might have a larger impact on girls’ four days of school each month attendance. Researchers concluded Risk of gender-based violence during while menstruating.18 Conversely, that the primary impact of menstrual menstruation may be particularly research in Malawi concluded cup provision was on convenience and high for adolescent girls, who that menstruation and menstrual ease of managing menstrual blood, as experience sexually threatening health–related barriers played a opposed to improving attendance. The behavior from their male classmates limited role in school absenteeism Ghana and Nepal studies used very and teachers, as well as from family for girls.33,34 Others have noted that small sample sizes, however, so these members and family friends.10,14,26,39 the latter evidence was based on findings may not be representative of Moreover, girls and women in data from girls ages 14 to 16 years, larger trends. humanitarian relief environments potentially excluding girls who had may also be at particular risk of 35 Stigma and shame associated with already left school by that age. menstruation in many cultures violence. The limited infrastructure means women and girls may have Researchers in Ghana and Nepal can also afect girls’ well-being to travel far from home at odd hours tried to explore this link more closely and performance in school, even to privately change and wash their by assessing whether provision of when they do attend. Concerns menstrual materials.13 To mitigate menstrual management materials about leakage afect girls’ ability to these challenges, the WASH sector has impacted girls’ school attendance, concentrate and participate in the prioritized building well-lit, gender- and their findings underscore classroom and may discourage them separated latrines and washing the complexity of this potential from attending school altogether facilities.13,40 association. Researchers in Ghana when menstruating, limiting their

FEBRUARY 2016 5 OPPORTUNITIES TO IMPROVE low-resource settings. For example, MENSTRUAL HEALTH IN LOW- Sustainable Health Enterprises (SHE) RESOURCE SETTINGS is working with communities in Rwanda to turn discarded banana Current evidence indicates that fibers into afordable, biodegradable girls and women do face some risks sanitary pads.43 In addition to related to menstruation, including manufacturing afordable products the potential for infection, violence, and employing local staf, SHE stigma and emotional distress, and provides menstrual education in restricted educational and workplace schools and is working to eradicate participation. Although the full impact taxes on menstrual health products, of these risks has not been quantified, with plans to franchise their model addressing menstrual health is in other countries. The simple fundamental to girls’ and women’s sanitary pad machine developed sexual and reproductive rights and by Arunachalam Muruganantham well-being. Promising opportunities allows women to manufacture to improve menstrual health through and sell low-cost sanitary pads in partnership and innovation are their communities.44 Each machine highlighted below. PATH/Eric Becker PATH/Eric produces 200 to 250 pads per day and employs ten women who operate as an Many women prefer commercial products Working across sectors to address independent business.44 Finally, BeGirl menstrual health like sanitary pads over the traditional cloth often used for menstrual management. creates underwear and reusable pads 45 Menstrual health is a cross-sectoral Here, a woman sews reusable sanitary pads that work together or separately. issue that requires a coordinated in a factory in Kenya. Both products incorporate a pocket response and partnership between that can be filled with the reusable governments and stakeholders or disposable absorbent material 45 in health, WASH, education, and about menstruation and available to users. BeGirl estimates employment. The WASH sector reproductive physiology. that the underwear lasts for two years has been a leader in integrating • Ensure that girls grow and develop and the reusable pads for one year, and menstrual health in development in contexts where menstruation is that use of the pad alone will keep 150 and humanitarian settings, seen as healthy and positive. disposable sanitary pads out of the environment. influencing other actors to address • Ensure that girls and women menstrual health and stimulating are supported by their families Long-lasting alternatives such as 40 collaboration. For example, WASH and communities at the time of menstrual cups may also transform activities to address menstrual health menarche and during menstruation. how girls and women manage their in humanitarian settings motivated menstrual health. The limited use As stewards of their country’s the United Nations Population Fund of insertable items such as cups or public health, governments can also to provide female refugees and tampons in many of these locations take action to improve menstrual internally displaced persons with may result from fears that they health. The governments of India, dignity kits that include culturally interfere with , cultural Kenya, South Africa, and Uganda appropriate sanitary pads or cloths, beliefs that deter girls and women 40,41 have recognized the importance underwear, and soap. The WASH from touching their genitalia, a lack of menstrual health by making and education sectors have worked of familiarity with the concept, and/ commitments to improve access to together to improve infrastructure and or limited resources such as soap sanitary supplies for low-income access to menstrual health supplies in and water for cleansing.46 However, adolescent girls.20,42 the hopes of improving girls’ school menstrual cups ofer some benefits attendance and participation. over sanitary pads, including that Innovating: Menstrual health they are more cost-efective due to However, uptake of menstrual health supplies and their delivery initiatives is limited, and current their longevity, with some lasting as activities are fragmented. Civil Access to afordable and good-quality long as ten years (although they are 47 society, education, public health, and menstrual management supplies expensive to purchase initially). commercial actors can integrate supports girls and women to manage Furthermore, these products would menstrual health in their ongoing their menstrual health efectively.4 result in less stress on an already weak sanitation infrastructure.46,47 Research work in order to: A number of social entrepreneurs on menstrual cups in low-resource • Provide both girls and boys with are working to improve access to settings shows that, although uptake clear and accurate information sanitary pads for girls and women in may be slow initially, adolescent girls

6 OUTLOOK and women find cups acceptable.27,46-48 development partners, and the private REFERENCES For example, 76 percent of women sector must work together to ensure 1 Kane J. Here’s how much a woman’s period who tried the cup in Bihar, India that girls and women in low-resource will cost her over her lifetime. Hufngton Post. May 18, 2015. Available at: www. (N = 245 approximately) preferred it to settings no longer face discrimination hufngtonpost.com/2015/05/18/period-cost- their usual menstrual management as a result of their basic biology. lifetime_n_7258780.html. Accessed October method.47 Learning to use menstrual Taking advantage of opportunities 13, 2015. cups also ofers supplementary to address menstrual health through 2 Menstruation and menstrual suppression survey: factsheet page. Association of Reproductive opportunities to share information health and sexuality education, access Health Professionals website. Available at: www. about overall reproductive to appropriate and afordable supplies arhp.org/publications-and-resources/studies- and health.19,46,48 and infrastructure, and improved and-surveys/menstruation-and-menstrual- collaboration across sectors could suppression-survey/fact-sheet. Accessed These innovative products November 16, 2015. reduce disparities and contribute to ofer potential solutions to the 3 Every woman’s right to water, sanitation improved physical, mental, and social and hygiene page. United Nations challenges girls and women face in well-being of girls and women. Ofce of the High Commissioner for managing their menstrual health; Human Rights website. Available at: however, these commodities also Additional evidence may also help www.ohchr.org/EN/NewsEvents/Pages/ Everywomansrighttowatersanitationandhygiene. require testing to determine their to engage policymakers and global aspx. Accessed November 16, 2015. acceptability and utility to girls and stakeholders around this issue and 4 Phillips-Howard P, Otieno G, Burmen B, et al. women in low-resource settings. New highlight worthwhile interventions. Menstrual needs and associations with sexual commodities must be desirable and The upcoming multi country Global and reproductive risks in rural Kenyan females: a cross-sectional behavioral survey linked with pragmatic for users, afordable and Early Adolescent Study (www.geastudy. HIV prevalence. Journal of Women’s Health. easily accessible—and, ideally, have org) should provide critical new 2015;24(10):801–811. limited environmental impact. evidence on menstrual health. Future 5 United Nations Population Fund (UNFPA). research activities might include: Programme of Action, International Conference on Beyond the supplies themselves, Population and Development, 20th Anniversary additional work is needed to ensure • Assessing feasibility and impact of Edition. Cairo: UNFPA; 1994; New York: 2014. access to both new and existing integrating menstrual health into 6 World Health Organization (WHO), United sexual and reproductive health Nations Children’s Fund (UNICEF). Consultation menstrual management products. on Draft Long List of Goal, Target, and Indicator Specific approaches could include education and service delivery Options for Future Global Monitoring of Water, market-shaping eforts to identify interventions. Sanitation, and Hygiene. WHO/UNICEF Joint Monitoring Programme for Water Supply and locally appropriate products and • Determining how girls and women Sanitation. August 2012. brands and reduce the cost of supplies can maintain reproductive health 7 United Nations Educational, Scientific and Cultural to end users, defining minimum when disposable materials are not Organization (UNESCO). Good Policy and Practice performance standards, and an option or reusable materials are in Health Education Booklet 9: Puberty Education & 12–14,23,31 Menstrual Hygiene Management. Paris: UNESCO; developing partnerships with national preferred. 2014. and international manufacturers to • Identifying efective menstrual 8 United Nations Population Fund (UNFPA). The lower prices for high-quality products. health–related interventions that Power of 1.8 Billion: Adolescents, Youth, and the Following the example of Kenya, will improve girls’ comfort, self- Transformation of the Future. UNFPA State of eliminating taxes on menstrual health World Population 2014. New York: UNFPA; 2014. esteem, and confidence to attend 9 Garg S, Sharma N, Sahay R. Socio-cultural aspects supplies could help make commercial and fully participate in school while of menstruation in an urban slum in Delhi, India. sanitary products more afordable menstruating. Reproductive Health Matters. 2001;9(17):16–25. for women. 10 Sommer M. Ideologies of sexuality, menstruation • Collecting surveillance data and risk: girls’ experiences of puberty and on menstrual health to better schooling in northern Tanzania. Culture, Health & CONCLUSION understand the efects and Sexuality. 2009;11(4):383–398. At the most basic level, menstrual demographics of menstruation, 11 McMahon SA, Winch PJ, Caruso BA, et al. ‘The girl with the period is the one to hang her head’— health is an issue of equity for including puberty trends, and to Reflections on menstrual management among 49 girls and women. The sexual and tailor programs. schoolgirls in rural Kenya. BMC International Health and Human Rights. 2011;11:7. reproductive rights of girls and There are clear and compelling women are compromised when 12 Sommer M. Global Review of Menstrual Beliefs and reasons to address menstrual Behaviors in Low-Income Countries: Implications they must alter their daily routines; health as an issue of sexual and for Menstrual Hygiene Management. New York: face stigma in their communities, reproductive rights. Improving girls’ Colombia University; 2011. schools, and workplaces; and be at and women’s menstrual health can 13 House S, Mahon T, Cavill S. Menstrual Hygiene risk of poor sexual and reproductive Matters: A Resource for Improving Menstrual contribute to larger eforts to reduce Hygiene Around the World. New York: WaterAid; health outcomes because they cannot gender inequities and improve their 2012. manage menstruation with dignity. health, confidence, and community 14 Mason L, Nyothach E, Alexander K, et al. ‘We keep Governments, global health and it secret so no one should know’: a qualitative engagement. study to explore young schoolgirls’ attitudes and experiences with menstruation in rural western Kenya. PLOS One. 2013;8(11):e79132.

FEBRUARY 2016 7 15 Boosey R, Prestwich G, Deave T. Menstrual 33 Lloyd CB. New Lessons: The Power of Educating hygiene management amongst schoolgirls in Adolescent Girls. New York: Population Council; ISSN: 0737-3732 the Rukungiri district of Uganda and the impact 2009. Outlook is published by PATH, the leader on their education: a cross-sectional study. Pan 34 Grant MJ, Lloyd CB, Mensch BS. Menstruation and in global health innovation. Selected African Medical Journal. 2014;19:253. school absenteeism: evidence from rural Malawi. issues are available in additional 16 Jewitt S, Ryley H. It’s a girl thing: menstruation, Comparative Education Review. 2013;57(2):260– languages. Outlook features evidence school attendance, spatial mobility and 284. on reproductive health issues of interest wider gender inequalities in Kenya. Geoforum. 35 Sommer M. Putting menstrual hygiene to readers in low-resource settings. This 2014;56:137–147. management on to the school water and issue is made possible with support 17 Sommer M, Sutherland C, Chandra-Mouli sanitation agenda. Waterlines. 2010;29(4): from the William and Flora Hewlett V. Putting menarche and girls into the global 268–278. Foundation. The opinions expressed herein do not necessarily reflect the views population health agenda. Reproductive Health. 36 Montgomery P, Ryus CR, Dolan CS, et al. Sanitary of the donor or PATH. 2015;12:24. pad interventions for girls’ education in Ghana: a 18 Tamiru S, Kuribachew M, Acidria P, et al. Towards pilot study. PLOS One. 2012;7(10):e48274. Outlook is sent at no cost to readers. To be a sustainable solution for school menstrual 37 Sommer M, Ferron S, Cavill S, et al. Violence, added to the Outlook mailing list, please hygiene management: cases of Ethiopia, Uganda, gender and WASH: spurring action on a contact [email protected]. South Sudan, Tanzania and Zimbabwe. Waterlines. complex, under-documented and sensitive topic. Previous issues of Outlook are available 2015;34(1):92–102. Environment & Urbanization. 2015;27(1):105–116. online at: www.path.org/publications/ 19 African Population and Health Research Center 38 WaterAid, National Confederation of Dalit series.php?i=3. (APHRC). Use of Menstrual Cup by Adolescent Organizations. Research on the DFID Supported Girls and Women: Potential Benefits and Key IPAP Programmes in Five States. Unpublished Contributors Challenges. Policy Brief No. 22. Nairobi: APHRC; report. 2013 draft. WaterAid: India. November 2010. This issue was written by Bonnie Keith 39 Chandra-Mouli V, Svanemyr J, Amin A, et al. 20 Sommer M, Hirsch JS, Nathanson C, et al. and produced by Scott Brown and Jennifer Twenty years after International Conference on Kidwell Drake. Outlook appreciates the Comfortably, safely, and without shame: defining Population and Development: where are we with menstrual hygiene management as a public inputs of the following experts and adolescent sexual and reproductive health and reviewers: Venkatraman Chandra-Mouli, health issue. American Journal of Public Health. rights? Society for Adolescent Health and Medicine. 2015;105(7):1302–1311. Jane Hutchings, Celina Kareiva, Catherine 2015;56:S1–S6. Lane, Nancy Muller, Marni Sommer, and 21 United Nations General Assembly. Transforming 40 Sommer M. Menstrual hygiene management Laura Wedeen. Our World: The 2030 Agenda for Sustainable in humanitarian emergencies: gaps and Development. A/RES/70/1. New York: October recommendations. Waterlines. 2012;31(1&2): Copyright © 2016. PATH. All rights 21, 2015. 83–104. reserved. The material in this document 22 Mahon T, Fernandes M. Menstrual hygiene in may be freely used for educational or 41 Abbott L, Bailey B, Karasawa Y, et al. Evaluation of noncommercial purposes, provided South Asia: a neglected issue for WASH (water, UNFPA’s Provision of Dignity Kits in Humanitarian sanitation and hygiene) programmes. Gender & that the material is accompanied by an and Post-Crisis Settings. Final report. New York: acknowledgment line. Development. 2010;18(1):99–113. United Nations Population Fund (UNFPA); 2011. 23 Sumpter C, Torondel B. A systematic 42 Kasiko M. National best practice in advocacy review of the health and social efects of for menstrual hygiene management (MHM) for menstrual hygiene management. PLOS One. schools in Uganda. Presented at: 4th Annual MHM 2013;8(4):e62004. and WASH in Schools Virtual Conference. 2015. PATH is the leader in global health 24 Mason L, Laserson KF, Oruko K, et al. Adolescent Available at: www.unicef.org/wash/schools/files/ innovation. An international nonprofit schoolgirls’ experiences of menstrual cups and Uganda_-_National_best_practice_in_advocacy.pdf. organization, we save lives and improve pads in rural western Kenya: a qualitative study. Accessed January 14, 2016. health, especially among women and Waterlines. 2015;34(1):15–30. 43 What we do page. Sustainable Health Enterprises children. We accelerate innovation 25 Bharadwaj S, Patkar A. Menstrual Hygiene and website. Available at: sheinnovates.com/our- across five platforms—vaccines, drugs, Management in Developing Countries: Taking work/. Accessed November 17, 2015. diagnostics, devices, and system and Stock. Mumbai: Junction Social; November 2004. service innovations—that harness our 44 Venema V. The Indian sanitary pad revolutionary. entrepreneurial insight, scientific and 26 Sommer M. Where the education system and BBC World Service. March 4, 2014. Available public health expertise, and passion for women’s bodies collide: the social and health at: www.bbc.com/news/magazine-26260978. health equity. By mobilizing partners impact of girls’ experiences of menstruation and Accessed January 14, 2016. around the world, we take innovation schooling in Tanzania. Journal of Adolescence. 45 Products page. BeGirl website. Available at: to scale, working alongside countries 2010;33:521–529. www.begirl.org/products/. Accessed November primarily in Africa and Asia to tackle 27 Oster E, Thornton R. Menstruation and Education 17, 2015. their greatest health needs. Together, we in Nepal. Cambridge: National Bureau of 46 African Population and Health Research Center deliver measurable results that disrupt Economic Research; 2009. (APHRC). Attitudes Towards, and Acceptability the cycle of poor health. 28 Lukale N. Stand up tall and break the taboo of of, Menstrual Cups as a Method for Managing menstruation in Africa. Hufngton Post. May Menstruation: Experiences of Women and 28, 2014. Available at: www.hufngtonpost. Schoolgirls in Nairobi, Kenya. Policy Brief No. 21. com/nelly-lukale/stand-up-tall-and-break- Nairobi: APHRC; November 2010. MAILING ADDRESS t_b_5405523.html. Accessed November 17, 2015. 47 Abdul Latif Jameel Poverty Action Lab (J-PAL). PO Box 900922, Seattle, WA 98109 USA 29 Alexander KT, Oduor C, Nyothach E, et al. Water, Menstrual Management and Sanitation Systems. sanitation and hygiene conditions in Kenyan Study overview. Chennai, India: J-PAL at Institute STREET ADDRESS rural schools: are schools meeting the needs of for Financial Management and Research. 2201 Westlake Avenue, Suite 200, menstruating girls? Water. 2014;6(5):1453–1466. 48 Tellier M, Hyttel M, Gad M. Assessing Acceptability Seattle, WA 98121 USA 30 BSR. Female Factory Workers’ Health Needs and Hygienic Safety of Menstrual Cups as a www.path.org | [email protected] Assessment: Bangladesh. HERproject. July 2010. Menstrual Management Method for Vulnerable 31 Das P, Baker KK, Dutta A, et al. Menstrual hygiene Young Women in Uganda Red Cross Society’s Life practices, WASH access and the risk of urogenital Planning Skills Project. Pilot study report. Kampala: infection in women from Odisha, India. PLOS One. WoMena, Ltd; December 2012. 2015;10(6):e0130777. 49 Sommer M. Menarche: A missing indicator in 32 United Nations Children’s Fund (UNICEF). population health from low-income countries. Sanitation: The Challenge. New York: UNICEF; Global Health Matters. Public Health Reports. 2005. September–October 2013;128:399–401.