A resource for improving menstrual hygiene around the world Sarah House, Thérèse Mahon and Sue Cavill p.2 Introductory pages Copyright © WaterAid. All rights reserved. This material is under copyright but may be reproduced by any method for educational purposes by anyone working to improve the lives of women and girls through strengthening menstrual hygiene knowledge and practices, as long as the source is clearly referenced. It should not be reproduced for sale or commercial purposes without prior written permission from the copyright holders. The authors would appreciate receiving information on when, where and for what purpose the materials have been used. Please send details to [email protected] Disclaimer This resource is a synthesis of good practice. While every effort has been made to obtain permission for the inclusion of materials, and also to verify that information is from a reputable source, checks have not been possible for all entries. Therefore, users are encouraged to follow up with the original references when considering using sections of this resource. This resource is for information only and should not be used for the diagnosis or treatment of medical conditions. WaterAid has used all reasonable care in compiling the information but makes no warranty as to its accuracy. A doctor or other healthcare professional should be consulted for diagnosis and treatment of medical conditions. All examples of commercial products included within this resource are for learning purposes only and do not suggest endorsement by WaterAid and co-publishing organisations. Cover: A young woman producing low cost, First edition, 2012 hygienic sanitary pads in Mirpur, Dhaka. After sewing, the pads are sterilised using an auto- clave and then packed for sale. (Photo: Tridhara Photography/Anisur Rahman p.3 Menstrual hygiene matters About this resource In November 2010, WaterAid, with support from the A peer review process involving 21 individuals (see research consortium SHARE (Sanitation and Hygiene acknowledgements) with expertise from across relevant Applied Research for Equity), brought together 16 sectors was undertaken. Specific expert advice was practitioners and researchers with expertise in water, taken to develop and review the sections of this resource sanitation and hygiene (WASH), health, education and relating to health and menstrual hygiene, in particular gender to share knowledge and experiences and develop a Module 1, Section 1.6, and Toolkit 1, Section T1.3.4. research programme on menstrual hygiene. These sections were written by Suzanne Ferron, an independent consultant, registered nurse and registered The group noted that while there is a need for further health visitor. They were reviewed by Brad Kerner, research to fill critical gaps in our knowledge about Adolescent Reproductive Health Adviser, Save the menstrual hygiene and its impacts, there is a wealth of Children; Dr Belen Torondel, Research Fellow, London practical experience that has not yet been documented School of Hygiene and Tropical Medicine; Dr Penelope and synthesised so that it can be more widely shared and Phillips-Howard, Senior Researcher, Centre for Public applied. This resource has been produced to address this Health, Liverpool John Moores University; and Dr Vendela gap. It presents comprehensive and practical guidance on McNamara, Associate Specialist in Sexual Health, what is already being implemented in different contexts to University Hospitals Leicester. Professor Alison Fiander, encourage replication. Chair Obstetrics and Gynaecology, Wales College of Medicine, and Fistula Surgeon at Disability Hospital, The resource has been produced at WaterAid by Sarah Dar es Salaam, reviewed Toolkit 7, Section T7.3.2, on House, Thérèse Mahon and Sue Cavill, with inputs incontinence and fistula and sanitary protection. from a wide range of individuals and organisations who have shared their experiences and resources through The authors have incorporated the reviewers’ comments as documentation, interviews and focus group discussions. far as possible and with particular care to correct any factual The resource was jointly funded by SHARE and WaterAid. errors. However, the opinions noted in this resource do not necessarily represent those of the reviewers or co-publishing organisations, but are solely those of the authors. p.4 Introductory pages Well designed and appropriate water, sanitation and hygiene facilities that address menstrual hygiene can make a significant difference to the schooling experience of adolescent girls (Photo: WaterAid/ASM Shafiqur Rahman) Co-published by: p.5 Menstrual hygiene matters Contents 7 Women and girls’ experiences of menstruation 63 Module 3 Menstrual hygiene – sanitary protection materials and disposal 8 Foreword 64 3.1 Comparing sanitary protection materials 9 Acknowledgements 75 3.2 Production, distribution and costs 90 3.3 Washing, drying, storage and disposal 11 Contributors to the resource 101 Module 4 Working with communities on menstrual 15 The purpose of this resource and how to use it hygiene 15 The purpose of this resource 102 4.1 Getting started 15 Who this resource is for 103 4.2 Practical menstrual hygiene interventions 16 Approach and format of the resource at community level 16 Structure of the resource 17 Menstrual hygiene – an overview 113 Module 5 Working with schools on menstrual 18 Acronyms hygiene 114 5.1 Getting started 122 5.2 Practical menstrual hygiene interventions Modules in schools 21 Module 1 Menstrual hygiene – the basics 129 Module 6 Menstrual hygiene in emergencies 22 1.1 Why considering menstrual hygiene is 130 6.1 Getting started important for all 136 6.2 Standards and guidelines on menstrual 24 1.2 What is menstruation? hygiene in emergencies 25 1.3 Cultural and religious beliefs, social norms 142 6.3 Practical menstrual hygiene interventions and myths on menstrual hygiene in emergencies 30 1.4 Girls’ first experiences of menstruation 31 1.5 Girls’ experiences of menstrual hygiene in 151 Module 7 Supporting women and girls in school and their impact vulnerable, marginalised or special 32 1.6 Health problems related to menstrual hygiene circumstances 38 1.7 How women and girls can keep themselves healthy during their menstrual period 152 7.1 Making a difference for women and girls in vulnerable, marginalised or special 45 Module 2 Menstrual hygiene – getting started circumstances 156 7.2 Menstrual hygiene challenges of women and 46 2.1 What we should be doing at household, girls in vulnerable, marginalised or special community, sub-national, national and circumstances and actions to support them international levels 164 7.3 Integrating menstrual hygiene into services 48 2.2 Institutional and sector responsibilities and programmes 51 2.3 Building confidence and competence 56 2.4 Men and boys’ involvement in menstrual hygiene 60 2.5 Resourcing for menstrual hygiene p.6 Introductory pages 171 Module 8 Menstrual hygiene in the workplace 287 Toolkit 5 Working with schools on menstrual hygiene 172 8.1 Menstrual hygiene challenges for women in the workplace 288 T5.1 Checklists and other tools 176 8.2 Good practice for menstrual hygiene in the 289 T5.2 Technical designs and specifications workplace 299 T5.3 Case studies, examples and further information 179 Module 9 Research, monitoring and advocacy 302 T5.4 Bibliography 180 9.1 Research, obtaining feedback and monitoring 303 Toolkit 6 Menstrual hygiene in emergencies 187 9.2 International treaties, the Millennium Development Goals, legislation and policies 304 T6.1 Checklists and other tools 190 9.3 Advocacy on menstrual hygiene 305 T6.2 Technical designs and specifications 318 T6.3 Case studies, examples and further information 321 T6.4 Bibliography Toolkits 323 Toolkit 7 Supporting women and girls in 201 Toolkit 1 Menstrual hygiene – the basics vulnerable, marginalised or special circumstances 202 T1.1 Checklists and other tools 204 T1.2 Technical designs and specifications 324 T7.1 Checklists and other tools 211 T1.3 Case studies, examples and further 325 T7.2 Technical designs and specifications information 328 T7.3 Case studies, examples and further 237 T1.4 Bibliography information 333 T7.4 Bibliography 241 Toolkit 2 Menstrual hygiene – getting started 335 Toolkit 8 Menstrual hygiene in the workplace 242 T2.1 Checklists and other tools 242 T2.2 Technical designs and specifications 336 T8.1 Checklists and other tools 243 T2.3 Case studies, examples and further 337 T8.2 Technical designs and specifications information 337 T8.3 Case studies, examples and further 248 T2.4 Bibliography information 337 T8.4 Bibliography 249 Toolkit 3 Menstrual hygiene – sanitary protection materials and disposal 339 Toolkit 9 Research, monitoring and advocacy 250 T3.1 Checklists and other tools 340 T9.1 Checklists and other tools 251 T3.2 Technical designs and specifications 349 T9.2 Technical designs and specifications 270 T3.3 Case studies, examples and further 349 T9.3 Case studies, examples and further information information 278 T3.4 Bibliography 351 T9.4 Bibliography 281 Toolkit 4 Working with communities on menstrual hygiene 282 T4.1 Checklists and other tools 282 T4.2 Technical designs and specifications 283 T4.3 Case studies, examples and further information 284 T4.4 Bibliography p.7 Menstrual hygiene matters “I didn’t know “I am always what was happening [at changing my soiled menarche] or what to do to “During winter napkin at interval of eight to manage menstruation. I used cotton it is very difficult, we ten hours as there are hardly any wool, pages from an exercise book, have to sleep alone [during facilities available to change my leaves from trees. I suffered much menstruation], and there is not pads and it is embarrassing to ask embarrassment at school because I enough warm clothes at night. anyone to use their bathroom for leaked and stained my uniform.” Many times I have to ask father said purpose.” Woman with a physical impairment for [a] quilt.” Female NGO field worker from Tanzania1 Girl from Nepal2 from India3 “We believe that it is important to tell our daughters about menstruation “We are eager to but we don’t know much.