Addressing Vaginal Bleeding Throughout the Life Course in Low and Middle- Income Countries

Downloaded from http://gh.bmj.com/ on July 31, 2017 - Published by group.bmj.com Analysis Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle- income countries Marni Sommer,1 Penelope A Phillips-Howard,2 Therese Mahon,3 Sasha Zients,1 Meredith Jones,1 Bethany A Caruso4 To cite: Sommer M, ABSTRACT Phillips-Howard PA, Mahon T, Girls and women experience numerous types of vaginal Key questions et al. Beyond menstrual hygiene: bleeding. These include healthy reproductive processes, addressing vaginal bleeding such as menstruation and bleeding after childbirth, What is already known about this topic? throughout the life course but also bleeding related to health conditions, such as ► Girls and women require water, sanitation, in low and middle-income information, education and supplies to correctly countries. BMJ Glob Health fibroids or cancer. In most societies, the management of menstruation is handled covertly, something girls are manage the numerous types of vaginal bleeding 2017;2:e000405. doi:10.1136/ they experience. bmjgh-2017-000405 often instructed about at menarche. The management of other vaginal bleeding is often similarly discreet, although ► In most societies, the management of menstruation behaviours are not well documented. In many societies, and other vaginal bleeding is handled covertly as Received 12 May 2017 cultural taboos frequently hinder open discussion around cultural taboos frequently hinder open discussion. Revised 15 June 2017 vaginal bleeding, restricting information and early access Accepted 17 June 2017 What are the new findings? to healthcare. Additionally, the limited availability of clean, ► Cultural, societal and financial constraints negatively accessible water and sanitation facilities in many low impact girls and women’s ability to adequately and middle-income countries augments the challenges manage vaginal bleeding, and to differentiate when girls and women face in conducting daily activities while such bleeds require health intervention. managing vaginal bleeding, including participating in ► The limited availability of clean, accessible water school or work, going to the market or fetching water. and sanitation facilities in many low and middle- This paper aims to highlight the key vaginal bleeding income countries augments the challenges girls experiences throughout a woman’s life course and the and women face in conducting daily activities while intersection of these bleeding experiences with their managing vaginal bleeding. access to adequate water and sanitation facilities, information and education sources, and supplies. The aim Recommendations for policy is to address the silence around girls and women’s vaginal ► Breaking the silence around girls and women’s bleeding and their related social, physical and clinical vaginal bleeding and their related social, physical management needs across the life course; and highlight and clinical management needs across the life critical gaps that require attention in research, practice and course require attention in research, practice and policy around this neglected topic of health and gender policy, including improved education, training and equality. communication. INTRODUCTION information, supplies water and sanitation. Attention to women and girls’ health risks Based on the recent, growing knowledge base 1Mailman School of Public and outcomes beyond the reproductive years of the challenges women and girls in low and Health, Columbia University, is increasing,1 2 with life course approaches middle-income countries (LMIC) face during New York, New York, USA emphasising that health is dynamic and cumu- menstruation due to these needs being 2Liverpool School of Tropical lative, and influenced by genetic, biological, largely unmet,4 5 this paper hypothesises that Medicine, Liverpool, UK 3 3WaterAid, London, UK behavioural, social and economic contexts. the evidence to date represents the ‘tip of an 4Rollins School of Public Health, This paper assesses the range of vaginal iceberg.’ A life course approach is required, Emory University, Atlanta, bleeding episodes (‘episodes’ herein used to one that looks at vaginal bleeding including Georgia, USA represent episodic vaginal bleeding, including and beyond menstruation, to comprehen- Correspondence to both menstrual and due to other causes) that sively address the critical needs of girls and Dr Marni Sommer; ms2778@ girls and women may experience during the women for information, supplies, water and columbia. edu life course, and their associated needs for sanitation in LMICs. Sommer M, et al. BMJ Glob Health 2017;2:e000405. doi:10.1136/bmjgh-2017-000405 1 Downloaded from http://gh.bmj.com/ on July 31, 2017 - Published by group.bmj.com BMJ Global Health Throughout the life course, girls and women experi- or abnormal bleeding, which can include spotting ence numerous episodes of vaginal bleeding, many of throughout the month, episodes of very heavy and painful which remain hidden due to misinformation, fear, embar- bleeding or months with no bleeding. Women are likely rassment, shame and taboo.6 This features the more to experience episodes of bleeding for 4–6 weeks after a widely known bleeding experience of monthly menstru- miscarriage and 4 weeks postpartum.11 This has particular ation, as well as other less discussed bleeding episodes, significance for those in LMIC with high fertility rates (ie, including those related to pregnancy, childbirth and multiple pregnancies and/or miscarriages). In addition, postpartum, miscarriage, cancers and endometriosis (see it is estimated that 5%–15% of women of reproductive table 1). To navigate these experiences, girls and women age globally have abnormal uterine bleeding.12 Episodes require factual and supportive information that enables of vaginal bleeding may occur prior to menarche,13 14 them to differentiate between healthy and abnormal occur during perimenopause15 and may occur postmeno- bleeding, to understand and take care of their bodies or pause due to illness conditions. those of dependents who may require assisted care, and Although minimal prevalence data exist across LMIC, to seek health advice appropriately. To manage vaginal there are likely to be significant numbers of women who bleeding hygienically and with dignity requires adequate experience vaginal bleeding related to reproductive (clean, safe, private, affordable and accessible at any health conditions, such as fibroids or endometriosis. time) water, sanitation and hygiene (WASH) facilities, One study from Nigeria suggested that 29% of women and supplies (ie, soap, sanitary products, basins). Basic of reproductive age have fibroids.16 Both conditions essentials required to manage menstrual needs have can mean extremely heavy irregular bleeding along only recently been characterised (see box 1). The ways with discomfort. A cross-sectional internet study in which women and girls manage these bleeding expe- among 21 476 women in eight high and middle-income riences can vary greatly depending on factors associated countries found that 33% of women with fibroids experi- with the bleeding itself, their particular life course trajec- enced bleeding between periods compared with 14% of tory (age, agency, previous life experiences) and the women without, and significantly greater proportions of broader physical and social environments in which they women with fibroids reported heavy menstrual bleeding, operate. For women living in LMICs, support and WASH prolonged menstrual bleeding, and more frequent and services are particularly lacking. irregular menses as compared with their counterparts.17 Definition of adequate menstrual hygiene manage- In Senegal and Mali, 52 and 51 (per 100,000) of disabili- ment 18 ty-adjusted life years are estimated for uterine fibroids. Women and adolescent girls are using a clean menstrual The causes of both uterine fibroids and endometriosis management material to absorb or collect menstrual are unknown. blood, that can be changed in privacy as often as neces- As life expectancies increase, women across LMIC are sary for the duration of a menstrual period, using soap more likely to experience uterine or cervical cancers,19 and water for washing the body as required, and having both of which cause vaginal bleeding. Cervical cancer, access to facilities to dispose of used menstrual manage- caused by certain strains of human papilloma virus ment materials. They understand the basic facts linked (HPV), is the most common form of cancer currently to the menstrual cycle and how to manage it with dignity 7 reported among women in sub-Saharan Africa, with and without discomfort or fear. 34 000 out of 100 000 diagnosed each year (and limited 20 The types of bleeding experienced over the life course screening suggests underdiagnoses). HPV is spread There are numerous types of vaginal bleeding experi- through vaginal, anal and oral sex, meaning that previous enced by girls and women. Some are part of a healthy life events influence risk. reproductive cycle over the life course, and others are These issues suggest significant implications for the linked to specific disease conditions. The majority of girls, women and caregivers who may struggle to manage girls and women will experience monthly menstruation. illness-related vaginal bleeding for themselves or their Given the declining age of puberty (and menarche) and dependents. All vaginal bleeding episodes potentially 8–10 cause subjective experiences of fear, discomfort

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