EVIDENCE SERIES Menstrual Hygiene Management Introduction Fifty-one percent of the female population is of reproductive To date there is no global estimate of the percentage of age, meaning that at least 1.8 billion women and girls women and girls who lack the resources needed to manage around the world are in need of information, products, and their periods, but evidence from small-scale research private facilities to manage their monthly periods.1-2 Having studies suggests that many women and girls in developing one’s period demands access to affordable sanitary pads countries struggle to access adequate information, or other clean and absorbent products, a discreet place products, and disposal systems. Silence and stigma around to change or dispose of them, and water sources to wash the topic of menstruation, paired with women’s limited hands, sanitary products, and stained garments.3 Women participation in policymaking, makes programs to support and girls need to feel safe and comfortable to manage menstrual hygiene management (MHM) a low priority – but their periods while at work or school, and young girls need MHM can boost the health, comfort, and dignity of women information about what menstruation is, what it signals and girls and support them to become active participants in about their fertility, and how to safely handle it each month. society. Range of Menstrual Hygiene Products In developing countries, most girls and women repurpose A few studies have demonstrated a growing acceptance of cloths and rags, which they wash and dry during their menstrual cups.8-9 Although cups can be difficult to insert periods. These materials are familiar, convenient, affordable and are initially expensive, they can last up to ten years, and relatively comfortable. In some circumstances, promising a significant reduction in menstrual waste and a women also turn to pieces of cotton wool or other natural low cost in the long run.6 materials that are absorbent, but may be uncomfortable and unsanitary.4 The menstrual product category expands beyond just absorbent materials. Days for Girls manufactures a $10 The most commonly-used products available on the “Hygiene Kit” which contains washable pads and menstrual market are reusable sanitary pads made out of soft cotton.5 cups, moisture barriers, underwear, zip-bags for used Reusable pads are less expensive in the long-term and are products, a washcloth and travel soap, and instructions. more environmentally-friendly than disposable versions. Because the kit lasts three years, it is a good option for The main disadvantage of reusable pads is that they can women in areas with a limited supply of products.10 Women become contaminated if not washed and dried properly, may be in need of pain relievers to help them perform daily so thorough instructions for cleaning and a reliable water activities while they have menstrual cramps; however, source are essential.5-6 supplying medicine is a more difficult solution due to the need to strengthen distribution channels and finding funding Menstrual products may be either locally or commercially to subsidize the pills.5 produced, although local production is generally restricted to pads because tampons and menstrual cups are difficult Programs that aim to make products accessible must to make.5 Commercial products tend to be more expensive, consider the affordability and ease of use for the consumer. and are usually disposable versions that create waste.4 Local The choice between reusable and disposable products may production can create jobs in the community but may have a depend on the available disposal and water facilities, and limited reach to consumers. the model should be compatible with women’s traditional undergarments. While products should be culturally In many contexts, tampons and menstrual cups are not acceptable, programs can look for opportunities to correct culturally appropriate due to discomfort with insertion into misperceptions about insertable products. When partnering the vagina and misconceptions about what it means to lose with local producers, programs should ensure that products one’s virginity.7 Women and girls may have a greater risk of that can be made from readily available materials and infection if they don’t know how to insert or when to change distributed efficiently after production.4 these products or do not wash their hands before doing so.5 2 Strengthening WASH Facilities The stigma around menstruation means that the needs units for girls and boys, with lockable doors and high walls of women and girls for managing their periods are rarely to ensure privacy and security. Facilities should have incorporated into the design of sanitation facilities.11 In latrines and handwashing stations, as well as an in-unit response, the current climate for MHM favors interventions incinerator or disposal pit for girls to dispose of sanitary that integrate menstrual hygiene with the improvement of pads. Installing mirrors can help girls feel confident that they WASH facilities.6 Often such interventions are delivered have not leaked onto their clothes.5 through schools in order to promote dual goals of improved hygiene and consistent school attendance by girls. Additional challenges to MHM remain in emergency settings, where facilities may be connected to temporary waste Many schools in the developing world do not have facilities collection and water systems, and women must manage where girls can change or dispose their materials or wash their periods with limited products and in close proximity to in private.12 WASH facilities in schools should have separate others.4 Delivering Information Through Puberty Curriculum Curricula often focus on the basics of reproductive anatomy to comfortably teach the subject and making educational and fail to provide key information on how to manage pamphlets available. In Tanzania, findings from a study menstrual periods. Girls often seek advice from older on MHM knowledge and practices led to the creation of women, who may recommend traditional products and a book about puberty, which the Ministry of Education practices that may not meet the girls’ wishes for discretion incorporated into school health curricula.7 To reinforce and comfort.13,5 lessons from the classroom, schools can establish hygiene clubs for older students to teach younger students about UNESCO recommends that puberty education begin in MHM, handwashing, and other hygiene topics, or strengthen primary school so that girls understand what is happening relationships local health workers who can regularly visit the to their bodies and know what to expect before menarche.13 school with information and products.5 Given that the global dropout rate before the last year of primary school is 23% (as high as 42% in sub-Saharan Puberty education can be an effective way to break the Africa), it is especially important that menstrual hygiene silence and change perceptions among boys, who often education reach girls when they are young and still in do not understand menstruation is and resort to teasing school.13 For cultural reasons, schools may find it prudent to their female classmates.12 Co-ed puberty curricula generate de-couple MHM from sex education.5 understanding between boys and girls and encourage them to adopt respectful interpersonal behaviors.13,4 Education about menstruation requires training teachers 3 Supportive Environment In addition to creating a friendlier environment at school, ensure that women and girls can access facilities when they interventions can work to engender support for MHM in the need to.4,13 community. Some of the greatest challenges for women and girls are limited funds for products, embarrassment International and government support can ensure purchasing from male shopkeepers, and cultural taboos that funding and an enabling policy environment for facility force women to hide that they are on their period.6 improvements and supply of affordable products. The 2014 “MHM in Ten” meeting led UNICEF, UNESCO, WaterAID, and Increased access to information can challenge the Save the Children to prioritize MHM in their programming myths that prevent women from interacting with men or agendas for the next ten years. This global initiative has performing household tasks while on their periods.5 It can committed to achieving MHM in schools and building an also make others, especially men, aware of the needs of evidence base for MHM to inform future interventions.6 girls and women when they are on their periods. Male heads MHM programs should also engage with national of households who understand the value of MHM are more governments from the start of their work to ensure buy-in likely to make funds available for their wives and daughters and additional support for multi-sectoral involvement.14 to purchase products, and teachers and employers can Impact of MHM ON HEALTH conclusive quantitative evidence that improvements in MHM 15 Further research needed on the impact of menstrual reduce school absenteeism. On the other hand, qualitative hygiene on women’s health. A review on the health impact interviews with girls indicate that girls feel more comfortable of menstrual hygiene found that half of the 14 included when using better-quality menstrual products because they studies demonstrated an association between poor MHM do not worry as much about leaks or smells and they are 13 and reproductive tract infections, but the results were able to participate in sports and games with classmates. generally weak.15 Nonetheless, there is an understanding Even with better products, however, girls’ attendance that practicing proper hygiene and using sanitary materials demands access to a reliable water source and private toilet 8 can reduce a woman’s individual risk of infection.4,9 Improved facilities at school. knowledge about menstruation may reduce the number of unplanned pregnancies that occur because girls are not ON THE ENVIRONMENT aware that menstruating means they are fertile, or that MHM interventions can play a critical role in environmental they can still become pregnant if they have sex during their sustainability.