Ask any girl in the world about her period, and she’ll tell you it’s a problem. It can be messy and painful, and make you bloated and moody. It can lead to embarrassing accidents. But in some countries, menstruation has much more serious impact. If you’re a girl in a low- or middle-income country, your period can keep you out of school, lead to you losing your job and even make you a target of sexual violence.
In some places, cultural taboos and stigma force girls to sleep or eat away from their families or to abstain from social gatherings during menstruation. That kind of isolation and shame can profoundly affect girls’ psychological and social development. In other places, school-aged girls are so desperate for access to sanitary products that they are forced to engage in transactional sex to obtain them.
There are ways to address these issues. But first, the health community has to stop being so squeamish, say experts. General unease around the topic of periods is preventing the funding of studies needed to find solutions, says Nancy Muller, senior program officer in the product development group at PATH. “It’s a slow conversation that started in the last decade,” she says. “It’s a topic, a worldwide issue, that’s just not talked about. It’s seen as a private matter rather than the public health issue that it is.”
Public health experts specializing in what they call this “nascent” field note in a recent PLOS Medicine article that, “lack of evidence makes it difficult to promote recommendations to national governments, nongovernmental organizations and others interested in integrating MHM (menstrual hygiene management) into education and health strategies, and it reduces global buy-in to move this agenda forward.”
Until recently, there has not been much evidence-based research on menstrual health. Where there have been studies – in sub-Saharan Africa, Asia and South America – they have focused on the intersection of menstruation, education, and water, sanitation and hygiene (WASH) issues. In many countries, schools don’t have bathrooms that facilitate privacy, cleanliness or proper disposal of products. In India, one in four girls miss one or more school days during their periods, for reasons that range from physical discomfort or pain to lack of water, hygiene and disposal facilities in school toilets. Other reasons girls cited for skipping school during menstruation include worries about staining their clothes and relatives or teachers insisting they stay home.
According to Muller, studies in Kenya have shown that some girls become targets for sexual abuse by teachers and boys when it becomes known that they have started menstruating. Studies show two out of three girls who use sanitary pads in rural Kenya get them from sexual partners, which points to the broader problem that many girls don’t have access to products for managing their periods.
At one level, access is about affordability, and many girls and women simply don’t have the money to buy menstrual hygiene products. In Kenya, 65 percent of women and girls can’t afford sanitary pads.
But access is also about availability. Outside of cities, it is often difficult to find feminine hygiene products in the markets. And then there is the issue of acceptability and quality. Disposal sanitary pads are useless in places where many girls and women don’t wear underwear, and pose a huge problem for women who are trying to hide the fact that they are menstruating but can’t find trash cans to throw away their pads. On a community level, disposable products can clog up sanitation systems, causing damage to plumbing and pit latrines that can’t cope with a large volume of non-biodegradable material.
With few options for ways to keep clean and discreet during their periods, women often use materials like grass and cotton wool. Cloth is another alternative for pads, but has numerous drawbacks – its lack of absorbent qualities leads to frequent leakage and the material can harbor harmful microbes since it’s often washed in secret and not hung to dry fully in the sun. According to a recent PATH publication, some research links poor menstrual health to reproductive tract and urinary tract infections. And some of these infections can lead to increased susceptibility to HIV and other sexually transmitted infections, possibly resulting in infertility or problems during pregnancy.
One possible solution has been around for decades, but remains largely overlooked. Menstrual cups have the potential to “transform lives,” says Muller, describing them as “intriguing.” When women use cups to manage their periods, “there’s no odor, they don’t leak and some women report having shorter periods and less cramps,” says Muller.
Made of medical-grade silicone, these devices can hold up to 12 hours of menstrual flow. With a lifespan of up to 10 years, they eliminate the issue of disposability. But many women and girls face barriers to purchasing and using them correctly. Insertable products, such as tampons and menstrual cups, face taboos associated with women’s purity and virginity. Costing $18–$25, they are too expensive for many women. And menstrual cups are not easy to use – a women could need up to three months of training or advice before she’s comfortable using one.
Various NGOs and donors are waking up to the potential of menstrual cups. For example, the U.K.’s Department for International Development (DFID), Medical Research Council and Wellcome Trust are now supporting a large-scale trial in Kenya with menstrual cups to see if they improve girls’ school attendance and health outcomes.
The health community is also looking at other ways to improve menstrual health in low- and middle-income countries. Two years ago, Columbia University and UNICEF launched the “MHM in Ten” initiative to systematically map out a 10-year agenda for overcoming the menstrual hygiene management-related barriers facing schoolgirls.
What is already clear is that one key to improving menstrual health is education and empowering girls to understand their own bodies. PATH reports that research in five African countries found 66 percent of respondents were unaware of menstruation before they started their periods. In a meta-analysis of girls’ knowledge of menstrual health in India, about one-quarter of girls knew that the uterus is the source of bleeding and only about half considered menstruation normal.
“Girls need to be educated that menstruation is healthy and positive not dirty or polluting, to be seen as taboo,” says Venkatraman Chandra-Mouli, scientist in adolescent sexual and reproductive health at the World Health Organization (WHO). “Menstruation is a sign of good health.”