By Amanda Cave & Emily Wilson-Smith
Menstrual health has long been disregarded as a ‘women’s issue’, and therefore teeters on the edge of political debate. Over the last few years, however, discussion about menstrual hygiene management (MHM) in the public sphere has been increasing. From protests and petitions over the tampon tax in the UK, to poor sanitation facilities in developing countries and the first ever ‘Menstrual Hygiene Day’ on 28th May 2014, menstruation is slowly starting to receive the recognition it deserves and is being brought onto the international development agenda.
Poor menstrual hygiene management is a neglected driver of gender inequality. Irise International is an NGO working to develop a solution to MHM through supporting the education and empowerment of marginalised women and girls in East Africa. Irise presents the issues surrounding MHM in three main strands: lack of access to sanitary products and facilities, lack of knowledge about menstrual health, and taboos and myths surrounding menstruation. These three issues intersect with each other, impact on multiple human rights and subsequently fuel gender inequality.
1 – Lack of access to sanitary products and facilities
Irise’s research in target areas of Uganda found that 71% of girls used alternative materials such as bits of rag, mattress, dried maize cobs, or even cow dung and leaves to manage menstruation. Also, more evidence is needed, but initial medical research suggests that poor menstrual hygiene may increase girls’ risk of urogenital infections, negatively affecting their long-term reproductive health.
Furthermore, research has highlighted how toilets are often not suitable for menstruating girls in low-income contexts. There are typically no separate toilets for boys and girls, and girls struggle to secure privacy for themselves since many cubicles tend to lack doors. Low light levels, dirty facilities, and unreliable access to water also make it difficult for girls to change and wash their menstrual products. This significant lack of sanitation facilities in schools presents huge barriers to girls engaging in the public spheres of education and, later, employment. One young woman’s reflections on her school days clearly demonstrates this:
“With the dawn of every single period; the heat, the sitting arrangement, the lack of proper washing facilities, the lack of sanitary pads, the anxiety and self-consciousness made me feel like I was in prison, a monthly prison.”
2 – Lack of knowledge
Knowledge is a hugely important part of menstrual hygiene. When Irise began their research, 75% of girls they worked with believed period pain was a sign of illness, and 43% were afraid to run or dance during their period. Over half of girls reported missing school during their period. After the implementation of Irise’s education programs, however, girls have increased knowledge:
“Now I no longer get worried; because of the pads I got I can be able to do everything, even playing, jumping and sitting in class.” – Florence.
“It helped because I no longer fear when I am in class, because I know it’s normal for every girl.” – Agnes.
Lack of knowledge impacts on girls’ sexual and reproductive health; they are poorly equipped to make informed decisions about their own body. It also means that they are vulnerable to harmful advice and misconceptions. For example, a common one in Uganda is the idea that sex will help ease period pain. Irise has come across cases where girls are told by their doctor that sex is the only solution to manage the pain. They even heard of cases where doctors have encouraged girls to have sex with them in order to ease their period pain. Thus, there is a real vulnerability that comes with lack of knowledge.
3 – Taboos and myths
Taboos and myths surrounding menstruation reinforce already existing negative attitudes towards women. Girls are missing school due to the lack of accessible products and facilities and a dearth of knowledge, but even when they do attend school, girls face further problems. As one girl explains, “The shame of blood leaking through your skirt, boys calling you names, sores and infections, to mention but a few, makes you hate being a young healthy woman.” Pervasive myths and taboos that surround menstruation increase discrimination against women. For example, a common myth in Uganda is that painkillers cause infertility. Irise have even come across this being taught in medical schools. One girl’s experience illustrates the impact myths like this can have:
“I started to have pains on the first day of my period and crawled to the school matron’s door. She told me the pain would cease when I give birth to a child. I started to look forward to having a child. She told me that I was not allowed to take any painkillers because no one is allowed to interfere with the natural process. The pain being natural, I had to bear it.”
Furthermore, the notion that menstruation is dirty is deeply rooted in patriarchal attitudes towards women. This stigma perpetuates the view that menstruation is a secret subject not to be discussed, preventing girls from accessing the information they need. Ideas that a menstruating girl could cause harm or contaminate others persist; for example, she could affect crop production or ‘bewitch’ people. It is therefore harder for girls to be in school during menstruation because these myths contribute to low confidence and fears of humiliation by others. One girl recalls,
“My male class teacher called me forward to punish me for missing class the previous day. Startled, I tried to explain how I was resting and trying to get relief from the pain of my period. Unfortunately, he would not listen to me and I lost my seat for the class.”
So, what can be done?
Irise believes that a replicable and sustainable solution is in reach and can be developed and disseminated globally over the next five years. There is no reason why appropriate sanitary products and information should not be available to every girl, even in low-income rural contexts. Their model combines the delivery of rigorously tested education materials with establishing local access to a range of affordable sanitary products. Irise works through partners and harnesses existing infrastructure in order to institutionalise change on this issue. They are currently piloting their model with a portfolio of partners in central Uganda, which will reach 20,000 people by September 2016. They have also recently completed the first fully powered randomised control trial looking at the impact of their work on girls’ outcomes.
Whilst global attention is slowly being brought to the issue of MHM, much more still needs to be done for it to be prioritised. An estimated 4 – 5 million girls in Uganda and Kenya alone struggle to access sanitary products. The problem persists across low-income contexts in sub-Saharan Africa. Innovative, cheaper products have been developed but are still not locally accessible to the majority of girls. Many households have the resources to access these cheaper products, but desire will only translate into demand if those who control the resources (often men) understand the importance of the issue. Misinformation needs to be tackled to ensure girls are enabled to use products confidently and safely, and, perhaps most importantly, menstruation needs to be discussed openly so that it is no longer taboo. Ultimately, in order to successfully tackle MHM, attitudes towards women and girls must change.
Menstruation matters, because girls matter. Period.
Emily is a Co-founder and Director of Irise International. She is also an Honorary Research Fellow at the University of Sheffield and a Teaching and Research Associate at Kampala International University with several years experience of women’s health and development. Follow her on twitter @emswsmith.
Featured image shows girls posing after feedback interviews with the Irise team about the Irise program. Photo courtesy of Emily Wilson-Smith.
AusAID (2011), Menstrual hygiene management, Civil Society WASH learning fund, Australian Government, Australia.
Crofts, T. and Fisher, J. (2012), Menstrual hygiene in Ugandan schools: An investigation of low-cost sanitary pads, Journal of Water, Sanitation and Hygiene for Development, 2(1), pp. 50-58.
Wendland, C. et al. (2012), Integrating a gender perspective in sustainable sanitation. Factsheet of Working Group 7b. Sustainable Sanitation Alliance (SuSanA) (April) pp. 1–8.
Wilson E (2014), Menstrual Hygiene in the Context of Reproductive Health. Federation of African Medical Students’ Regional Conference: ‘Working towards MDG 5: The present and future of reproductive health in Sub-Saharan Africa.’
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