Menstrual Hygiene Management Naomi Radke, seecon international GmbH

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Contents Introduction Beliefs, Myths and Taboos Menstrual Hygiene, Human Rights and MDGs Health Risks of Poor Menstrual Hygiene Management Menstrual Hygiene Management: Hardware Menstrual Hygiene Management: Software

1. Introduction Menstruation 52% of women worldwide are in reproductive age and most of them thus are menstruating monthly. Still, the majority of them are not in conditions to take care of their menstruation in a hygienic manner or are impaired by it. Menstruation is supposed to be invisible and silent. Source: KJELLEN ET AL. (2012) Source: http://www.mcmaster.ca/museum/Exhibitions_Fierce.html [Accessed: 07.08.2013]

2. Beliefs, Myths and Taboos Harmful restrictions In some cultures, women and girls are told that During their menstrual cycle they should not bathe (or they will become infertile) Touch a cow (or it will become infertile) Look in a mirror (or it will lose its brightness) Touch a plant (or it will die) Young women chatting about menstrual issues. Source: UNICEF (2008)

2. Beliefs, Myths and Taboos Other restrictions Restrictions on girls during their menstrual period in Afghanistan, India, Iran and Nepal. Source: (HOUSE et al. 2012).

Relieving restrictions 2. Beliefs, Myths and Taboos Relieving restrictions Women may appreciate the ‘banishment’ to menstrual huts as they are given a rest period from the normal intensity of daily chores. Zulu menstruation hut. Source: RINDSTAD (2013)

2. Beliefs, Myths and Taboos Parental Education Education by parents about reproductive health, sexuality and related issues is often a no-go area leading to a low knowledge and understanding on these issue Source: http://phil2100dsu12a.wordpress.com/2012/07/10/abortion-the-solution-is-viability/ [Accessed: 07.08.2013]

Lack of facilities and sanitary products (1/2) 3. Menstrual Hygiene, Human Rights and MDGs Lack of facilities and sanitary products (1/2) ... Can push many girls out of school. Relationship between menstrual hygiene and school drop-out of girls from the higher forms due to lack of facilities, affordable sanitary products, fear of bloodstains and more. Millenium Development Goal (MDG) 2: Achieve universal primary education  Participation of girls especially in Africa and Asia lags far behind the boys’ in higher forms of primary education Millenium Development Goal (MDG) 3: Promote gender equality and promote women  The lacking behind in primary education to not providing adequate facilities and sanitary products infringes gender equality and the promotion of women

Lack of facilities and sanitary products (2/2) 3. Menstrual Hygiene, Human Rights and MDGs Lack of facilities and sanitary products (2/2) Stigma around menstruation hurts human rights, especially human dignity but also the right to non-discrimination, equality, bodily integrity, health, privacy and the right to freedom from inhumane and degrading treatment from abuse and violence.

4. Health Risks of Poor Menstrual Hygiene Management Poor protection and inadequate washing facilities may increase susceptibility to infection In case of female genital cutting: blockage and build-up of blood clots is created behind the infibulated area: pain, additional infection risk Risk of infection higher than normal during period as the blood forms a pathway into the uterus

Inappropriate hygiene practices (1/3) 4. Health Risks of Poor Menstrual Hygiene Management Inappropriate hygiene practices (1/3) Certain practices are more likely to increase the risk of infection e.g. using unclean rags. Inappropriate practices often due to the non-affordability of sanitary products for poor women. Findings from Bangladesh: 80% of factory workers are women 60% of them were using highly chemically charged rags from the factory floor for menstrual cloths Infections are common, leading to 73% of women missing work for on average six days a month Women had no safe place either to purchase cloth or pads or to change/dispose of them When women are paid by piece, those six days away present a huge economic damage to them but also to the business supply chain

Inappropriate hygiene practices (2/3) 4. Health Risks of Poor Menstrual Hygiene Management Inappropriate hygiene practices (2/3) Unclean sanitary pad materials (local infections/bacteria can travel up the vagina and enter uterine cavity) Changing pads infrequently (skin irritation by wet pads) Insertion of unclean material into vagina (easier infection , also of uterine cavity) Using highly absorbent tampons during light blood loss or no menstruation (toxic shock syndrome, vaginal irritation) Source: HOUSE ET AL. (2012)

Inappropriate hygiene practices (2/2) 4. Health Risks of Poor Menstrual Hygiene Management Inappropriate hygiene practices (2/2) Wiping from back to front following urination or defecation (bacteria can travel easier into vagina) Unprotected sex (increased risk of sexually transmitted diseases) Unsafe disposal of used sanitary materials or blood (risk of infecting others with diseases) Frequent douching (forcing liquid into vagina can introduce bacteria into uterine cavity) Lack of hand-washing after changing a sanitary towel (can spread infections) Source: HOUSE ET AL. (2012)

Sanitary protection materials (1/4) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials (1/4) It is critical that any programme aiming to support women or girls with sanitary protection materials involves them in the planning discussions and decisions about the options to be supported. Schoolgirls participating in a menstrual cup project. Source: APHRC (2010)

Sanitary protection materials (2/4) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials (2/4) Disposable sanitary towels In resource-poor settings often very expensive and hard to dispose of Often difficulty of proper disposal (generates solid waste) But reduce barriers of girls staying at school Source: HOUSE ET AL. (2012)

Sanitary protection materials (3/4) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials (3/4) Cloth or cloth pads A sustainable sanitary option, but it must be hygienically washed and dried in the sunlight (natural steriliser) But shame of drying the clothes outside, so often hide them in damp unhygienic places Locally made reusable cloth pads and cloth in Kenya. Source: HOUSE ET AL. (2012)

Sanitary protection materials (4/4) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials (4/4) Menstrual cup New technology appropriate for poor women and girls Cup made of medical silicone rubber that is inserted into the vagina to collect menstrual blood Removed and emptied less frequently than sanitary pads Needs to maintain a high standard of hygiene especially during insertion, removal and general cleaning Menstrual Cup by The Moon Cup (UK). Source: http://www.mooncup.com/photographs.html [Accessed: 07.08.2013] Instructions for menstrual cups. Source: RUBYCUP (2013)

Sanitary protection materials – advantages/disadvantages (1/2) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials – advantages/disadvantages (1/2) Sanitary protection option Advantages Disadvantages Natural materials (e.g. mud, cow dung, leaves) Free Locally available High risk of contamination Difficult and uncomfortable to use Strips of clothes Easily available in the local market Re-usable If old cloths are not cleaned well they can become unhygienic. Users need somewhere private, with a water supply and soap, to wash and dry the cloths. Toilet paper or tissues Loses strength when wet and can fall apart. • Difficult to hold in place. • May be too expensive for the poorest users Re-usable pads Available locally or on the internet Income generation opportunity, if locally made Cost effective as are re- usable More environmentally- friendly than disposable pads Users need somewhere private, with a water supply and soap, to wash and dry the pads. Cost is prohibitive to many potential users, if commercially produced Source: HOUSE ET AL. (2012)

Sanitary protection materials – advantages/disadvantages (2/2) 5. Menstrual Hygiene Management: Hardware Sanitary protection materials – advantages/disadvantages (2/2) Sanitary protection option Advantages Disadvantages Tampons Convenient and comfortable to use Not available in many contexts. Cost is prohibitive to any potential users. Generates a lot of waste to dispose, not environmentally-friendly. May not be culturally appropriate, particularly for adolescent girls, as need to be inserted into the vagina. Hygiene and availability of water and soap for hand-washing are particularly important, as need to be inserted into the vagina. Menstrual cups Re-usable Only need emptying, washing and drying May not be culturally appropriate for use, particularly for adolescent girls, as need to be inserted into the vagina. Hygiene and availability of water and soap are particularly important, for washing hands and menstrual cup, as need to be inserted into the vagina. Expensive first investment outlay. Panties/ Underwear Useful for keeping a sanitary product in place. • Good for keeping the vaginal area hygienic. Cost may be prohibitive to potential users. Cheap elastic can wear out relatively quickly. Source: HOUSE ET AL. (2012)

Sanitary infrastructure 5. Menstrual Hygiene Management: Hardware Sanitary infrastructure Absence of clean and private sanitation facilities that allow for menstrual hygiene may discourage girls from attending school when they menstruate. Menstrual hygiene: e.g. lockable toilets, closed bin for sanitary item disposal, sink for hand washing and cleaning of clothes (both inside toilets) 1 in 10 school-age African girls do not attend school during menstruation or drop out, due to this absence Teachers’ instruction time in school will be reduced by 10-20%  To manage menstruation hygienically, it is essential that women and girls have access to water and sanitation Source: HOUSE ET AL. (2012)

5. Menstrual Hygiene Management: Hardware Disposal If lack of opportunities, dispose secretly and easily: thus on defecation field, river or garbage dump Blocking toilets/filling up pits Disposing of non-biodegradable sanitary pads in pit latrines leads to quick filling and thus shortened service of the pit. Source: HOUSE ET AL. (2012)

6. Menstrual Hygiene Management: Software Education Education and information (in combination with hygiene and sex education) empowers women and girls with factual information about their bodies and how to look after them Teachers are rarely trained in teaching menstrual hygiene and consequently rarely teach it; male teachers may feel cultural norms forbid them

Further software. Awareness Raising 6. Menstrual Hygiene Management: Software Further software. Awareness Raising Promoting good practices for Menstrual Hygiene Management: How to capture the blood How to dispose of the cloth, pad, cotton How to keep yourself clean during the period How to manage the stomach pain from your period For an overview see Table 1.6 (p. 39, HOUSE et al. 2012) Community-wide approaches that include boys and men (Physical barriers are often connected to social barriers. Social barriers have to be overcome!) Integrate Menstrual Hygiene Management into a wider hygiene promotion approach on Water, Sanitation and Hygiene including risks and good practices

6. Menstrual Hygiene Management: Software Example of promoting menstrual hygiene management: Mother’s Day - Zambia Mother’s day: one day off work per month. Silent belief that this day was thought for a day of relief whilst having menstruation.

References KJELLEN, M., PENSULO, C., NORDQVIST, P., FOGDE, M. (2012): Global Review of Sanitation System Trends and Interactions with Menstrual Management Practices. Report for the Menstrual Management and Sanitation Systems Project. Stockholm: EcoSanRes, Stockholm Environmental Institute (SEI). URL: http://www.irc.nl/docsearch/title/180836 [Accessed:05.08.2013] HOUSE, S.; MAHON, T.; CAVILL, S. (2012): Menstrual hygiene matters. A resource for improving menstrual hygiene around the world. London: WaterAid. URL: http://www.wateraid.org/what%20we%20do/our%20approach/research%20and%20publications/view%20publication?id=02309d73-8e41-4d04-b2ef-6641f6616a4f [Accessed:05.08.2013] RINDSTAD, S. (2013): Symbolic Meaning of Menstruation. Available at: http://pub209healthcultureandsociety.wikispaces.com/Symbolic+meaning+of+menstruation+across+different+cultures+and+perspectives [Accessed:07.08.2013] RUBY CUP (2013): http://www.ruby-cup.com [Accessed: 08.03.2013] UNICEF (2008): Sharing simple facts. Useful information about menstrual health and hygiene. New York: United Nations Children's Fund (UNICEF). URL: http://www.unicefiec.org/document/sharing-simple-facts-useful-information-about-menstrual-health-and-hygiene-booklet-english [Accessed: 08.03.2013]

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