Menstrual Hygiene and Management in Developing Countries:
Taking Stock,
November 2004
Page 2
(Pages 1 - 3)
By Sowmyaa Bharadwaj andArchana Patkar
EMERGENCY SITUATIONS
Menstruation does not stop just because there is an emergency. Besides
the practical issues of obtaining, washing and disposing of sanitary towels,
women may have cultural issues to deal with. In some societies, women have
to go somewhere private whilst they are menstruating. If the whole household
is living in a single room or tent, this can be very difficult.
Paul Sherlock, OXFAM, GB
A less obvious but very felt practical need that also affected the self-respect
of women in Ikafe was how as refugees they had to cope with the process
of menstruation. Although after the first year or so in Ikafe some families
had begun to be able to purchase clothes, it was certainly not all, and
very few had more than one set. Old cloth to use during menstruation was
simply not available. Pastoralists have traditionally used cow-hide but
they now found themselves in Ikafe as cultivators, and cow-hide was not
available. Other tribes were used to using leaves that were not found within
the settlement. Many of those who came as refugees, especially people from
the urban centres, had become used to either using pads, or otherwise pieces
of cloth kept separately and used only for this purpose. In Ikafe, some
found themselves unable to use anything.
Lina Payne, Social Development Consultant
This paper is a beginning. While our initial findings are not encouraging
neither are they necessarily comprehensive. Our rapid review has revealed
some potential gems that merit further investigation, potential research
and development and scaling up. These are detailed in Section 4 below. Wherever
available, we have included contact details.
We hope that circulation of this stock take will encourage wider dissemination
of action and initiatives that have actually dealt with the issue substantively.
We also hope it will lead to focussed action at a practical level so that
the scope of hygiene and environmental sanitation will soon address menstrual
hygiene and management needs in a manner that is actually responsive to
the practical and strategic needs of women and girls, while safeguarding
the environment and addressing wider environmental health needs of the community
at large.
4. OUR KEY FINDINGS
4.1 Background: Perceptions, Associations
Over decades, women have been taught that having periods is shameful.
They have indirectly, if not directly, absorbed the messages that menstrual
blood is dirty, smelly, unhygienic and unclean. This message may be perpetuated
by advertisements for menstrual products or "feminine hygiene"
products. Even the term "feminine hygiene" implies that help is
needed with hygiene. With all these negative messages it is natural for
women to want to hide their blood and throw it away as garbage. To do otherwise
is to go against what they have been taught as women. But menstruation is
a natural physical process - a harmless by-product of a biological event.
Menstrual flow, simply put, is blood and tissue sloughed from the endometrium,
or lining of the uterus. This blood is free of toxins and does it contain
any bacteria except "good bacteria" which is found naturally in
the vaginal canal. The existence of any sort of 'menotoxin' or toxin in
the menstrual flow has never been proven by any reproducible studies. This
menstrual blood, like any bleeding, can harbour viruses like HIV, Hepatitis
B, and Hepatitis C. However, most transmission of blood-borne disease comes
not from contact with the menstrual blood but from contact with blood either
from the cervix or from microscopic tears in the vaginal wall.
On average, a woman loses about four tablespoons of blood each month.
To deal with the "mess" of it, women over the ages have used materials
like grass, sponges, cotton wads and other absorbents to catch the blood.
The embarrassment surrounding menstruation is a somewhat universal phenomenon,
found in most cultures of the world and with many associated code words,
euphemisms and phrases used as linguistic substitutes. [See the MUM page for examples.]
4.2 Attitudes around the world towards Menstruation
In several Asian and African cultures, women were put in seclusion in
special menstrual huts. These are still in use today in some parts.
The ability to bleed and not die equalled control of life powers in some
religions. In goddess worship, a woman's menses determines the status of
her power in the maiden, mother and crone figures. Menopausal women are
sometimes revered and looked up to for their wealth of knowledge and experience.
The Roman author, Pliny, in his Natural History wrote that a menstruating
woman can turn wine sour, cause seeds to be sterile, wither grafts, cause
garden plants to become parched and fruit to fall from a tree she sits under.
Aspects of this are echoed in Hindu socio-cultural practices.
A Hindu woman abstains from worship and cooking and stays away from her
family as her touch is considered impure during this period.
Jewish tradition regards a woman as ritually impure during menstruation
and anyone or anything she touches becomes impure as well. As time went
on, more items were added to include her breath, spittle, footprints, voice
and nail clippings.
Under Islamic law, a menstruating woman is not allowed to pray, fast
or have sex. She is not allowed to touch the Koran unless it is a translation
(as only the Arabic version is considered to be the holy book).
4.3 History of Menstrual Hygiene Products
IMPORTANT DEVELOPMENTS AROUND DISPOSABLES
1890 : First disposable pads "Lister's Towel" Johnson &
Johnson [MUM says: the first ones might have been in Germany, here]
1920-30s : First commercial tampons [see Tampax,
fax, Wix]
1920 : Improved disposable pad Curads brand [here]
1921 : Further improved Kotex disposables [here]
1970 : First adhesive pads [here]
1996 : Development of menstrual cup [MUM says, not true; the cup started
at least in the 1930s]
Even though there are no artefacts to prove it, in Ancient Egypt, there
were laundry lists that indicate the existence of cloth pads, belts and
tampon like items. A low status was accorded to those who chose the profession
of washing the "loincloth of menstruating women", thereby proving
that the practise of using cloth pads, was popular.
In the period of roughly 1700-1900, washing or changing underclothing
was considered unhealthy. Women feared blocking the flow or causing intense
bleeding. Then around 1880-1890, German doctors began proposing menstrual
devices for women to wear to improve their health. American patents for
menstrual devices began in 1854 for a belt with steel springs to hold a
pad, but the products really didn't start gaining in popularity until the
1870's.
Pieces of cloth, called "Granny Rags," made from old sheets,
pillowcases or other surplus material, then folded and pinned into underwear,
served the average woman for years before the advent of commercially made
disposable pads. Rags were washed after each use, hung out to dry, and used
over and over. When odour became an issue, the remedy was to boil the rags
5-10 minutes to get rid of the problem. Women travellers either took their
cloth pads home to wash them or burned them in the fireplace. England had
special portable burners in the 1890's specifically to burn menstrual pads.
Tampon-like materials have been around since ancient times. Hippocrates
wrote of their usage. Egyptians probably used grass or papyrus as tampons.
An interesting fact is that the letters "O.B." in modern-day OB
Tampons means ohne binde or "without
a pad." In World War 1, nurses used large
cotton pads to absorb blood from wounds of soldiers and would keep changing
these as and when the need arose. The soldiers carried back this idea and
the women soon started this practise to help deal with the menstruation
bleeding.
4.4 Experiences in Menstrual Hygiene & Management
4.4.1 IRAN
The Department of Immunology and Microbiology, Iran, in collaboration
with the University of Medical Sciences, Tehran conducted a study to test
the level of knowledge of girls between 15-18, regarding dysmenorrhoea and
menstrual hygiene. They found that 76% of the girls had adequate knowledge
about dysmenorrhoea, but only 32% practised menstrual hygiene such as taking
a bath and using hygienic material like sterile pads. 15% of the subjects
stated that dysmenorrhoea had interfered with their daily life activities
and caused them to be absent from school from between 1 to 7 days a month.
The main conclusion derived in this study was the necessity of educating
female students about personal hygiene associated with their menstrual period
and to adopt a healthy behaviour, which includes: appropriate nutrition,
exercise and physical activity, personal hygiene, and appropriate use of
medications based on a physician's prescription
4.4.2 UGANDA
FAWE, Uganda conducted a campaign to dispel the silence around sexual
maturation (SM), and to advocate for affordable sanitary towels to be available
at the local market. The project is being piloted in the 5 FAWEU districts
of focus; these are Kiboga, Kisoro, Nebbi, Katakwi, and Kalangala. Twelve
primary schools were selected from each of the pilot districts. FAWEU has
carried out workshops to open up dialogue on SM, to introduce hygienic sanitary
towels and to seek solutions to the poor SM management, at school and community
levels. The workshops revealed that poor menstrual hygiene and management
of the adolescent girls stems from beliefs, myths and attitudes within the
Community coupled with poverty. Many parents do not allocate any budget
to sanitary materials. FAWEU is seeking strategic partnerships at community
level to cultivate commitment on the part of all stakeholders to improve
SM management. The result of the advocacy is the falling prices of sanitary
towels on the open market. The workshop outcomes include increased demand
of sanitary towels in rural areas, with local shops beginning to stock them.
Lawmakers want the government to buy sanitary towels for female pupils in
primary schools. The biggest number of school dropouts are girls, because
of inconveniences during their menstruation periods.
4.4.3 KENYA
Girls are staying on longer in school in Kisumu District in Western
Kenya, after a sustained set of activities around hygiene ( including menstrual
issues) and sanitation. The schools have become more 'girl-friendly'.
Fewer girls drop out of education once they reach puberty and boys are more
willing to help to keep the school toilets clean and do other jobs they
would not do at home. The schools - working with two NGOs (Africa Now (AN)
and Sustainable Aid in Africa International (SANA) - have created a culture
in which boys in School Health Clubs share the duties of cleaning latrines,
sweeping classrooms and compounds and providing water to the latrines. The
girls at the schools after the interventions said they were managing menstruation
more easily and were more committed to remaining in school because new school
latrines had been built.
Women in Kenya have praised President Mwai Kibaki's promise to waive
heavy taxes levied on women's sanitary towels as a move which will greatly
enhance women's reproductive health and reduce the costly burden of hygiene
on poor women.
4.4.4 BANGLADESH
Perceptions of Hygiene Study, CEGIS/ UNICEF
This study was commissioned by UNICEF and the Department of Public Health
Engineering Bangladesh, to inform a large rural hygiene, environmental sanitation
and drinking water project covering plain land districts and the Chittagong
Hill Tracts. The scope of the study was restricted to perceptions of mainly
women and adolescent girls around hygiene behaviour in the areas surveyed.
The key findings were:
Women and girls were shy when queried about this issue
Once comfortable they listed a host of problems that they faced
Women in hilly areas used two or more saris/cloths to absorb the flow.
They had to search for secluded spots by lakes or rivers to wash these
cloths and rags
Spaces to wash and dry these rags/cloths were a problem
Damp rags were often reused, as drying in the open sunshine was difficult
Very few poor girls/women could actually afford sanitary napkins
In BRAC areas, there was a good demand for low-cost napkins
4.4.4.2 BRAC
In August 2003, a social development team from DFID Bangladesh visited
a BRAC Sanitary Napkin Production Centre in Maneckganj, Bangladesh as part
of an effort to review existing initiatives linked to menstrual hygiene
and sanitation in order to explore potential linkages with DFIDB's water
and sanitation and health portfolios. This is what they found as reflected
in their field notes:-
Production Centre: Well-organised operation located in a neat and hygienic
property on the outskirts of the town. Employs mainly adolescent girls,
some very young working in well-lit, airy and clean rooms supervised by
one man and one woman. There seems to be special attention all-round to
hygiene all employees wear face masks at all times, rooms are scrubbed
with phenyl, footwear is parked outside the rooms in racks, autoclaves and
drying machines are used for sterilisation. We also observed some trainees
who attend the centre without pay in order to learn various skills
(stuffing the napkins, sewing the loops, etc.) before they are enlisted
as regular workers. The workers are paid 40 taka a day and enjoy no paid
sick leave or holidays.
The production of the napkins is broken up into various steps requiring
different skills. The workers seem extremely efficient and well trained
and continued their specific task with ease while talking with us. After
stuffing the gauze with cotton against a moulded shape, each napkin is individually
weighed for precision before it is sewn to loops and passed into an autoclave
for sterilisation. After drying, it is pressed into lots of 12 and sealed
in a colourful blue opaque plastic packet. The entire operation is methodical
and output oriented producing about 500 napkins per worker per day and about
6000 packets of 12 each per day. (BRAC has 6 such centres in Bangladesh).
Each packet is sold to the BRAC health workers responsible for distribution
at 5 taka and s/he sells it in turn for 18 taka. A small percentage of the
production finds its way into the local market where it is sold at 20 taka
per packet and competes with the commercial brands, which range from 40
to 85 taka on an average. The supervisors explained that there is little
or no profit made on this production due to the fluctuating price of cotton
and gauze. Whatever the market price of these raw materials, BRAC has made
a commitment to maintain the price of the finished product at 15 taka.
Demand and Supply and Disposal Issues
On the supply of and demand for the napkins The managers at the
BRAC district centre explained that distribution was mainly done through
a door-to-door supply using a network of 800 BRAC healthcare workers in
the district. There had been no real attempt to supply the napkins through
commercial outlets as there was a perception within BRAC that women were
embarrassed to go out and ask for these products in shops. They assured
us that there was sufficient demand for the supply from these production
centres and no surplus production at all. They stressed that the low price
was maintained as BRAC was clear that this was an income-generating cum
hygiene-related service targeting poorer women and girls and not intended
for higher income groups at all.
On being queried about disposal issues BRAC workers reported that they
did talk to users about digging a pit in their backyard and covering the
napkins with soil, but that no systematic thought had been given to the
issue.
Continued
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