Menstrual Hygiene and Management in Developing Countries:
Taking Stock,
November 2004
Page 1
(Pages 2 - 3)
By Sowmyaa Bharadwaj and Archana Patkar
1. THE CONTEXT
The recently published HYPERLINK "http://www.wssinfo.org/en/40_MDG2004.html"
JMP report, Meeting the MDG drinking-water and sanitation target:
A mid-term assessment of progress (2004) is a staggering reminder
that we stand to miss the targets on Sanitation in both Africa and
Asia. Our own work over the past decade in the water and sanitation sector
has however made us acutely aware of the absence of certain issues from
the policy debate on sanitation and water.
The last decade has seen a widening of the sanitation issue to include
the crucial environmental health related areas of wastewater and solid waste
management particularly in urban and peri-urban areas. Most environmental
health initiatives have the overall objective of reducing childhood morbidity
and mortality in developing countries by reducing exposure to agents of
disease and to environmental hazards that exacerbate disease. Priority areas
include water supply and sanitation; solid waste management; vector control;
infection control, including medical waste management and improved hygiene
in health facilities; integrated programming of population-health-environment
activities in areas of sensitive biodiversity; and indoor air pollution.
Despite the obvious synergy between many of the specific areas outlined
in the list above and menstrual hygiene and management, our search yielded
very little subtext on menstrual hygiene or management.
The reproductive health, preventive health and right-based literature
also failed to discuss various rights based aspects of the issue or practical
and strategic needs of women and focussed primarily on the symptoms and
causes of toxic shock syndrome and dysmenorrhoea.
Overall the absence of MHM in the policy debate and hence in investments
and action, is striking. This, points to a glaring need to highlight this
issue in the policy debate together with practical work on what adolescent
girls and women require to manage their menstrual needs in terms of materials,
education and facilities for management and disposal.
2. APPROACH & METHODOLOGY
This paper collates our findings from a serious effort to take stock
of the current thinking, practices, barriers, investments and action linked
to this issue. It is based on wide electronic consultation and secondary
desk review with key stakeholders in the area of health, hygiene, water
and sanitation and women's rights and also incorporates the knowledge and
experience from more than a decade of first-hand experience in water, sanitation
and reproductive health in developing countries. For further details see
Annex1 & 2.
For this study, we consulted about 85 water and sanitation professionals
worldwide inviting information, case studies or data on personal/project/regional
experience linked to the following:-
Perceptions around menstrual hygiene issues (adolescent girls/boys;
women/ men)
Related social practices like seclusion, absenteeism, religious or social
exclusion
Absenteeism and drop-out linked to puberty, poor sanitation facilities,
social mores
Impact on mobility, labour & productivity
Health related issues - rashes and infections; other
The availability and affordability of materials - cost, bio-degradables,
ease of access & social acceptability. Kind of materials used -
cloth rags, sanitary napkins, other
Hygiene issues linked to washing & drying of cloths, spaces for drying
Issues related to disposal of used napkins, cloths
Was this issue ever articulated in your experience? If yes - please give
details of circumstances; stimulus and context.
The overall objective of this paper is to compile a brief overview
of initiatives in menstrual management as a precursor to action. We know
that this review is not exhaustive in its scope and we look forward to adding
more information and contacts to this stock take in the months ahead.
3. WHAT WE FOUND
Very few professionals have actively engaged with the issue although
it has crossed many a mind in passing.
Professionals from the Health or Water & Sanitation sector alike
were astonished at the absence of this issue from both technical and rights
based discourses, but unable in most cases to point us in the direction
of substantive work on these issues.
The literature on Gender mainstreaming in the Water & Sanitation
sector, is silent on Menstrual Management adequacy of water for washing
and bathing, availability of hygienic materials and solid waste management
of disposables. Initiatives in this area are restricted to very small pilots,
with poor follow-up and poor dissemination of results.
Although poor sanitation is correlated with absenteeism and drop-out
of girls in developing countries, efforts in school sanitation to address
this issue have ignored menstrual management in latrine design and construction.
Wider aspects of the issue such as privacy, water availability and
awareness-raising amongst boys and men remain largely unexplored by development
initiatives.
Hygiene promotion efforts have recently initiated a focus on this
area but mainly on the software aspects i.e. telling girls and women about
correct practices. These efforts do not currently target men and
adolescent boys, nor do they systematically inform infrastructure design.
Minimal effort has gone into production and social marketing of low-cost
napkins, reusable materials, research into bio-degradables, etc. Research
and development efforts have been limited to commercial ventures that even
today are unable to market products that are affordable for the poorest
of the poor.
The issue of washing of soiled materials and environmentally friendly
disposal of napkins is absent from waste management training, infrastructure
design and impact evaluation.
In short, Menstrual Management is missing from the literature
whether it be manuals to sensitize engineers to gender needs or technical
manuals on latrine designs, sanitation for secondary schools, solid waste
issues composting, bio-degradable materials or even simple training
modules for health and sanitary workers.
Our mailings generated immense interest in what would emerge pointing
to a crying need to investigate the issue thoroughly, to articulate it clearly
in relevant policy fora and to demonstrate viable practical solutions on
the ground.
3. A CALL FOR ACTION
I was brought up in the city of Pune. My parents were quite unorthodox
in their approach to menstruation and I did not have to endure exclusion
from religious functions, or seclusion at home and elsewhere and so
on during my periods. But I did face a major problem - attendance at
school. It was about 7 km away from my home and commuting was not direct;
hence I could not come home easily if I had a problem at school. The school
was located in an area with very little ground water, and municipal water
supply was also inadequate. As a result, on most days, all taps in the school,
including those in the toilets, ran dry. I needed to change every 4 to 5
hours for about 3 to 4 days and hence I had to remain absent from school
at the beginning of each period - which lasted for 9 or 10 days. One or
two of my teachers were concerned about the gaps in my attendance and I
distinctly remember two occasions on which I was asked why I remained
absent so often. Unfortunately, I did not have the courage to broach the
subject myself and I remained guiltily silent, as if I had no valid
reason, and accepted the blame.
When I was in my late twenties, the municipal corporation arranged to
send what is called a 'ghanta gaadi' (a mobile trash collection bin mounted
on wheels and trundled along by an employee of the Sanitation Department),
in the locality where we lived. One day in October, when I carried the trash
from our home to the gaadi, the employee, who happened to be a middle-aged
woman, told me not to trash any sanitary pads over the next 10 days, as
it was the Navratri festival. She was worshipping the goddess and hence
having to handle menstrual material would not be acceptable, she said. She
had no qualms about handling any other kind of trash! After some deliberation, our
family began make it a point to themselves deposit all trash in the large
containers provided in each locality by the municipal corporation, thus
avoiding passing on our 'dirty work' to others.
Real Life Case Study reported by Kalpavriksh, a Pune based NGO
On discussing this issue with senior specialists in the sector, reactions
have ranged from the supportive to the downright sceptical. One senior sector
specialist questioned the urgency and importance of addressing menstrual
hygiene and management issues when there are so many other issues that need
to be resolved first. The question we need to ask is Whose priorities
are driving project design and infrastructure investments today? Do these
reflect and match what poor women and girls need and want in their
own right as individuals and also in their role of primary water and sanitation
managers, mothers and health caregivers.
Across the developing world, the lack of appropriate and adequate sanitation
facilities prevents girls from attending school, particularly when they
are menstruating. Of the 113 million children currently not enrolled in
school worldwide, 60% are girls. There is conclusive evidence that girls'
attendance at school is increased through improved sanitation. Our survey
of school sanitation yielded little apart from the above accepted wisdom
on the reason for female drop-out. Investments in this sector, policy
initiatives to scale up coverage and innovative pilots on improved toilets,
have altogether failed to address this issue coherently. What is most disturbing
is that the gender dimensions of the issue are well-articulated, without
the corollary which would help to bring with it investment and action.
While menstrual hygiene is slowly creeping into the discourse and also
the design of some awareness and behaviour change programmes, disposal remains
a non-issue. We risk ignoring the disposal issue and links with solid waste
and sewage systems at our own peril as is clear from the scale of the environmental
problem this poses.
SOME SOLIDWASTE FACTS AND FIGURES
TO PONDER
Men and women dispose of various items down the pit, such as condoms,
plastic bags, sanitary towels and children's nappies. Such objects may cause
blockages when pits are emptied and lead to pits filling more rapidly than
needed. This O&M problem can best be solved through user education,
rather than trying to design an engineering solution, although the engineer
may then have to address household solid waste management. There may be
cultural restrictions on disposing of sanitary towel waste.
Gender for Engineers, Work in progress, WEDC
In an average middle class woman's lifetime, she is likely to use 15,000
sanitary pads or tampons.
Over 12 BILLION pads and tampons are USED ONCE and disposed of annually,
clogging our overburdened landfill sites.
An average woman throws away 125 to 150 Kgs of tampons, pads and applicators
in her lifetime. The great majority of these end up in landfills, or as
something the sewage treatment plants must deal with.
Plastic tampon applicators from sewage outfalls are one of the most common
forms of trash on beaches. For building owners, pads and tampons that are
flushed down the toilet are the most common cause of plumbing problems.
More than 2 billion sanitary items are flushed down toilets in the UK
every year. These include tampons and sanitary pads, condoms, dental floss,
cotton buds and even razorblades and syringes. When these items end up on
the beach or along riverbanks they are called Sewage Related Debris (SRD)
and in 2000 accounted for 6.5% of all waste collected during the annual
MCS Beachwatch Survey.
Social marketing and social franchising have been successfully used in
marketing of Oral Rehydration Salts and more recently for condoms, but these
concepts have as yet to be extended to the distribution of affordable, environmentally
friendly sanitary products for menstrual management. While women all over
the developing world are constrained by the lack of facilities and unavailability
of appropriate products to manage their menstrual needs, the problem is
exacerbated in conflict torn or emergency situations.
Continued
Pages 2 - 3
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