For young girls, their first period is not necessarily a fun experience. For young girls in developing countries, not knowing how to manage their periods may hinder access to education, according to a new study.
A recent study published in PLOS ONE journal found that in rural Uganda, providing free sanitary products and lessons on puberty to girls experiencing menstruation have positive effects on improving their attendance levels in schools. Even so, there are some caveats.
The cluster-randomized-controlled trial was conducted in partnership with Plan International across eight schools involving 1,124 girls in Uganda’s Kamuli district, an area that had been observed as having low performance in educational outcomes and literacy as well as high gender disparity.
Based on an earlier pilot study done by the group in Ghana, the group hypothesized that providing two different interventions – reusable pads and puberty education, plus a combination of the two – would improve school attendance for menstruating girls. At follow-up, 24 months after the interventions were provided, average school attendance had declined in all schools. Yet that decline drop was 17 percent greater in schools that did not receive any interventions compared to schools that did. This equates to an extra 2.5 days of school attended in the three-week follow-up period for girls who received either reusable pads or puberty education.
“While menstruation and surrounding stigma have received increased attention, the barrier presented by menstrual management remains under-researched,” Julie Hennegan, of University of Oxford’s Center for Evidence-Based Intervention, told Humanosphere. “We need a greater understanding of the impact of menses across women and girls’ lives, as well as evaluations of the impact of different interventions and strategies to address current deficits.”
In the past few years, menstruation and its effect on women in developing countries have been in the spotlight in the aid and development world. Aid agencies, NGOs and social entrepreneurs have taken on the subject, spawning products like Ruby Cup, a menstrual cup product originating in Denmark with a similar model to TOMS Shoes. Only in this case, the “buy one, give one” format links purchases in developed countries to donations in Kenya. There is also a movement to make menstrual hygiene a human right – with May 28 declared by WASH United as Menstrual Hygiene Day. Aid projects have sought to figuratively parachute sanitary pads and build working toilets into developing countries.
But what works in a community in East Africa may not be the same as what works in South Asia. This study specifically tries to assess the efficacy of interventions in the Ugandan community.
“We’re increasingly talking about this concept of menstrual hygiene. What do we mean by that? Wow do we define it, measure it? So that when we do translate these interventions and evidence to other places, we sort of have a list of well-defined concepts we would compare,” Hennegan said. “How do we think critically about the things that girls need, about interventions like education and sanitary provision, what are the pathways to which they also have an effect?”
At the time, the only other research on menstrual-hygiene management and school attendance was done involving menstrual cups in Nepal.
“There is still so much more we need to know,” Hennegan said. “Menstruation, and managing menstruation, is a multifaceted challenge connected to so many aspects of life. … I don’t think there will be a single ‘silver bullet’ to improve girls’ menstrual experience.”
In the Uganda study, the researchers found that menstruation is viewed widely in the community as “embarrassing” or “dirty.” Hennegan described some girls feeling that if they come to school and leak or start menstruating when they’re not expecting to, then they may get teased or not receive support. In a similar vein, girls may not engage in the classroom due to cramps or being afraid to stand up because they don’t trust that their pads won’t fall out.
The study also found that approximately 10 percent of the girls involved in the study had access to a sanitary pad at some point. However, the vast majority of girls who were using the trial-provided reusable pads had been using either new or old cloth to manage their menses.
It isn’t a secret that menstruation isn’t openly discussed, even in rich countries. In many cultures, some taboos or traditions around it limit the mobility of menstruating women. Advocates say such problems have negative consequences, from higher school dropout rates for girls to increased rates of cervical cancer.
But while addressing girls’ menstrual experience and its effects on school attendance is important, the researchers also provided a word of caution. During the study, many of the girls dropped out or transferred to new schools or communities for reasons not even connected to managing menstruation. In the study population, many students faced a lack of funds for school fees and requirements such as books and uniforms. They may also have to transfer to a new school to repeat a grade or move to a new community to live with different family members.
“If girls are being chased away from school because they can’t pay for the fees or requirements, then addressing menstrual management alone will not be enough,” Hennegan told Humanosphere. “Gaining a broad understanding of the many, unconnected challenges that girls face is key to effective intervention.”
Some girls, Hennegan said, even dropped out of school due to unplanned pregnancy. She said while providing puberty education could also lead to more comprehensive sexual and reproductive health education, the latter is harder to target due to resistance from either funders or local communities. She found that in conversations with the girls, there were many myths surrounding the use of contraceptive methods in particular.
And when it comes to providing puberty education, local organizations in countries like India have spawned movements of their own to counter the mainstream views of menstrual-hygiene management in the foreign-aid industry, which they say often focus a lot on fixing symptoms with short-term solutions as opposed to addressing underlying problems.
“The biggest barrier to change is that we pre-decide solutions, and then problem statements are tweaked to fit the already decided solutions,” according to a statement from Mythri Speaks Trust, an NGO based in Bangalore, India, that works on issues like menstrual hygiene and sexual violence. “A look at the work happening in the name of menstrual hygiene management globally will make this amply clear. By deciding that ‘developing nations’ like India and Africa need help in the form of toilets and sanitary napkins, the whole subject of menstruation has been put under the head of sanitation, when in fact it has to do with sexuality and childbirth.”
The researchers from the study in Uganda said there needs to be more information before translating menstrual hygiene interventions or programs for other communities. Hennegan said more education can greatly assist girls experiencing their periods for the first time. The study found that by providing them with information and a forum to talk with each other, especially in schools that receive the puberty education, the girls become great sources of support to each other.
“They were a lot more willing to say that they had talked to their friends like, ‘if I leak, another girl might [help out] and she might give me a skirt or check my skirt before I stand up,” Hennegan said. “These are pathways that may be hard to measure but are very important when we think of transporting these interventions to other places. … There’s a lot of nuance.”