“A Comparison of the Menstruation and Education Experiences of Girls in Tanzania, Ghana, Cambodia, and Ethiopia” (2014), by Marni Sommer, T. Mokoah Nana Ackatia-Armah, Susan Connolly, and Dana Smiles

In their 2014 article “A Comparison of the Menstruation and Education Experiences of Girls in Tanzania, Ghana, Cambodia, and Ethiopia,” hereafter “Comparison of Menstruation,” researchers Marni Sommer, T. Mokoah Nana Ackatia-Armah, Susan Connolly, and Dana Smiles examined various physical and social barriers impacting women’s management of menstrual health across Ghana, Cambodia, and Ethiopia. The authors examined barriers such as misinformation about menstruation and how schools limit girls’ ability to manage their menstrual cycles. They then compared their findings to a previous study led by Sommer on similar experiences shared by girls living in Tanzania. “Comparison of Menstruation” provides insight into the physical and social barriers to managing menstruation in low-resource contexts and serves as a precursor to the creation of educational resources intended to improve menstruation health management for women and girls.

Menstruation is a process in which women and girls expel blood and other tissues from the vagina approximately once per month. In order for menstruation to occur, the pituitary gland in the brain releases a hormone in order to cause the ovaries to release an egg cell each month, which is called ovulation. If the egg cell does not get fertilized by a sperm cell, the woman will not become pregnant, and the lining of the soft tissue of the endometrium sheds. Menstruation occurs approximately once every twenty-eight days, but cycles may vary in length among women and girls. Females typically use things like sanitary pads and tampons to manage their menstrual cycles.

In their article, Sommer, Ackatia-Armah, Connolly, and Smiles used their individual backgrounds in global health to highlight the physical and social barriers impacting women’s management of menstrual health. Sommer completed her doctoral studies looking at how girls who live in Tanzania manage menstruation and puberty. Ackatia-Armah holds a doctoral degree in anthropology and conducts research on policy and gender equality among people living in the US and Ghana. Connolly worked as a consultant for Catholic Relief Services, and Smiles worked from Brown University in Providence, Rhode Island.

The authors divided “Comparison of Menstruation,” into five main sections. First, in the introductory section, the researchers describe Sommer’s previous research and the difference between the urban and rural research settings in Ghana, Cambodia, and Ethiopia. Then, in the methodology section, the authors discuss how the research team identified themes on menstrual health in those countries. In the results section, Sommer and colleagues present three major themes they found throughout their study, which include past and present menstrual-related beliefs, insufficient menstrual related guidance, and menstrual hygiene management-related challenges in the school environment. In the discussion section, the authors describe how those themes impacted factors such as the health and education of girls. Lastly, in the conclusion section, Sommer and colleagues describe the cultural importance of their findings.

Sommer, Ackatia-Armah, Connolly, and Smiles begin “Comparison of Menstruation,” with a general description of the previous research on the physical and social barriers that impact women’s management of menstrual health across various cultural contexts. Sommer and colleagues highlight existing studies that sought to demonstrate such differences on menstruation practices around the world, including a previous study that Sommer conducted in 2006 to highlight Tanzanian girls’ specific experiences with menstruation in school settings. In that study, Sommer found that social and cultural views on menstruation impacted girls’ knowledge of the phenomenon and how to manage it. Also, Sommer found that access to clean WASH facilities in schools was lacking in Tanzania, which further negatively impacted the management of menstrual health. Using those findings as background for their 2014 article, “Comparison of Menstruation,” Sommer and colleagues state that they want to determine the various physical and social barriers impacting the management of menstrual health among school-aged girls in Ghana, Cambodia, and Ethiopia, in conjunction with Sommer’s study conducted in Tanzania. Similarly to how Sommer had published a puberty book for girls in Tanzania, they hoped they could publish an analogous copy specific to the experiences of the girls in each country.

Next in the introductory section, the authors describe the research settings in Ghana, Cambodia, and Ethiopia. Sommer and colleagues note that, in each country, the research team conducted their studies in both rural and urban settings to highlight any socioeconomic differences that could exist. The authors indicate that rural settings were generally more culturally traditional than urban settings, while also noting that urban settings were more ethnically and economically diverse than rural settings. In each country, the authors conducted their study in girls aged sixteen to nineteen, due to the fact that many girls in that age group had already undergone puberty and could speak to their experiences in a more comprehensive way.

In the methodology section of the article, the researchers state that their study was three-fold and included general observation, interviews with teachers and students, and three activities with groups of girls aged sixteen to nineteen. The authors mention that they conducted brief observations of the classrooms, but they mainly focused on the activities they completed with the girls. They reflect that the first activity encouraged the girls to write anonymously about their personal experiences with their first time menstruating, also called menarche, including their specific feelings toward the event and how they managed their first few menstrual cycles. In the second activity, the authors asked the girls to describe their ideal circumstances for managing their menstrual cycles at school. Similarly, the third activity sought to have the girls envision and draw images of their ideal WASH facilities for managing their menstrual cycles at school. The authors state that the use of anonymity in such activities was pertinent to empowering the girls to feel comfortable while discussing the sensitive topic of menstruation.

Throughout the duration of the study, the research team continuously coded their field notes for significant themes related to the research topic, which helped to highlight major trends and guide further observations, interviews, and activities. Later, the authors conducted a full analysis of their findings and identified similarities and differences among school-aged girls’ experiences with menstruation in Ghanaian, Cambodian, and Ethiopian schools.

Next, in the results section, Sommer, Ackatia-Armah, Connolly, and Smiles present three major themes that they found throughout their study. Those three themes were past and present menstrual-related beliefs, insufficient menstrual-related guidance, and menstrual hygiene management-related challenges in the school environment. First, the authors provide their findings on past and present menstrual-related beliefs. Specifically, Sommer and colleagues found that the stigmatization of menstruation, which often has led to the spread of inaccurate information on the phenomenon, was prevalent among those living in Ghana, Cambodia, and Ethiopia.

The authors found that parents often unintentionally misinformed their daughters of menstruation-related topics. For instance, in Ghana, parents told their daughters to properly dispose of all sanitary products in hidden waste bins, as improper disposal was thought to cause infertility. Girls from Cambodia reported that female family members had told them to keep their first sanitary product they used during menarche, as they believed it could protect the girl from bad luck. In Ethiopia, some girls were told to consume hot drinks during their menstrual cycles, as hot drinks were thought to cause heavier menstrual bleeding. In Ethiopian culture, menstrual blood is considered to be impure, so many girls adopted that belief in order to quickly expel the blood. However, others reported being told to abstain from doing anything to increase a heavier menstrual flow. Many of those types of reports differed between whether the girl lived in a rural or urban setting.

Particularly, as Sommer and colleagues share results concerning the theme of past and present menstrual-related beliefs, they highlight a series of beliefs shared among the three cultures concerning the relationship between menarche and sexual behavior. In Ethiopia, girls feared getting their first period, as many parents had instilled in their daughters that menarche was associated with sexual behavior. For instance, one Ethiopian girl recollected her menarche and shared that her mother hit her with a stick upon seeing the girl’s blood-stained skirt. The girl stated that her mother hit her repeatedly, because, according to the authors, her mother believed that sexual behavior had caused the bleeding.

Similarly, in Ghana, the authors found that parents taught their daughters that irregular menstrual bleeding was associated with pregnancy. For instance, one Ghanaian girl recalled that after menarche, her next menstrual cycle did not occur for three months. While such irregularity between menarche and the second menstrual cycle is normal, according to the authors, that girl’s family believed she was pregnant and forced her to visit the doctor for confirmation. The girl provided that the doctor confirmed that she was not pregnant, but she had expressed that her family was then convinced that she had received an abortion to terminate the supposed pregnancy.

Sommer and colleagues then share the theme of insufficient menstrual-related guidance. The authors indicate that girls received varied information on menstruation depending on where they lived. The girls who the authors interviewed lived in different parts of Ghana, Cambodia, and Ethiopia. Girls living in urban settings reported receiving more accurate information from their parents than girls living in rural settings. In fact, the authors found that many girls in rural settings did not receive any information from their parents on menstruation at all. Thus, the girls reported feeling fearful upon their menarche. One girl in urban Cambodia reported that upon her menarche, although she had no prior knowledge of menstruation, her mother told her that the occurrence was normal. However, in rural Ethiopia, one girl reported that a friend was the only one who taught her about menstruation.

The authors then report on the theme of menstrual health management-related challenges in the school environment. Sommer and colleagues indicate various physical and social barriers that prevented girls from managing their menstrual cycles at schools. The authors found the most prominent physical barrier to be a lack of access to clean WASH facilities at schools. For instance, many schools in Ghana and Ethiopia reportedly prioritized other classroom needs over building and maintaining WASH facilities. One girl living in rural Ghana reported that her school’s toilets were shared between the girls and boys, so she felt uncomfortable managing her menstrual cycle. Similarly, many Cambodian girls disclosed that they wished they had clean water to wash their hands and remove blood stains from their skirts. Then, Sommer and colleagues describe the most prominent social barrier, which was shame and embarrassment about menstruation. In Ethiopia, many girls reported being ridiculed by their male peers when sanitary pads were visible or the girls had stained their skirts or chairs with blood.

Next, in the discussion section of the article, the authors describe how the themes that they had found impact factors like the health and education of girls. Sommer and colleagues acknowledge that the specific views and attitudes toward menstruation vary across different cultural contexts around the world. For instance, decreased health outcomes related to nutrition may be associated with various stigmatized beliefs on menstruation, as the authors had found many nutritional restrictions associated with menstruation. The authors indicate that those nutritional restrictions may be detrimental to the health and development of girls. Also, shame and embarrassment perpetuated by sharing toilets with male peers in many of the studied settings led girls to stop attending school, as they were unable to manage their menstrual cycles. The authors indicate that that may reinforce gender discriminatory environments because of power dynamics allowing boys to ridicule girls into avoiding the bathrooms. Through that analysis, the authors suggest adapting Sommer’s puberty book originally written for Tanzanian girls, and customizing it for each country’s specific cultural views and beliefs.

In the conclusion section, the authors describe the cultural importance of their findings. Sommer and colleagues indicate that their study helped to provide new insight into the various ideas surrounding menstruation in differing cultural contexts to explain physical and social barriers to the management of menstrual health in schools. However, the authors explicitly state that their findings are general, and further research is needed to provide a more comprehensive review of girls’ experiences with menstruation in such areas.

Following the publication of “Comparison of Menstruation,” Sommer published puberty books specific to girls located in Ghana, Cambodia, and Ethiopia. Sommer continued to work on projects that aimed to address the barriers to managing periods in low and middle-income countries. Sommer also published various versions of her puberty book for girls in Nepal and South Africa. Likewise, other researchers have utilized the work of Sommer and colleagues in order to help improve the management of menstrual health in vulnerable populations. For instance, in 2017, Jane M. Ussher, a researcher and professor at Western Sydney University in Sydney, Australia, and her colleagues brought attention to how social factors such as cultural views of sex have further hindered women’s sexual health in refugee populations. In the article titled, “Negotiating Discourses of Shame, Secrecy, and Silence: Migrant and Refugee Women’s Experiences of Sexual Embodiment,” Ussher and colleagues referenced “Comparison of Menstruation,” to demonstrate how shame and embarrassment of menstruation may be influenced by cultural views of sex in addition to physical factors like lack of WASH facilities, supplies, and education resources.