Menstrual Hygiene Management in Low-Income Countries

Menstrual hygiene management, or MHM, is a concept that concerns girls' and women’s access to the appropriate information and resources to manage menstruation. In December 2012, the Joint Monitoring Program, or JMP, was one of the first organizations to define MHM as a global development goal. Since then, other organizations like WaterAid and the United Nations have expanded MHM’s definition to include menstrual education that is biologically accurate and free of taboo and stigma. Many women in low-income countries lack those necessities for MHM due to high prices of menstrual sanitary products, lack of access to clean water and sanitation facilities, and social stigma surrounding menstruation that prevents it from being talked about. However, as more organizations began to frame MHM as an issue of public concern rather than a woman’s private problem, more researchers, organizations, and governmental bodies have begun to address issues at the root of inadequate MHM.

Menstruation, also called a period, is when blood and endometrial tissue, or tissue lining the inside of the uterus, sheds from the uterus through the vagina. Menstruation occurs approximately once every twenty-one to forty days and typically lasts three to five days. Menstruation is a part of the menstrual cycle, the cycle in which women’s bodies prepare for pregnancy each month, and occurs as a result of ovulation. Ovulation is when an egg cell is released from the ovaries, through the fallopian tubes, and into the uterus. If a sperm cell fertilizes an egg cell, then an embryo is formed leading to pregnancy. The endometrial tissue thickens the inside of the uterus to provide nutrients for the embryo to grow into a fetus. But if fertilization does not occur and an embryo is not formed, then the endometrial tissue is not needed and expelled through the vagina during menstruation.

In order to properly manage their menstruation, women need access to water, sanitation and hygiene facilities, materials like sanitary pads and tampons, and knowledge of why and how menstruation occurs according to the United Nations Children’s Fund, or UNICEF. Such resources are vital to women’s MHM in both high- and low-income countries. The World Bank, an international organization made up of financial policymakers from 189 different countries, categorizes countries according to their gross national income, or GNI per capita, which counts the average amount of money a person in a certain country makes each year. As of 2021, the World Bank defines low-income countries as having a GNI per capita between $1,045 and $4,095 US dollars, while high-income countries have a GNI per capita of $12,696 or higher.

In low-income countries, women are often unable to access the resources necessary for proper MHM due to circumstances such as the lack of necessary sanitation infrastructure and the inability to afford menstrual products. MHM resources such as menstrual pads are often unaffordable to the average woman in a low-income country, so they end up using materials such as cloth or toilet paper instead. Such materials do not keep women and girls clean as they are not as absorptive, which can put a woman at risk of health problems such as urinary or reproductive tract infections. Many low-income countries also lack clean and private water, sanitation, and hygiene facilities, which UNICEF calls WASH facilities. That may exacerbate the feelings of shame and embarrassment girls might experience when menstruating because they do not have a private place to change or dispose of their sanitary pads. Additionally, even where women and girls do have access to WASH facilities, those facilities may still lack clean water and waste disposal systems to clean or get rid of sanitary pads. As a consequence, girls who do not have access to WASH facilities may be more likely to miss school days due to the inability to manage their menstruation.

Additionally, according to Marni Sommer, a public health and development researcher at Columbia University in New York City, New York, many societies hold certain stigmas around menstruation that can lead to feelings of shame and embarrassment for menstruating girls. That stigmatization exists worldwide but may be more profound in low-income countries, according to Sommer. Women and girls may be excluded from schools, religious gatherings, and other social and cultural events as a result of the stigma around menstruating. For instance, in Delhi, India, Sommer states that women and girls were found to be prohibited from entering places of religious worship while menstruating, because cultural beliefs viewed menstrual blood as dirty. According to UNESCO, such negative feelings toward menstruation may cause girls to feel marginalized in their communities, discouraging them from participating in school or other public functions. Moreover, according to Sommer, because menstruation is a stigmatized topic that many communities do not publicly discuss, important conversations about getting the necessary resources for MHM to girls on a societal level do not happen.

Sommer explains that international researchers, organizations, and companies began to pay more attention to MHM after realizing its connection to girls’ school dropout rates in low-income countries. In 2001, the Rockefeller Foundation funded research studies in Uganda, Kenya, and Zimbabwe that documented the challenges related to menstruation that girls faced in school. The Rockefeller foundation found that girls in low-income countries often miss days of school while menstruating because they do not have the resources to manage menstruation and may feel shame and embarrassment over menstruating. According to Sommer and her colleagues, an increase in menstrual-related studies such as that one helped motivate international organizations and companies to direct their efforts to addressing barriers to MHM to help girls stay in school. For example, in 2006, the US-based hygiene company Procter & Gamble founded a program called Always Keeping Girls in School. Always Keeping Girls in School encourages girls in different African countries to attend school while menstruating and funds puberty education and provides sanitary pads to local communities in Africa where those necessities are lacking. Sommer notes that at the time of the program’s establishment, the Procter & Gamble-funded puberty education was the only resource many girls had to learn about menstruation.

Around the same time, in 2005, UNICEF held a meeting titled Water, Sanitation, and Hygiene Education for Schools in Oxford, United Kingdom, to call attention to the consequences of a lack of WASH facilitates on many health issues, including MHM. At that meeting, Vanessa J. Tobin, then chief of the Water, Environment, and Sanitation section of UNICEF, expressed the need for girls to have clean and private WASH facilities to adequately manage their menstruation. At that meeting UNICEF shared a message from a Nigerian girl named Chidinma Ejere to highlight the need for improved WASH facilities. In her message, Ejere stated that girls at her school often left school while menstruating due to a lack of access to water and sanitary facilities necessary for the girls to stay clean.

Also at that meeting, Archana Patkar, the founder and former director of a social development organization called Junction Social in Mumbai, India, gave a presentation on the effects of menstruation-related challenges on girls’ education. According to Sommer, Patkar was one of the first people to use the term MHM to address stigma surrounding menstruation and a lack of WASH facilities, sanitary pads, and menstrual education as obstacles to MHM in low-income countries. In her presentation, Patkar stated that policymakers often overlooked menstruation-related challenges, and schools and other public infrastructure are rarely designed with girls’ needs in mind. Patkar called on organizations to recognize MHM as an issue that needed to be addressed at a societal level to improve access to WASH facilities and hygiene promotion for girls. Following Patkar’s presentation, researchers still did not use the term "MHM" until 2012, when organizations clearly defined MHM and included menstruation-related challenges in global development goals according to Sommer.

In December 2012, the Joint Monitoring Program, or JMP, which is a part of the World Health Organization, or WHO, and UNICEF, met in The Hague, the Netherlands, for the Second Consultation on Post-2015 Monitoring of Drinking-Water, Sanitation, and Hygiene. At that meeting, sixty international experts and stakeholders met to discuss the WASH-related problems and inequalities facing countries throughout the world. Ultimately, those organizations defined four targets they hoped to achieve by 2040. The second target specifically addressed and defined MHM, targeting menstruation-related challenges in low-income countries. The JMP defined MHM as women and girls having access to an absorbent material to collect menstrual blood, private WASH facilities to change and dispose of those materials, and water and soap to clean their bodies during menstruation. The JMP placed an emphasis on providing access to those services and supplies in schools, stating that each school should have private WASH facilities and at least one toilet per twenty-five girls.

According to the JMP, that meeting in 2012 was one of the first instances in which MHM was properly defined and explicitly added to a list of global development goals. In a 2013 review of MHM in low-income countries, Sommer states that girls in low-income countries often had less access to the appropriate resources for MHM than girls in high-income countries, largely due to a lack of public resources in low-income countries. While global development goals had prioritized access to clean water and sanitation, the public health community had not yet placed a specific emphasis on menstruation, according to Sommer. She attributes the stigmatization of menstruation as a possible reason for that lack of prioritization, arguing that viewing menstruation as a girl’s private issue dissuades public institutions from intervening to help put the appropriate infrastructure in place to help women and girls manage menstruation. More specifically, Sommer explains that the people who design or implement WASH facilities and waste disposal systems are typically male, so those infrastructures do not reflect the unique needs of menstruating women and girls. Sommer cites the JMP’s decision to define MHM as a global advocacy issue as an important moment that pushed MHM to be more widely considered as an issue of public responsibility.

In 2014, the United Nations Educational, Scientific, and Cultural Organization, or UNESCO, published the booklet Puberty Education and Menstrual Hygiene Management, which outlines puberty education curricula with a specific focus on MHM that teachers can utilize in schools around the world. UNESCO published that booklet based on the puberty education curricula in ten countries in Africa at that time, interviews with experts, and presentations of participants of the Technical Consultation on Improving Menstrual Education and Menstrual Hygiene Management in the Education Sector in Nairobi, Kenya, in 2013. After reviewing an array of puberty education curricula, UNESCO found that schools generally taught puberty education at age fourteen. That age is often after a girl first menstruates, so UNESCO argues that such puberty education needs to be provided at an earlier age. Also, much of the puberty education curricula only included information about reproduction without discussing MHM. Based on those findings, UNESCO argues that the definition of MHM ought to include access to menstrual education that can help girls understand the changes their bodies undergo during puberty. Menstrual education includes teaching about the menstrual cycle, the reproductive system, and menstrual hygiene in a manner that is biologically accurate and free of taboos. That expanded definition places emphasis on providing girls with facts about menstruation that will allow them to practice adequate MHM without embarrassment.

In 2014, UNICEF partnered with Columbia University to create MHM in Ten, a ten-year plan for addressing MHM in schools, specifically in low-income countries. MHM in Ten is an interdisciplinary approach to address challenges related to menstruation in schools, including researchers, non-governmental organizations, and governing bodies like the United Nations. The plan is aimed at improving water and sanitation and reproductive health education in an effort to improve MHM in low-income countries. As of 2020, UNICEF holds the annual Virtual Conference on Menstrual Hygiene Management in Schools. The conference evaluates yearly progress that has been made toward achieving MHM in Ten’s goals. According to UNICEF, by 2018, important progress had been made toward achieving MHM in Ten’s goals since the plan’s establishment. For instance, at the sixth annual conference in 2017, Erin C. Hunter, a public health researcher at the University of Sydney in Sydney, Australia, presented a tool she and her team had been working to create that would measure schoolgirls’ sense of self-efficacy in managing their menstruation. The tool includes questions that ask about schoolgirls’ attitudes towards different aspects of MHM. Other researchers have presented tools for measuring MHM in other low-income countries like Hunter’s, highlighting different menstruation-related challenges for girls in different communities. Nonetheless, UNICEF maintains that more work is needed to improve monitoring and policies in low-income countries to help more women appropriately manage their menstrual hygiene.

The concept of MHM has influenced researchers to study and address menstruation-related challenges in low-income countries at a social and political level. According to Sommer, as more researchers, organizations, and stakeholders increasingly MHM as a public issue resulting from an area’s policies and infrastructure rather than just as a girl’s private issue, more attention is being directed to address the necessary changes in public services. As it has helped define menstrual issues as a public issue, the concept of MHM has helped to improve educational and health outcomes for women and girls.