A Review of Menstruation Hygiene Management Among Schoolgirls in Sub-Saharan Africa

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Some adolescents believe that menstruation is the removal of bad blood. Less than half of the schoolgirls think that menstruation is a natural process. A few schoolgirls believe that the insertion of methylated spirits in their vaginas will stop excessive bleeding. Some ethnic groups in particular areas of Malawi pay a man called a fisi to have sexual intercourse with a girl who has begun menstruating as a sexual initiation rite. The cultural norm is to keep menstruation a secret. In Western parts of the country cattle owners do not let menstruating women attend to their cows, for fear that the milk may turn bloody. Myths surround the burning of used products, thought to cause cancer or infertility.

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Ninety-five percent of the schoolgirls indicate that they use reusable menstrual cloths all or some of the time. The girls cannot afford to buy disposable pads habitually, or they are unable to find them in local shops. Most girls keep their reusable cloths in place with underwear, but several girls from the rural schools affirm that they do not have money to buy underwear. The girls report several problems with menstrual cloths smelling bad or falling out at school. Furthermore, the menstrual cloths are large, quickly become saturated, trigger rashes, and can be seen through uniforms. In schools where girls sit on the floor, they delay rising until everyone else departs for fear of leakage. Girls skip school on their heaviest days or leave early when their menstrual cloths soak through. Studies carried out in Malawi and Lesotho report that used sanitary pads are often discarded in open pits, due to the lack of adequate disposal mechanisms. Subsequently, they are carried around the school grounds by dogs and crows, becoming visible to everyone. Some believe that used sanitary napkins can be manipulated to make someone sterile.

In Tanzania, many girls do not disclose to anyone when they initiate menarche because it is believed to be associated with improper sexual behavior; they fear they would be accused of premarital sexual activity. Consequently, over half of the rural respondents from the Tanzanian study claim to have disclosed their “secret” for the first time to the researchers. Some believe that if a menstrual cloth is seen by others, the cloth owner may be cursed. Cultural initiation rituals following menarche in Tanzania were commonplace in the past, often including female circumcision. However, these beliefs and practices continue only in certain ethnic groups, such as the Masai and Zaromo. Compulsory schooling is linked to a decrease in these initiation rituals. Some believe that those with irregular menses suffer with the illness called mchango in Swahili, literally meaning “snake” or “worm. Mchango is linked to many health problems and is perceived to have physical as well as spiritual origins. Mchango is also linked to menstrual pain and light menses. Women experiencing these symptoms believe it can decrease their ability to conceive, cause a miscarriage, or turn a woman’s uterus around. Findings from a qualitative study conducted in northern Tanzania reveal that menarche is tied to improper sexual behavior. Many schoolgirls learn from their primary teachers that their mothers will die if the girls inform them when they have started menstruating. The primary teachers instruct that menstruation must be kept secret, except for informing a sister or a paternal aunt. Schoolgirls report that their challenges during menstruation related to hygiene, leakages, and insufficient privacy are often the cause of the embarrassment and stigma.

An Ugandan study demonstrates that most girls from poor urban settings learn about menstruation from their peers and sisters, while the majority of girls from rural areas receive information from their mothers. Findings suggest that the rural mothers feel more comfortable discussing menstruation with their daughters than the urban poor mothers who typically stay silent. Due to the belief that menstrual blood is impure or dirty, menstruating girls are often prohibited from cooking or holding newborns. An Ugandan study reveals that sometimes the schoolgirls stay in their sanitary pads longer than recommended to lessen the number used per cycle. Discussion on the topic is discouraged by local culture or religion and mothers often do not wish to talk about it for fear that it will lead to discussions about reproductive health. Besides, mothers often deliver information based on cultural beliefs and restrictions to be applied, rather than physiological or practical facts. Uganda is an example of a sub-Saharan African country that does not include any modules about menstruation in the puberty education curriculum for primary school, often leaving girls unprepared at the onset of menses. Findings suggest that some primary school teachers believe that it is the responsibility of more senior teachers to discuss menstruation with the girls. Other teachers believe that it is unimportant to discuss menstruation in school because they assume that the girls' mothers are speaking with them about menstruation. The Ugandan school curriculum broaches the biology of menstruation, but does not include information regarding the physiological, financial, and social aspects. Yet, most girls from rural areas respond they have never heard their teachers mention menstruation in their science classes. Ugandan study champions several initiatives which are producing low-cost pads locally as a third option. These initiatives seek to minimize the financial barriers that schoolgirls face and offer more eco-friendly options, while also providing sufficient menstrual protection. Girls prefer to stay home from school and the lack of appropriate products is one of the principle reasons that girls do not attend school during their period, as noted by Crofts and Fisher (2012) in Uganda Sanitary pads for one girl cost one tenth of a family’s monthly income, meaning this is a ‘luxury’ most families cannot afford. A Ugandan study highlights that sanitary pads are disposed of in the latrines or toilets in most schools. This poses problems because it causes the latrines to fill up quickly and the toilets to become clogged. Other girls dispose of them in school dustbins, while some girls resort to burying them in their home gardens in rural areas. A small proportion of schools use incinerators to burn menstrual waste, although this presents environmental hazards and should not be viewed as the ideal solution.

The literature review of sub-Saharan Africa reveals that MHM is a widespread multifaceted problem. To improve the situation, MHM must be viewed through a wide lens. Currently, there is a lack of MHM education and knowledge, suitable feminine hygiene products, adequate sanitation facilities, and methods to manage pain during menses. These are factors that contribute to school absenteeism and reduced performance, myths and misconceptions, and negative feelings and experiences regarding menstruation. In addition to schoolgirls, many other groups desire more education about MHM, including mothers, teachers, men and boys, and community and government leaders. There is a lack of IEC materials about menstruation and puberty. There is a need to provide accurate education to eliminate the many existing myths and misconceptions regarding MHM. Schoolgirls’ experiences with MHM have not been widely studied nor discussed, largely because it is a sensitive and taboo subject. There is a dearth of literature pertaining to MHM in sub-Saharan Africa, with many of the studies being conducted by graduate students and few being published in peer-reviewed journals. Some literature suggests that the provision of free sanitary pads to schoolgirls increases attendance among schoolgirls. For example, Ghanaian researchers conducted a pilot test in four schools in poor areas. Two treatment sites received sanitary pads in addition to puberty education, one treatment site was provided education only, and one control village received no intervention. After six months of providing free sanitary pads, quantitative results demonstrated that school absenteeism declines significantly. The girls who were the recipients of the sanitary pads respond that they are better able to concentrate in school, have higher confidence levels, and can more easily participate in a range of everyday activities during menses. Negative experiences such as soiling and embarrassment have decreased. The girls prefer sanitary pads over traditional methods, mostly because they provide greater protection against accidental soiling and minimize the embarrassing scent. The results are most pronounced in the most rural school

The results indicate that more schoolgirls can be provided with sanitary pads to reduce school absenteeism and improve performance. Based on the current status of MHM in sub-Saharan Africa, some researchers draw the conclusion that tampons and menstrual cups are not feasible options because of practical and cultural reasons. Practically, they believe their cost is prohibitive. They also claim that insertion materials are often seen as culturally inappropriate. Thus, girls commonly question the effects insertion materials have on their fertility and health. However, other researchers suggest that menstrual cups are a reasonable option in sub-Saharan Africa. For example, a Kenyan research study explores the feasibility of introducing menstrual cups among adolescent and adult females. The study participants receive menstrual cups combined with MHM educational sessions.

Girls state they are less likely to miss school since they began using menstrual cups. Girls believe there is less chance of embarrassment because menstrual cups minimize the risk of soiling clothes. Furthermore, they report not having to change as often and feeling more comfortable at school. Additionally, girls claim that using a menstrual cup reduces the burden of purchasing sanitary pads monthly. They still experience challenges with finding ways to clean and sterilize the menstrual cup. Yet, the girls note that it takes less water to clean the menstrual cup compared to the water needed to wash and reuse menstrual cloths. Girls state that while other methods caused them to need more baths than usual because of their perceived smell and level of discomfort during menses, menstrual cups reduce the necessity for additional baths. The girls express their gratitude for receiving supplementary educational sessions, which teach them how to use the menstrual cups as well as about other reproductive health content. Some of the challenges related to using the menstrual cups include limited access to water, toilets, privacy, and security. This study demonstrates that menstrual cups and other insertion materials may become more culturally acceptable as long as they are introduced with proper education and guidance. Besides the components of MHM that were addressed in the problem statement, there are many other underlying factors that compound the MHM issue in sub-Saharan Africa. These include the social systems, political indifference, cultural customs, poverty, educational achievement of parents, the distance to school, and the domestic workload many girls are faced with in sub-Saharan Africa. None of these things can easily be changed through a single program or intervention, which all add to the challenge of improving MHM. Some of these interventions are beyond the scope of what will be discussed in the recommendations and policy implications, but all are important to consider.

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