Breaking the silence around menstruation: experiences from urban and rural India

INTRODUCTION

Worldwide, around 1.2 billion people are adolescents, aged 10-19 years with about 90% of them living in low and middle-income countries (LMICs); of these, 500 million are adolescent girls living in developing countries.^1,2 Adolescence is a period of transition of physical and mental health, and is quite challenging for all adolescents. The adolescent girls face one more challenge of managing their menstruation amid other pubertal changes in schools. Menstruation is a normal physiological process, but it still remains a huge taboo in India. There is a culture of silence around menstruation or “periods” and is quite deep rooted in Indian society. There have been several campaigns by the government regarding menstrual hygiene and accessibility to sanitary pads has improved over the years. However, the conversation about “periods” has not been normalized and shame is still associated with menstruation.

MENSTRUAL HEALTH IN INDIA

Lack of access to menstrual education and sanitary products affects the menstrual health. It is a subject that affects half the population around the world. However, we can say that the issue is particularly relevant in India where according to NFHS4, not even 50 percent of rural women used hygienic methods during their menstrual period. The situation is better in urban India, where around 77 percent women were using either locally prepared napkins or tampons during periods.³ The use of unhygienic methods (husk, ashes etc.) can lead to severe reproductive health problems in women. Some women use rags as a replacement for sanitary pads. Even rags that are cleaned but not dried properly can develop bacteria. Due to lack of knowledge about menstruation and social taboo, girls experience feelings of fear, shame and guilt during menarche. It is often described as a release of ‘bad blood” or “dirty blood” and girls do not talk about menses without hesitation. There is still a lack of adequate guidance on menstrual hygiene management (MHM); especially in developing countries, where girls continue to face inadequate supply of water, disposal facilities, and privacy issues in schools. In addition to this, there is lack of accessibility and availability of adequate sanitary hygiene products, which force some girls to use unhygienic materials.⁴ A study by Das et al in India has shown that due to the use of unhygienic materials, girls are potentially at more risk of developing urogenital symptoms and infections.⁵ Moreover, there is inadequate social support for girls, along with gender inequality, and social taboos around menstruation in many countries including India, leaving girls to experience shame and fear while trying to cope with their menstruation.⁶ In addition to stripping girls of their self-esteem, there is growing evidence which suggests that inequitable school environments negatively impact girls’ ability to succeed academically, and limit their long-term economic potential.⁷ Studies done in India revealed that awareness about menstruation was around 48% (95% CI 43% to 53%, I2 98%, range 3–100%). The awareness varied according to area and setting, being lower in slums. Mothers were the most common informants about menstruation followed by friends, relatives and teachers. Around 25% of girls knew uterus a source of bleeding.⁶ A study done in urban and rural Rajasthan, revealed that majority of the girls (49.6 % in urban, 43.5% in rural) had no idea about the source of blood during menstruation. Only 27% of urban as well as rural girls could correctly tell that the uterus is the source of blood in menstruation.⁸ Dabade et al demonstrated the knowledge about menstruation among adolescent girls as 63.4% in urban area as compared to 47.6% in rural area.⁹ A study done by Shanbag et al also revealed that 73.7% girls perceived menstruation as a normal phenomenon, In this study mother was the most common informant followed by friends, relatives.¹⁰ These findings are similar to that of a study conducted in Wardha, among school going adolescent girls, where mother was the informant (40.67%) followed by friends (19%).¹¹ Similar findings were observed by Gupta et al that majority of the study participants in urban (71.3%) as well as in rural area (57.7%), got the information about menarche from their mothers.¹² A study done by Mudey et al also revealed that majority of the study participants (40.6%) got the information about menarche from their mothers.¹³

In a study by Verma et al it was found that although majority of the girls in both rural and urban area, believed that girls should not be obliged to follow any type of restrictions during menstruation, but there were some of the girls who had positive attitude towards restrictions. This is probably due to the reason that these girls are brought up in the family environments, where cultural taboos and restrictions are very common and they perceive them to be normal phenomenon.⁸ In a meta-analysis done by Ejik et al, it was found that common restrictions during menstruation were food related (Pooled prevalence, PP 38%, 30% to 46%, I² 99%), touching people or special foods (PP 50%, 36% to 64%, I² 99%). Regarding the disposal of sanitary pads, it was reported that routine waste disposal was significantly more frequent in urban (PP 70%, 60% to 79%, I² 98%, n=16) compared to rural settings (PP 28%, 95% CI 19% to 38%, I² 99%, n=25, p<0.0001). ⁶

Evidence also suggests that there is a significant difference in the usage of sanitary pads in urban and rural areas, with majority of girls living in urban areas using sanitary pads. Studies conducted in schools revealed that some girls preferred combined use of sanitary pad and cloth (95% CI 9% to 18%, I² 99%). Financial constraints were cited as the most common cause for not using sanitary pads. Several studies conducted in India have found that food as well as religious restrictions are very common. Girls face restrictions in socializing, cooking, playing, moving in and out of the house.⁶ Many studies have revealed that menstruation related problems had affected students’ class concentration, sports participation, socializing with peers, school attendance as well as academic performance.¹⁴ Another study showed urban–rural disparity in access to sanitary napkins, where 37.1% of urban girls compared to only 1.6% of rural girls used pads. The limited use of sanitary napkin was due to lack of access and financial problems.¹⁵

MENSTRUAL HYGIENE SCHEME

In last few years, menstrual hygiene management has received a lot of policy attention in India. In 2014, the Indian government launched “Menstrual Hygiene Scheme” (MHS) under a new adolescent health programme, Rashtriya Kishor Swasthya Karyakram (RKSK). The aim of MHS is to increase awareness, accessibility, use and safe disposal of high-quality sanitary napkins among adolescent girls in rural areas. Different organisations working on menstrual health and hygiene in the country have come together to form an alliance to work for the cause. In the past 3 years, several state governments such as Kerala, Odisha, Andhra Pradesh have started free distribution of sanitary pads in schools. However, due to the huge diversity in sociodemographic characteristics of the population in India, the menstrual experience for the 120 million adolescent girls is not the same. Considerable variations exist between different states, urban and rural area, and between the rich and poor. Evidence available is mostly from school-based studies, ignoring the practices of drop out adolescent girls.¹⁶

WAY FORWARD

Experts believe that implementation of the government’s schemes is a big issue. A major problem is overburdened accredited social health activists (ASHA), who are tasked to promote menstrual health and hygiene management. They are the back bone of primary health care system in India and are first contact of health system with the community. Another issue is that field health workers need full understanding of menstrual hygiene management and should be fully motivated to work for the same. So, it is very important to impart scientific knowledge to the health workers in their own language so that they can use it for community awareness.¹⁶ Since the behaviour change regarding menstrual hygiene and restrictions associated with it requires involvement of all stakeholders. So, only educating the adolescent girls is not enough; their mothers, their family members and school teachers etc. should be included in awareness programs. Only then we can think of making the conversation about menstruation normal. In addition to that local context matters; cultural beliefs and attitudes towards menstruation vary across the country, and awareness campaigns must take these points into consideration. In our country, menstrual hygiene management is considered as a matter for women only and it is believed that it should be kept private and not discussed. As a result, girls/women are not able to express their needs and affect the behaviour change within their homes, community and society at large. It is suggested that male attitudes towards menstruation are one of the important factors driving the stigmatization and myths about periods.^17,18 So, it is important to recognise and include the gender equality to promote menstrual hygiene and positive reproductive health.

CONCLUSION

Stigmas and restrictions around menstruation go beyond denying entry to women in temples; they percolate into their daily lives. The situation is comparatively worse in rural India, where apart from taboos, women face the additional concern associated with lack of affordable sanitary products. The introduction of Menstruation Hygiene Scheme in India has led to a pathway for government intervention in the menstrual hygiene discourse. Under the scheme, there have been a range of policy decisions taken by government: distributing pads in schools and Anganwadis and building toilets in every village as a part of the Swachh Bharat initiative. Although there have been various initiatives by the central and state government, one of the important things missing from the menstrual hygiene discourse in India is the lack of efforts at normalizing menstruation for women. The schemes have mainly revolved around technical aspects such as the construction of toilets and distribution of pads and, have missed out on the opportunity to educate stakeholders i.e., families of girls, where menstrual taboos and stigma are prominent.

It is also essential for the central government and state governments of various states to come together and formulate a uniform menstrual hygiene policy so that all the stakeholders and different sections that make up the menstruating population of India get sufficient attention to their specific and unique issues. The priorities should include strengthening and improving the capacity of spreading awareness by training the facilitators.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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