Menstrual restrictions among young females in urban slums of Cochin

INTRODUCTION

‘Weeping of a disappointed womb’, the menstruation flow is often associated with the weeping of restricted menstruating women from ancient times. Regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina is called menstruation.

Throughout the world, different perceptions, as well as differences in attitude, have always surrounded menstruation. But currently, there is openness towards it.¹ Cultural taboos, as well as feelings of shame and uncleanliness, is related to menstruation.² Differences in hygiene practices are seen between countries, cultures, religions, and ethnics groups.² For interacting with menstruating women and practices for managing menstruation there are social norms or unwritten rules.

Women and girls face restrictions in mobility and behavior during menstruation due to their "impurity".² Muslim menstruating women are not allowed to pray, fast or have sex while Hindu woman is not allowed to worship and cooking. In some cases, women have to stay away from her family. Restrictions and isolation of menstruating girls impart a negative attitude towards menstruation.³ This leads to significant issues in reproductive health. In the global burden of disease estimates menstrual problems are not included. Gender equality (sustainable development goals (SDG) 5) and quality education (SDG 4) will be met with improvement in menstrual hygiene management.

Scientific information and healthy menstrual hygiene practices are needed for positive reproductive health. Lack of these leads to taboos and socio-cultural restrictions.⁵ Literature regarding menstruation is limited to knowledge, attitude, and problems. The socio-cultural aspects of menstrual hygiene restrictions are not much studied. Socio-economic conditions and cultural significance results in cultural norms and restriction practices.

This study was conducted among women from urban slums of Kochi, India. The main objective was to assess prevalence, factors, and patterns of restrictions faced by young women (between 15 and 35 years) regarding menstruation. As interventions can be easily done in youth (between 15 and 25 yrs.) their restriction patterns are studied. For most girls, mothers are a source of information regarding menstruation. So patterns of restrictions followed by young mothers between 25 and 35 years were also included.

METHODS

A community-based cross-sectional study was carried out in the month of September and October 2018 among young females of Urban slums in Kochi corporation. Out of 74 divisions of Kochi corporation, data is collected purposively from three divisions (65th division Manapattiparambu and 48thdivision AKG Nagar,May first road) catered by Amritha urban health center Kaloor. It represents the lower class of the urban population with close buildings and less privacy. According to WHO youth is between 15 and 24 years and young women are between 25 and 44 yrs. Young females between 15 to35 yrs are taken for study. Only one female within the age limit will be interviewed from each household (as restrictions will be the same in the same house) whose informed consent will be taken. if young women are <18 interviews were done in the presence of her parents. If more than one young female is present in a house youngest among them is taken for study. Young women were available always. Youth, being students if not available were approached the next day at their convenient time. They were excluded if not available after that.

Using a prevalence rate of 46.4% restriction sample size was determined using a standard formula: Z2 PQ/d2 with an absolute precision of 5% (d). Applying the above formula, the minimum sample size required was 111. However, a sample of 130 young females was selected to accommodate the refusals or non-responses.

Quantitative data is collected by using a pre-designed, structured, close ended, self-administered Questionnaire. Questionnaire was modified based on experience on pilot study conducted. The purpose of the study and the nature of the information which had to be furnished by the study subjects were explained to them. Unmarried women were not taken to calculate frequency of those avoided intercourse during menstruation .For those who didn't face any restrictions, questions regarding factors affecting restriction were not asked .For questions regarding knowledge about the use of sanitary pads, those who use 3-4 pads on the second day were considered to know about changing. Those who felt difficulties for washing and drying were those without place to wash and dry, because of their belief such clothes shouldn't be seen by others. Those who felt changing difficulties were those who felt difficulties to change clothes when wet.

It was felt that with these groups and informants we will be able to get the required information on factors influencing the menstrual restrictions. Quantitative analysis involved labelling and coding of all data in order that similarities and differences can be recognised. Statistical analysis was done using spss23 and a minimal level of statistical significance was 0.05.

RESULTS

Only 8.8% young females felt they had restrictions during menstruation but when asked in detail 88% faced different types of socio-religious restrictions. Socio demographic details are given in Table 1.

47.2% of females faced difficulty during menstruation. 40.8% were physical difficulties like pain and 5.6% due to menstrual hygiene maintenance difficulties and 2.4% both physical and hygiene maintenance difficulties. But none reported the difficulty was due to restrictions.

Socio-religious restrictions

88% avoided religious ceremonies and 87.2% avoided religious place visit .100% of Hindus and Muslims avoided both religious place visit and religious ceremonies, whereas 10%chritians avoided religious ceremonies. Christians didn’t avoid religious place visit (p value was found to be significant 0.000). Intercourse was avoided by 68%. Certain rooms were avoided by 28% during menstruation. Commonly avoided room is prayer room 27.2% due to the impact of feeling of impurity. Many don’t have separate rooms for prayer. But majority are not allowed or fear to go near deities during menstruation.

No restrictions were reported by young females regarding co-sleeping with husband or children and discussing about menstruation and it’s problems. There were no restrictions for going out except one reported restriction for attending public functions.

17.6% avoided food during menstruation. Fat rich food were avoided by 6.4%, gastritis inducing food were avoided by 4% and fish was avoided by 0.8%. About 6.4% avoided other types of food. Commonly avoided other food items during menstruation are sweet food, fat rich food, iron rich foods like dates, green leafy vegetables, pappaya, pineapple, gastritis inducing food. There is no scientific basis for such restrictions. Many believe iron rich food causes more bleeding and such misbeliefs are followed over generations.

Personal hygiene maintenance restrictions

Restrictions while using sanitary pads

75.2% do not know sanitary pads are more hygienic, 44.8% believe there is less facilities in public toilets for disposing,44% felt difficulties due to less public toilets and 33.6% do not know about frequency of changing sanitary pads.25.8% wash pads before disposal as menstrual blood is seen by others. Surprisingly only 4% felt there is lack of toilet facilities in schools and 3.2% felt lack of availability of sanitary pads in their educational institutions.

Many don’t change sanitary pads when they go outside, even in schools. Reasons are lack of enough toilet facilities .The majority of them also washed the used sanitary napkins and wrapped them in a newspaper or a plastic bag before disposal. The reasons for washing disposable pads are the fear of bad smell as menstrual waste is collected weekly. Also some believed menstrual blood should not be seen by others.

Restrictions while using cloth

51.25% have washing ,drying and changing difficulties. In this 14.4% faced washing and drying difficulties and 16.85% faced washing, drying and changing difficulties and 20% had changing difficulties, 34.4% did not use cloths and 12.8% did not faced any restriction.

Restrictions while using menstrual cup

72% do not know about menstrual cups, 11.2% have seen videos but do not know how to use it, 12.8% fear to use it, 1.6% felt price was higher and 1.6% don’t use due to frequent need for sterilisation.

Mothers were source of doubt for about 37.6%, friends for 20.8%, both mother and friends for 5.6%, relatives for 17.6%, both friends and relatives for 2.4%, others 3.2%, internet 1.6%, others 3.2% and none 3.2%. Alarmingly health workers were source of doubt only for 8%.

Source for restrictions were traditionally followed patterns, patterns taught by elderly mainly mother or mother in law and self-imposed restrictions. Reasons for restriction is 14.4%considered it was good and give rest to body. Some consider menstruation as an opportunity to take rest but in fact she have to do other strenuous day to day activities. Most religious restrictions are meant for rest but some religious restrictions are based on the belief of uncleanliness. Such restrictions impart a belief to young female that she is unclean 8% women thinks they are unclean. Majority of women (57.6%) fear to disobey religious restrictions. And when enquired whether they feel these restrictions are necessary. 77.6%women felt these restrictions are necessary, 40.8% felt no need to change. Only two youth among 125 females reported religious restrictions based on the belief of uncleanliness have to be changed and they believe family member should bring the change. Some stated they were allowed to sit only on one chair so that others won’t use that chair and get unclean. Restricted female herself reported there is no logic in such practice as they go to public places. Out of 22.4% who felt religious restrictions were unnecessary only 1.6% were affected by religious restrictions. 2.4% felt religious restrictions have to be changed. 8% believe family members should make change and 1.6% believe religious leaders should initiate change. 56.8% felt more public toilets and facilities should be there. They felt political leaders should bring change. 40.8% young females do not need any change.

DISCUSSION

Only 40.8% women faced physical difficulties during menstruation in our study, which is lower compared to studies done in Thiruvananthapuram (47.6%) and Karnataka (56.8%) whereas in Mumbai it was 70.8%.^4,6,7

In the present study females avoiding religious place visit was 87.2% and avoiding religious ceremonies was 88%, similar to studies in Gandhinagar 87.5% and Uttarakhand (84.67%).^8,9 As per a study in Mumbai showed 85.4% faces restrictions out of which 97.6% were religious restrictions.⁴ In a study in Indore 86.44% avoided religious place visit and 84.74% avoided religious ceremonies.¹⁰ Religion influences most of taboos and menstrual hygiene restrictions throughout Indian states.^11,12

88.8% avoided sexual activities in Chittor, Andhra Pradesh while in our study 68% avoided sexual intercourse during menstruation.¹⁰ 90.3 per cent reported not having sex during menstruation, of whom most abstained willingly according to study done in Delhi.¹³ In our study 17.6 % avoid certain food which is less compared to studies in other states . A study in Amritsar showed 27.3% and in Karnataka showed 28.4.^7,14 For study in Andhra Pradesh 18.5% stated that they did not avoid taking any specific food during the days of menstruation.¹⁰

A study in Uttarakhand showed 48% girls asked doubts to mother 22.67% to sisters 12% to friends whereas in our study 37.6% asked doubts to mother 17.6% to sisters and 20.8% to friends.¹⁵ As per a study in Indore, inculcation of menstrual habits was mainly done by mothers in 35.22% of students. This result is in accordance with results of Dasgupta et al 2008 in which mother was first informer in 37.5% of girls.¹⁶ Mothers were primary source of information for 53.3%,sisters for 12.7 % and friends for 6.2% in a study conducted in Amritsar.¹⁴

In a study in Karnataka among high school girls showed 39.8 % changed sanitary pads twice but in Andhra Pradesh based study only 59.69% used sanitary pads twice.^7,10 In the present study 26.4% respondents changed their sanitary pads two times or less per day .Because of comfort ,manageability and mass media publicity, most adolescent girls use sanitary pads.¹⁷

Lack of access to clean water and embarrassment of cloth being seen by men are the problems faced by women who uses cloths during menstruation.¹⁸ In our study 51.25% faced such difficulties which were higher compared to other studies in Gandhinagar (33.8%) and Karnataka (28.4%).^7,8 Surprisingly in our study, only 35.4% young women don’t used reusable cloths. 25.1% don’t use clothes in a study in Karnataka.⁷ Rest used cloths either alone or along with sanitary napkins. Proper washing and drying in sunlight is inevitable as women using cloths are prone to bacterial vaginosis.¹⁹ In a study from Rajasthan and Delhi very few used cotton wool or sanitary napkins.^20,21 According to Dasgupta et al, reasons for not using menstrual absorbents in market is poverty, high cost and ignorance.²² Different rituals leads to restrictions and these are followed over generations.¹⁷ According to study in Ranchi education, cultural beliefs and family environment influence menstrual hygiene practices.²⁴

Societal fear of women and embarrassment to express their views were the limitation of the study. As we administered self-administered questionnaire we couldn’t verify respondents answers.

CONCLUSION

Only few (8.8%) felt they had restrictions and more than two third had restrictions (88%) and felt these restrictions are necessary (77.6%). Factors for restrictions were as they were followed over generations, self-imposed, due to fear to disobey other females. Only change majority need is installation of public toilets and facilities.

This paper provides explanation of restrictions practised and origin of such restrictions during menstruation. The status of pollutant itself can never allow women empowerment and gender equity. Moreover, the taboos being connected as part of the tradition will not disappear from the lives of women, as majority believe that traditions are to be respected and kept intact. The key issues identified from the community will be an asset for combating restrictions effectively.

Recommendations

Value added education with women empowerment and gender equity and health education with special emphasis on the menstrual taboos and menstrual hygiene should be there at school level .Innovative cultural and societal approaches will be required to combat restrictions. Trustworthy channels in social media is a good approach for educating women related issues as many women learned about menstrual cups through social media. But they have to be effective as many fear and don’t know how to use menstrual cups even though they have seen videos. Issues of lack of public toilets and lack of toilet facilities should be addressed.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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