Year : 2020 | Volume
: 9 | Issue : 2 | Page : 99--104
Menstrual hygiene and infections: Menacing women health
Priya Sharma1, NL Gupta2,
1 Center for Public Health and Healthcare Administration, Eternal University, Baru Sahib, Himachal Pradesh, India
2 Department of Psychology, Eternal University, Baru Sahib, Himachal Pradesh, India
Center for Public Health and Healthcare Administration, Eternal University, Baru Sahib, Himachal Pradesh
Good menstrual hygiene is fundamental to health, education, work and wellbeing of women everywhere. Menstruation is a natural part of human existence. Yet it has been neglected for decades in all sectors as well as at individual level. Menstruation remains a taboo in many societies and various negative cultural attitudes and beliefs are still associated with it. Menstruating women and girls are often associated with terms like dirt, filth, stink, impure and so which leads to forceful seclusion, reduced mobility, social, cultural and dietary restrictions. Adolescent girls are mostly kept away from facts and thus remain ignorant of the issues they suffer due to ignorance in their daily health and hygiene practices which result into adverse health outcomes. To delineate determinants of menstruation and to assess progress on perspectives with respect to change in the process of menstruation. Relevant available literature with appropriated methodology on the topic menstruation was taken up with focus on studies over the last decade. The search was strategically done to include an extensive list of concepts, beliefs, process and management to capture the various degrees of difference in perceptions and expressions, demographic and sociocultural factors as well as related subject matter adjusted accordingly to different set of data. The United Nations millennium development goal 2 and 3 directly focused on menstrual hygiene and management for universal education and on gender equality and women empowerment. However, less attention was paid on these issues in developing countries and even the work done on this is not much to explore this neglected aspect of women health. Literature on these particular aspects of women remain extremely scarce and to make things even worse sanitary section is just not touched and more so combined with stigma around it.
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Sharma P, Gupta N L. Menstrual hygiene and infections: Menacing women health.Int J Health Allied Sci 2020;9:99-104
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Sharma P, Gupta N L. Menstrual hygiene and infections: Menacing women health. Int J Health Allied Sci [serial online] 2020 [cited 2020 Aug 9 ];9:99-104
Available from: http://www.ijhas.in/text.asp?2020/9/2/99/282145
Menstruation is generally considered as an unclean practice in the Indian society. The issue of menstruation is approached with hesitance and misinformation because of deeply rooted cultural taboos. Around the world women have developed their own personal strategies to cope with menstruation, which vary from country to country and depend on economic status, the individual's personal preferences, local traditions and cultural beliefs, and education status. Menstruation concerns women and men alike as it is among the key determinants of human reproduction and parenthood. The burden of reproductive tract infections (RTIs) is a major public health concern worldwide and RTI are particularly widespread in low income settings. The proportion of this burden that can be attributed to poor menstrual hygiene management (MHM), as opposed to sexually transmitted infections (STI); iatrogenic infections; or endogenous infections caused by agents other than those introduced through poor menstrual management is unknown. This is an important sanitation issue which has long been in the closet, is deeply buried and still there is a long standing need to openly discuss it. Globally, according to 2005 World Health Organization estimates, 448 million new cases of curable STIs occur annually in adults aged 15–49 years. In India, the annual incidence of STIs is estimated to be 5%. The prevalence of self-reported morbidity varies in different regions in India. Various community-based studies in India have shown the prevalence of RTIs to range from 39% to 84%. “Women only are the guardian angels of female health.” The development of the individual and progress of the nation depend mainly on the educational system of the country. As education is intimately related to all aspects of life, it is the responsibility of the adult members of the society to shape the development of the coming generation in accordance with its ideals of life.
Objective of the Review
The objective of this review is to critically summarize the published data and evidence on the menstrual health and hygiene to assess the factors for existing prevalence of menstruation related problems and to manage them adequately.
Basic Facts About Menstruation
- Menstruation is when your body sheds the lining of the uterus (womb)
- Cramping is caused by contractions of the uterus and is normal
- On average, menstruation starts between the ages of 10 and 15
- On average, menstruation ends between the ages of 45 and 55
- The average menstrual cycle is between 28 and 35 days
- Menstruation is a normal bodily function for women
- Menstruation signals that a girl can become pregnant
- Bathing during menstruation is safe
- Girls and women should not douche (wash the inside of their vagina)
- During menstruation, girls and women need to wash the skin outside and around their vagina (vulva) at least once a day
- Homemade menstrual cloth needs to be washed with water and soap and then dried in the sun
- Menstrual materials (sanitary pads or homemade cloth) should be changed three to six times a day.
Factors Leading to Poor Menstrual Hygiene
The economic, social, cultural, educational and several other factors have a direct association with the menstrual health which has an obvious effect by the environment the women are born, brought up, grow to womanhood, marry and thus pass on the same process to their daughters in starting their own families. All these factors form a major reason for the increased prevalence of RTIs/STIs in addition to various other factors such as the inability of women to take decisions on their own, their low status within the family, and their unhealthy behaviour.
Poverty, both personal and structural, emerged as a very important economic barrier to the accessibility of hygienic sanitary materials. Women and girls in poor countries can't afford sanitary pads or tampons, which would normally be changed around four times a day during menstruation.
Many tribal women/girls don't use anything because cultural barriers which leads to embarrassment. Even in their homes, a culture of shame forces women to find well-hidden places to dry the rags. These places are often damp, dark, and unhealthy. This practice is responsible for a significant proportion of illness and infection associated with female reproductive health.
Facilities and service factors
- Due to institutional and domestic poverty, schools' and homes' water supply and sanitation is inadequate
- Furthermore, sanitation facilities for girls in schools are improperly designed
- Add to this that most of the shops in rural areas are inadequately stocked with sanitary materials
- Inadequate water supply and sanitation facilities
- Anxiety and panic among the girls because of their fear of foul smell and of staining their uniforms
- Lack of washing facilities which is stressful to the girls and compromises their hygienic standards
- Lack of privacy was an important problem both at home and at school. This leads to contribution to girls' poor performances in school as well as at home and is the major reason of their high failure rates confiding to short- and long-term impacts on their educational achievements and hence their future.
Impact of Neglected Menstrual Hygiene
Menstruation affects women's social life
A Hindu woman abstains from worship and cooking and stays away from her family as her touch is considered impure during this time. Jewish tradition regards a woman as ritually impure during menstruation. Anyone or anything she touches becomes impure as well. Even her breath, spit, footprints, voice and nail clippings can be considered impure. Under Islamic law, a menstruating woman is not allowed to pray, fast or have sex. She is not allowed to touch the Koran unless it is a translation. Restrictions followed by menstruating girls-various studies revealed different types of restrictions practiced during menstruation. Study conducted by Paria et al. revealed 64.72% of urban and 78.57% of rural girls practiced different restrictions during menstruation. Among them 76.96%, 33.14%, 10.67% of urban girls did not attend any religious occasion, play outside, and not attend school, respectively, whereas in rural girls this percentage was little higher as 78.57%, 28.22%, and 17.70%, respectively. Food taboos are common during menstruation. Shanbhag et al. revealed that 42.6% avoided certain food items common ones being sweets (21.6%) spicy food (3.9%) curd and milk products (9.1%).
Menstruation affects women's health
- Psychological issues, i.e., mental and emotional stress
- Abdominal pains and vomiting. The dizziness might be due to anemia caused by the loss of blood. Teenage pregnancies, preterm birth, illegal abortions and adverse pregnancy outcomes
- Vaginal rash, bad odor, bacterial vaginosis – is a polymicrobial syndrome characterized by the imbalance of resident bacterial flora in the vagina. Risk of urogenital symptoms, vulvovaginal candidiasis. These vaginal imbalances are primarily nonsexually transmitted and could plausibly be introduced to the reproductive tract through the materials used for absorbing menstrual blood, pelvic inflammatory disease, toxic shock syndrome, acquisition of STIs, human papillomavirus infection and RTIs.
Menstruation affects school performance
- Absenteeism from school and missing out on subjects
- Dropping out of school
- Of the many drawbacks of the initiation rituals, pregnancies out of curiosity and eagerness to try out what was taught, and early marriages imposed
- There is a substantial lacuna in the knowledge about menstruation among adolescent girls. Good hygienic practices such as the use of sanitary pads and adequate washing of the genital area are essential during menstruation
- Across the developing world, the lack of appropriate and adequate sanitation facilities prevents girls from attending school, particularly when they are menstruating. Of the 113 million children currently not enrolled in school worldwide, 60% are girls. There is conclusive evidence that girls' attendance at school is increased through improved sanitation.
Community-based studies in India have shown a high prevalence of RTIs but here is a lack of sizeable literature from urban slums and resettlement areas. A total of 802 women were interviewed. A total of 352 (43.9%) women currently had symptoms of RTIs.
Study carried by Yasmin et al., 2013 revealed 82.3% used sanitary pad only. 15.7% of the respondents uses old washed cloth and out of them 69.5% had problem while washing and drying of the cloth which mostly consisted of lack of privacy 93.7%. Keeping the cloth in places away from prying eyes became a problem for them and for that they usually dried and stored in un-hygienic places. 98.6% of the respondents followed some restriction or taboo during menstruation. Regarding hygienic practices during menstruation 85.7% had daily bath. Others felt bathing should be restricted in the first 2 days of menstruation as bathing increases the menstrual flow. It was seen that religious taboos and restriction on type of food was maximum in Muslims 97.3% and 59.4% respectively. 80.3% of the respondents had toilet exclusive to the family but 19.7% uses common toilet with user per toilet being mostly 15–20 persons. 38.8% of respondents' family had to keep water stored in their toilet. 10.2% of respondents complained of excessive white discharge. It was seen that hygienic practice like hand washing, daily bath had significant relationship with presence of continuous supply of water and presence of toilet exclusive to their family.
Shanbhag et al., 2012 revealed only 44.1% used sanitary pad during the menstrual cycles. Among those who used cloth, only 31.3% used soap and water to clean them. 56.8% used soap and water to clean their genital organs and 88.8% of the girls took bath daily during menstruation. A large proportion of the girls dried these washed clothes in the sun 68.4%, but about 16.4% dried them inside the house. A large majority 71.7% reused these clothes for 1–2 months, 20.4% for 3–4 months and 7.9% for 5–6 months. The queries on the frequency of change during the time of menstruation revealed that 39.8% changed sanitary pad or cloth twice a day, 29.5% three times a day and 21.7% once a day. A large proportion 56.8% of the study population used soap and water to clean their private parts while the rest 43.2% used only water. 53.8% cleaned their private parts after micturition all the time. 8.5% never cleaned their private parts after micturition. Also, it was revealed that cultural practices which was followed during menstruation included restrictions to go to the place of worship (94.2%) and special functions held on attaining menarche (45.6%) Overall it was seen that out of the 329 who had attained menarche, 323 (98.7%) did not practice all the 10 steps of good menstrual hygiene during menstruation Perceptions towards menstruation many of the girls mentioned that they experienced fear (44.1%) on attaining menarche, while some of them (26.1%) were anxious. About 74.2% felt that menstrual cycle is a natural phenomenon while 17% felt that menstruation occurred due to the curse of God. Majority of them (56.8%) felt that menstruation poses a huge physical and psychological burden on them.
Hamal and Susma 2014 revealed that only 4.8% used single use disposable sanitary pads, while remaining 95.2% used reusable cloths. Those who used reusable pads, more than 90% of them dried outside house with direct sunlight after washing whereas some of them used to dry those reusable pads inside their house with no sunlight. The disposal of sanitary pads and reusable cloths (no longer used) was done in multiple ways. 44.6% of them buried, some threw it with other wastes 19.3%, some threw in toilet pans 10.8%, while burning and throwing in streams or rivers were also ways of disposing them. During menstruation, 63.9% of the respondents mentioned taking bath daily whereas 34.9% bathed on alternate days. During menarche 75.9% slept in their own room, while 13.3% slept in other rooms' of their own house. 10.8% of them slept at cow sheds/huts. All of them had some kind of restrictions enforced in them. The most restricted practice during menstruation was related to attending religious function or ceremony. They were not allowed to attend religious functions or go to sacred places. And others were related to kitchen works, not allowed to eat together or even entering the kitchen. Some of them were even not allowed to enter their house. Only (20.5%) had missed one or more school days during her periods and the reason was lower abdominal pain.
STIs rank among the top five conditions for which sexually active adults seek health care in the developing countries. As per the community based STI/RTI prevalence study (2003), over 6% of the adult population in India suffers from one or the other STI/RTI episode annually. There is enough evidence to suggest that early diagnosis, treatment and management of STI/RTI including inducing behavior change through education amongst the target groups will reduce transmission of STI/RTI and HIV.
Every year approximately 10% of women worldwide are exposed to genital infections including urinary tract infections and bacterial vaginosis, and 75% of women have a history of a genital infection.
Census 2011 reveals that 67.3% of the rural population lacks toilets, and the worst-affected states are Jharkhand 91.7%, Madhya Pradesh 86.4% and Chhattisgarh 85.2%. Rural schools often lack functional toilets, or do not have water and provide the privacy required for changing pads. As a result, open defecation, bathing in dirty ponds or river water, reusing menstrual products, washing menstrual rags without using soap and not drying them in sunlight has become the norm. A discernible escalation in the incidence of infections, especially of the urinary tract and reproductive tract, among women using conventional methods and those changing outdoors has been reported in the literature. Studies report that rural women store menstrual rags in damp dark corners of the house because of the culture of shame and embarrassment.
In a study done by Ahmed and Yesmin 2008 it was found that 95% of women and 90% of adolescent girls use rags during menstruation. Forty percent of women change their rags only once a day while 75% of adolescent girls change three times. Sixty percent of women wash the rags in unsaved water. Ninety percent of women and 70% of adolescent wash the rags with only water. Ninety-five percent of women and 80% of adolescent girls reuse the rags. The majority of women and adolescent girls dry the rags in dirty and dark places. In a study carried out by Thakre et al., 2011 sanitary pads were used by 49.35% of the selected girls. The practice of the use of old clothes was reported in 45.74% of the subjects. Satisfactory cleaning of the external genitalia was practiced by 33.85% of the girls.
Study done by Shah et al., 2013 revealed that at baseline 90% of girls were using old cloths. At the end of the study, 68% of adolescent girls said their first choice was falalin cloths, while 32% said it was sanitary pads.
Dasgupta and Sarkar 2008 revealed 48.75% girls knew the use of sanitary pad during menstruation. Another study done by Dasgupta et al., 2008 revealed that the prevalence of RTIs was more than three times higher among girls having unsafe menstrual practices.
Study done by Dhingra et al., 2009 found that level of personal hygiene and management of menstruation was found to be quite unsatisfactory. Ninety-eight percent of the girls believed that there should be no regular bath during menstrual cycle. All the girls followed cultural practices without much questioning.
Anand et al., 2015 revealed a meager 15% of women used sanitary pad/locally prepared napkins during menstruation in India. Both RTI and vaginal discharge were positively related with nonuse of hygienic methods.
The results of the study carried out by Dube andSharma 2015 showed 40% rural girls and 60% urban girls considered menstrual as natural phenomena while 39% of urban girls and 56% of rural girls took it as disease. Eleven percent of urban and 28% of rural girls were not aware about the gap of periodic menstruation cycle.
The study carried out by Mohite andMohite 2016 revealed that out of 230 girls, 12.6% were practiced disposable adsorbent sanitary napkins whereas 87.3% practiced reusable cloth materials. Higher percentages of girls, 77.3% were practiced an insanitary method of disposal of materials and practices of personal hygiene including bath during menstruation and cleaning of external genital parts followed by 95.2% girls respectively. The rate of utilization of Integrated child development services (ICDS) and subcenter services was 16.9% and 27.2%, respectively.
The study carried out by Paria et al. depicts that more number of girls in the urban area were using sanitary pads as compared to girls in the rural area and this difference is also highly statistically significant (P = 0.000). Ninety-nine 36% girls in the urban and 54.88% girls in the rural area were using cloth. Seventy-five 27.27% girls in urban 30.45% girls in rural area had changed the pads only once per day. 31.27% of urban girls and 71.42% of rural girls reused pads during menstruation period. Cleaning of external genitalia was satisfactory only in 47.63% of the urban and 37.96% of the rural girls. Hygienic practices are more satisfactory in urban area as compared to rural area (P = 0.023). Majority of urban girls (83.63%) had toilet facility in home whereas 56.39% of rural girls deprived of this facility.
In the study carried out by Shivaleela et al., 60.9% and 39.9% respondents had good knowledge and practice of menstrual hygiene respectively. 62.4% were using rags and pieces of cloth. Majority 82.2% of girls were using absorbent material during menstruation and two third 66.2% of girls were using commercial made sanitary pads as absorbent material during menstruation. Out of 157 girls who were using clothes 52.9% of the respondents were washing clothes with soap and water. 45.2% of the respondents dried their washed clothes in sunlight. 51.9% of girls change their pads or clothes three and above times per day. 20.2% of the respondents were disposing their used sanitary pads in dustbin. One-third 33.3% of girls use paper to dispose the pads by wrapping. Two-third 67.3% of respondents were taking bath daily with soap during menstruation. Study by Tarhane and Kasulkar 2015 revealed 79% girls used sanitary napkins while 21% girls used clothes as absorbent during menses. Jogdand and Yerpude 2013 revealed 34.63% girls reported use of old cloth for protection during menstruation. 78.99% girls were restricted to attend religious occasions during menstruation.
Sudeshna and Aparajita 2012 revealed that majority of the girls preferred cloth pieces rather than sanitary pads as menstrual absorbent. More than half of the girls were ignorant about the use of sanitary pads during menstruation. Only 13.2% girls used only sanitary pads during menstruation and around 24.2% used both reusable cloth and sanitary pad. Apparently, poverty, high cost of disposable sanitary pads and to some extent ignorance dissuaded the study population from using the menstrual absorbents available in the market.
This article reveals that off late much emphasis has been laid on menstrual health but there is a large part of population that remains ignorant regarding the basics of menstruation. Although literacy rate has improved over the years in India but people lack specific education on menstrual health. Cultural beliefs are a major lacunae for good menstrual hygiene as though besides the ignorant population, the other part of population that has knowledge but still has not evolved with time due the restrictions that have been traditionally imposed on them. Much work has been done on this subject but a lot more is needed before the targets are achieved. It is important to realize that women are the driving force for good health and improving the health indicators. Even if a single aspect of woman health as it will not account to positive growth of women. Eventually, it will leave a negative impact on not just the family but the whole society and the whole nation. Taboos surrounding menstruation cannot be ignored. In a patriarchal framework, menstruation is a taboo topic which is by far the most important reason why menstruation is poorly managed in rural areas. Women feel embarrassed or ashamed while making a purchase from a male shopkeeper or while drying rags in the view of men as they have always been instructed to do so since generations. Shame is systematically ingrained into the female psyche. There is hardly any change in the trend in the last few years when it comes to menstrual health. Good MHM is the right of every woman and nothing should stop her from reaching it.
Management of Menstrual Hygiene
It is a right of women and girls to have necessary knowledge, facilities and environment to manage menstruation hygienically with dignity. In Indian context, there are scare data on menstrual practices among adolescent girls due to population diversity and cultural practices. Menstrual hygiene day is a global platform that brings together nonprofits, government agencies, the private sector, the media and individuals to promote MHM. Menstrual hygiene day will help to break the silence and build awareness about the fundamental role that good menstrual hygiene plays in enabling women and girls to reach their full potential. It catalyzes a growing, global movement for MHM and supports partnerships at global, regional, national and local level. MHM is a subject of deep concern in most developing countries, where women, especially rural women, face challenges in acquiring hygienic absorbents, clean water for washing and a private space for changing. Every month they are forced to opt for unhygienic ways to catch the flow and hide signs of menstruation, without caring for their own health and well-being. The aim should be to create awareness in order to overcome the silence around MHM and break the taboos within the broader society, communities, and also among family members. Various steps that can be taken are: mass awareness, communication with girls and women to raise awareness and stimulate change in practices, community mobilization to initiate dialogue among community members to deal with issues of stigma and exclusion of girls, Film screening, Parades, walks, and other public advocacy events, special MHM educational programs and celebrations at schools and at health centers, social media campaigns about menstruation, teachers to normalize menstruation and dealing with myths and misconceptions. It should be responsibility of all to merge efforts to solve this one big issue which has been neglected over the decades.
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Conflicts of interest
There are no conflicts of interest.
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