"Menstruation is the only blood that is not born from violence, yet it is the one that disgusts us the most!" - Maia Schwartz.
Adolescence is a phase of transformation from puberty to adulthood. Menstruation is a naturally occurring phenomenon in a woman's reproductive life that marks the beginning of her sexual years. Also termed as menses, menstrual cycle, or period, it is the monthly discharge of blood from the vagina of a woman. Despite being a significant event in a woman's life, it remains a monthly challenge for millions of young girls around the globe, including India, thereby having a drastic impact on their health, education, and daily life. To understand the whole scenario, we need first to know the fundamental aspects concerning menstruation.
Why do Women Bleed Every Month?
Menstruation is a natural phenomenon regarded as a physiological and psychological milestone in a woman's reproductive life. Girls menstruate at an average age of 12 years. However, some can get the same as early as eight years or as late as 16. Menses occur because of hormonal changes in a girl's body. The release of hormones like estrogen and progesterone from her ovaries forms the thick inner lining (i.e.endometrium) of her uterus (also known as the womb). It makes the uterus ready for an egg to fertilise and give birth to a baby after contact with sperm. However, menstruation occurs if there is no fertilisation of the egg. The lining of the uterus breaks and results in the discharge of menstrual fluid through the vagina, which contains blood, endometrial cells, and mucus. It typically lasts for 3 to 5 days. The cycle keeps repeating after every 28 to 29 days. Women generally stop menstruating (menopause) at the age of 45 to 50 years, after which there are no chances of getting pregnant.
So, Where Lies the Challenge?
As per the Census 2011 Report, approximately 336 million women in India are of reproductive age and menstruate for 2-7 days every month. However, over the years, menstruation has always been surrounded by taboos and myths, especially in India. Menstruating females are excluded from many aspects of socio-cultural life such as cooking, sexual intercourse, bathing, worshipping, eating together, and even touching certain things like pickles or plants. Even slight contact with menstruating women is considered toxic.
Studies have revealed that menstrual waste is linked to witchcraft and danger in certain parts of the world and is therefore buried. It is believed that if the witch finds the menstrual cloth, it will make the woman infertile. There is an unnecessary shame and embarrassment attached to it that makes people awkward to talk openly on the topic. These exclusions severely impact the lifestyle, emotional state, and, most essentially, the reproductive health of young girls. It further expands youth's low level of knowledge and understanding of puberty, menstruation, and reproduction.
Despite being a healthy and regular part of a girl's life, menstruation is still considered impure and dirty. It is one of the reasons why girls find it challenging to manage their period every month. Below is the harsh reality of India, a progressive country, yet, regressive when it comes to menstrual hygiene.
Lack of Awareness:
"Many women fail to educate their daughters on menstruation on account of the taboo attached to it. Hence, least information is passed on to generations in India!" - Supriya Khanna, ICMR.
According to a 2012 study by the Indian Council for Medical Research, about 71% of the adolescent girls in India have no idea about menstruation until they get it themselves. Only 38% speak to their mothers about the same. Mothers themselves are unaware of how to explain it to their daughters and what could be regarded as menstrual hygiene management. The study revealed that 70% of mothers considered menstruation to be dirty and a curse. Schools and teachers in villages were also found least helpful and abstained from talking about it. It indicates the negligence of the parents and teachers to prepare their daughters/students for the same, which results in extreme anxiety and distress amongst girls. Cultural taboos associated with menstruation prevent them from seeking help and protection. Lack of support from the families increases their domestic responsibilities adding to the misery of unhealthy periods.
The UNICEF Report, 2014 stated that 79%, 66%, 56%, and 51% of girls in Tamil Nadu, Uttar Pradesh, Rajasthan, and West Bengal were ignorant of menstrual hygiene.
Low Access to Safe Menstrual Absorbents & Other Amenities:
"In rural areas, two to three women will use the same cloth after washing or drying it. Even if sanitary napkins are available, women are discouraged from using them!" - Meenakshi Sharma, Coordinator, Menstrual Hygiene Management, WASH alliance.
Access to sanitary products is another significant affair—one sanitary napkin costs between five to twelve rupees in India. A menstruating girl requires around three pads per day and an average of 15-20 pads per period which comes to around ₹80-100. However, considering the Census 2011 Report, 70% of India's population lives in rural areas and is dependent on manual labour, 75% of which survive on ₹33 per day. Therefore the monthly menstrual expenditure remains far beyond their reach.
A 2012 study revealed that only 12% of menstruating females in India utilise sanitary products while others rely on ash, leaves, old rags, cloth, and mud. Some even fill up old socks with sand and tie them around their waists to absorb menstrual blood. Millions of families are unable to afford basic menstrual kits. According to the 2014 study by Dasra, a charity that works for this cause, nearly 23 million girls drop out of school every year due to lack of access to sanitary products, adequate water, and clean toilets. Girls often fear getting stained due to blood and body odour leakage and being made fun of by their classmates. It leads menstruating girls to leave school.
The poor condition of a toilet in one of the Indian schools
Types of Menstrual Absorbents Used:
The preference for menstrual absorbents varies with women. In the rural, slum, and tribal areas, girls mostly prefer reusable cloth pads, mud, dust, ash, cow dung, animal skin, leaves, and rags. The sad part is that they put soil in their undergarments, which comes directly in contact with their private parts.
Some of the menstrual absorbents used by rural women
An Indian woman washing bits of cloth used by her during her menses
While in urban areas, most of the girls prefer using commercial sanitary pads. They are expensive compared to cloth pads and are non-reusable and harmful to the environment. According to various studies, deodorised and non-deodorised sanitary products contain chemicals like Organochlorines. These bacterias cause a delay in the decomposition of these products in the soil. It is one of the reasons why experts have suggested organic pads over commercial pads.
Nowadays, girls also prefer using tampons which provide internal protection. They are a soft material (mostly cotton) inserted into the vagina to absorb the flow. Again these are expensive and not easily degradable.
Girls are also choosing menstrual cups over pads. These cups are made of silicone rubber which can be folded and inserted into the vagina to collect the blood. They can be worn for 6-12 hours, depending on the flow, and reused for years. It is a sustainable and environment-friendly option.
Water Hyacinth Pads sold under the trade name 'Jani' are also preferred as they are cost-effective and biodegradable.
Banana Fibre Pads made from the waste of banana tree fibre sold under the trade name 'Saathi' are provided to rural women. They are eco-friendly and decompose within six months after use.
Rural women also prefer Bamboo Fibre Pads made of bamboo pulp because they are affordable, easily decomposable, and possess antibacterial properties.
The Impact of the COVID-19 Pandemic
While the whole world has been affected by the pandemic, it has also worsened women's menstrual health. The imposition of lockdown has led to inadequate production and supply of menstrual hygiene products in rural and urban areas.
Consequences of Poor Menstrual Hygiene
Unhygienic menstrual conditions often lead to numerous health problems amongst women. The surveys conducted by the Ministry of Health in 2002, 2005, 2008, and 2012 revealed that these issues are preventable. However, menstruation is such a hush affair in India that it becomes difficult for women to seek medical help or even maintain proper hygiene. Approximately 120 million Indian adolescent girls encounter menstrual dysfunctions. Following are the impacts of poor menstrual hygiene:
Introduction of bacteria or fungi through dirty cloth, rags, or mud can cause infections in the reproductive and urinary tracts, damaging the kidney if left untreated.
There is a delicate balance of good and bad bacteria that live in the vagina. An imbalance in the pH of the vaginal secretions can lead to Bacterial Vaginosis (BV), which mainly affects women when trying to conceive. Genital infections are 70% more frequent in women using unsanitised menstrual absorbents.
The vulnerability to Cervical Cancer (Cervix cancer, i.e. the opening of the uterus) also increases due to these infections. As many as 60,000 cervical cancer deaths are reported every year, two-thirds of which are poor menstrual hygiene.
Other issues associated with the same are irregular periods, prolonged or short periods, heavy or light flows, dark or light-coloured, painful periods, and psychological problems such as anxiety, embarrassment, and shame.
A Glimpse into Diverse Menstrual Experiences
"Sometimes, my periods are delayed for a month or two. Moreover, they are extremely painful when they arrive," says Pinky, 14 years old, living in Kanpur with her family. Just like her mother, she too uses cloth as a menstrual absorbent. She disposes of the same in the field where she goes to defecate. She stays at home on the days she gets her period. Her brother and father are told that she is ill or has a fever.
"I wish menstruation would never happen to me. Since I got my periods, I am bound by restrictions at home," says Priya, 13 years old, who lives in a peri-urban area of Kanpur. She hates going to school when she menstruates because the school toilets are dirty with no water.
"I play volleyball even when I am on my periods. I mean, why not? My periods cannot be an excuse to skip my favourite sport!" says Kaveri, 12 years old who lives in Tamil Nadu. Her school provides sanitary pads free of cost, which are of poor quality. However, she says they are helpful in an emergency.
"When I got my periods for the first time, I did not understand what was happening. My mother asked me to use bits of cloth which I had to hide from my father and brother." shares Guddi Kumari from Bihar when asked about her first period.
Government Schemes Introduced to Promote Menstrual Hygiene in India:
The Right of Children to Free and Compulsory Education Act, 2009, provides drinking water standards and separate sanitation facilities in schools for every boy and girl.
The Jan Aushadhi Suvidha Oxo-Biodegradable Sanitary Napkin scheme provides biodegradable sanitary pads for Rupee one per pad.
SABLA Program: The Ministry of Women and Child Development program focuses on health, hygiene, and sexual health.
The Ministry of Rural Development initiated the National Rural Livelihood Mission to support self-help groups in manufacturing sanitary pads.
Menstrual Hygiene Day is an annual awareness day marked on 28th May initiated by a German-based NGO, WASH, in 2014 to highlight the importance of menstrual hygiene management. It is widely observed in India.
Menstrual Hygiene Management: An Initiative Under The Swachh Bharat Abhiyaan is a constitutive fragment of the Swachh Bharat Mission Guidelines (SBM-G), issued by the Ministry of Drinking Water and Sanitation to help all adolescent girls and women to manage their Menses effectively.
These guidelines provide the duties of the state governments, district administrations, engineers, and technical experts inline departments, school principals, and teachers.
A few of the guidelines are as under:
Funds must be collected and used to raise awareness on menstrual hygiene at all places, especially in schools.
To spread awareness on menstruation, every adolescent girl, woman, and their families, including adolescent boys and men, is informed. Nodal Officers, Anganwadi supervisors, and workers must be trained for the purpose.
Electronic models must be developed to meet the demand for sanitary napkins or other menstrual absorbents (pads, tampons, or menstrual cups).
A separate toilet must be provided with private space for cleaning and washing.
Adequate and sustained water supply and soap must also be provided
Along with access to safe disposal of menstrual absorbents
Although these schemes and missions were introduced with an excellent perspective, their implementation has many loopholes. Action and investment are still needed. Millions of girls in India still do not have access to hygienic menstruation due to several factors such as the uncertain supply of sanitary products or poor sanitary products, lack of water and sanitation facilities, and limited awareness amongst teachers and other frontline workers involved in the mission.
What can be done?
The gap between effective planning and successful implementation of the existing policies has to be reduced. There is a strong need to follow a strategic approach in combating these issues. One of the prime barriers to using sanitary products primarily in rural areas is often the price and unavailability. Women from the highest quintile are more than four times as likely to use a hygienic method as women from the lowest quintile (89% versus 21 %). The COVID-19 pandemic has further added to the misery due to loss of income and livelihood. To overcome this barrier, low-cost napkins (organic that are safer and environment friendly than the regular pads available in packets) locally produced by self-help groups can be a better option. Providing sanitary napkins free of cost at public places can be of great help.
Adolescent girls and women can be trained on using sustainable products such as organic pads, and conducting campaigns on hygienic ways to manage their menses is a must. They must be made aware of the importance of frequently changing menstrual absorbents during the day, and they must understand the negative symptoms and when to access healthcare.
In schools, girls throw their pads in the toilets or leave them there unwashed due to a water shortage and a lack of sanitary facilities. It makes the toilets dirty and a breeding space for flies, pathogenic germs, and mosquitoes. There is a need to install menstrual waste disposal machines (incinerators) and provide girls with proper knowledge on various disposal techniques.
There is a need to ensure comprehensive sex education for all genders both in and out of schools, so they do not resort to unreliable sources for answers. It will improve their knowledge about puberty, menstruation, and reproductive health.
There is a strong need to break the silence and awkwardness around menstruation. Menstrual hygiene management cannot be addressed alone by the schools. It is an important area that requires the support of the wider society, communities, and families.
Celebrities, public figures, and political leaders are mighty voices that can help in drawing attention towards this subject. Bollywood Movie 'Padman', starring Akshay Kumar and Radhika Apte, is an example of removing it from the barren lands of stigma by producing national interest and attention.
Role of Boys & Men in Menstrual Hygiene Management
The involvement of boys and men in menstrual hygiene management is significant. There is a strong need to educate them on the topic to raise the issues on the same confidently. The traditional silence around it has to be destroyed by encouraging the participation of men in conversations and campaigns intending to break stigmas and taboos associated with menstruation. Men and boys can influence experiences of menstruation of women and girls through many roles, including fathers, brothers, husbands, teachers, community leaders, employers, co-workers, and policymakers in domains such as household, work, school, and the community at large.
Their support can be extended towards advocating clean and sufficient toilets, providing or buying sanitary products for their friends/wives/daughters/co-workers without any disgust or shame, creating a positive environment, communicating care and empathy, and keeping a check on their health.
In India, everything is sold openly, and a sanitary pad is concealed in a black or translucent bag before being sold. It highlights how attention on menstruation remains negligible. It has to be stopped. There should not be any shame attached to menstruation. It is biological and a life-giver. It is, therefore, the responsibility of society to observe and participate in ensuring menstrual hygiene, for it is not a challenging task. A guilt-free and healthy period is the fundamental right of every girl. All we need is a little effort to support the cause. PERIOD!