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Though menstruation is a natural part of life for more than half the world’s population, half a billion girls and women still lack the support they need to manage their periods safely and confidently. The costs to women, their families, and society are enormous and entirely unsustainable, even as access to information about menstruation, to sanitary menstrual products, and to facilities where menstruation can be managed in privacy, are instrumental to success in school and at work. The availability of menstrual care materials alone has been found to reduce absenteeism from work by 21 percent, while increasing school participation and improving learning outcomes. And long-standing stigmas and taboos around menstruation are found even in countries that have attempted to address this issue with policies dedicated to menstrual health and hygiene.
However, because it cuts across distinct sectors—health, education, gender equality, water hygiene and sanitation (WASH), and environmental conservation—menstrual health and hygiene (MHH) is a much more complex and difficult public health issue than many realize. Wide-scale programming can be particularly difficult to formulate, since public health interventions rarely fit neatly into any one of these sectors. As a result, it may be tempting for organizations to simplify their statements and products and to offer a silver bullet for what is actually a much more multifaceted and complicated problem.
Fighting misconceptions and long-standing stigmas needs to start with MHH education at a young age and for all genders. Lack of knowledge around menstruation is a global issue. In developed countries like the USA, only 21 percent of elementary school students are taught about puberty, meaning that girls often do not learn about menstruation until after they’ve had their first period.
Can you imagine your first period arriving without having even a basic understanding of what is happening to your body? This is the experience for millions of girls in some rural areas of India where less than 3 percent of them are aware of menstruation before they have their first period, leading to fear and confusion over the origin of menstrual blood and how to manage it safely and hygienically.
But who should young people turn to with questions regarding menstruation? Family members are their closest sources of information, but that information can be inconsistent, outdated, and is often deeply rooted in tradition. In Bangladesh, for example, the perceived links between menstruation and the ability to conceive children have been cited as making the conversation “inappropriate” for mothers to have with their young daughters.
A lack of knowledge about female biology can also have long-lasting implications. Up to 53 percent of women in developing countries have reported they do not use contraceptives due to concerns over how they would affect their menstruation. Contraceptive-induced menstrual bleeding changes are normal, but without proper education around the menstrual cycle, they may be perceived as a sign of poor health — even feared as deadly.
Fortunately, we do not have to start from scratch to make a significant change. Work by USAID in Ghana has shown that incorporating holistic menstrual health education leads to more positive feelings around menstruation as a normal biological process. Additionally, programs like Grow and Know have already developed puberty education material that is grounded in the social and cultural context of each country.
MHH programs are only starting to be more rigorously evaluated, and the available evidence base is incomplete. For policymakers to develop and implement successful MHH interventions, we will need to prioritize data-driven learning and invest in MHH research. For example, the Menstrual Practice Needs Scale (MPNS-36) is the first validated tool that allows researchers and practitioners to measure quantitatively how menstrual management practices and experiences are perceived by menstruators, thus providing critical data to design interventions that take into consideration actual experiences.
Until now, most studies have been qualitative, looking at the practices of the menstruators, i.e., what products they are using, rather than at whether those practices are satisfying their actual needs. Researchers at the Johns Hopkins Bloomberg School of Public Health systematically reviewed 54 measures, trials, and studies of MHH interventions and found a lack of consistent definitions and methodologies. The MPNS-36 may serve as a stepping stone to a complete set of tools needed to evaluate MHH practices and to begin drawing comparisons between the various methods.
Menstrual health is a complex social issue that cuts across the sectors of WASH, health, education, gender equality, and environmental conservation, and might best be addressed through collective impact initiatives, or systems change, which have proven successful in comparably complex circumstances in the past. Partnerships provide opportunities for real progress, but because coordinating joint efforts requires significant time, financing is needed to develop the structures needed to be effective. Our current understanding of MHH has been limited by the lack of access to research funding, including for intervention trials, longitudinal studies, and impact evaluation.
The Global Menstrual Collective and The African Coalition for Menstrual Health Management are two examples of collective impact initiatives working to open dialogues, strengthen policies, and coordinate MHH activities. Earlier this year, the Global Menstrual Collective (then named The Global Menstrual Health and Hygiene Collective) published a joint statement calling on all who support the Beijing Declaration of the Fourth World Conference on Women to prioritize comprehensive and inclusive menstrual health for all. More than 30 NGOs, UN agencies, academic institutions, private sector organizations, and networks endorsed this joint statement.
However, to strengthen these collective efforts, it is not enough to bring organizations together. There must be funding for a neutral party that drives the initiative by removing ownership questions between the various participants. These neutral secretariats, or backbone organizations, guide strategies, develop key messaging, support activities, and create shared practices that build on the strengths of each member organization.
Menstrual health programming must ensure that girls and women have the knowledge, materials, infrastructure, and enabling environment to manage their menstruation. This need cuts across programming for WASH, SRHR (Sexual and Reproductive Health and Rights), and Gender Equality. The linkages are especially evident when looking at Sustainable Development Goals 3 (good health and well-being), 5 (gender equality), and 6 (clean water and sanitation), where integration is quite obviously needed. In other words, the funding has to take an ecosystem approach, realizing that a single intervention is rarely enough to create lasting change.
By incorporating MHH components into existing programs, it is possible to amplify the impact that even small investments can make. For example, WASH plays a significant role in delivering quality SRHR services such as safe and hygienic facilities for childbirth. With many waste and sanitation systems ill-equipped to allow hygienic, private, and comfortable management of menses, there is a strong association between the availability of WASH infrastructure and the ability for menstruators to participate fully in society.
Improved data on MHH are needed on both psychosocial and financial aspects to show the impact MHH has on an individual, household, or societal level. According to the World Bank, for every 1 percent increase in the number of girls completing secondary education, a country's gross domestic product grows by 0.3 percent. As we start to see a shift towards better data, we also expect to see a shift towards better and more inclusive solutions.
In recent years, we have seen an increase in policies addressing MHH around the world. Still, we are missing ways of holding governments accountable for ensuring that these policies get funded. Kenya is an example of a country that succeeded in establishing a dedicated MHH policy but has found it difficult to provide adequate financing. “A major challenge continues to be inadequate funding for implementation,” as Neville Okwaro of the Ministry of Health in Kenya put it; “even the policy development process relied heavily on support from a few partners, which is not sustainable long term.”
The emergent Sanitation and Hygiene Fund (SHF) aims to bring dedicated funding to these often de-prioritized issues by working with governments to help close the sanitation, hygiene, and menstrual health gap and accelerate the delivery of sustainable sanitation and hygiene services for people with the highest burden and lowest ability to respond.
In addition to working with governments, development actors and funders must encourage the private sector to identify, accelerate, and scale-up innovations that have already gone through a tried-and-tested development and incubation process. Procter & Gamble, for example, which makes 27 percent of its net sales from “baby, feminine and family care,” including tampons and menstrual pads, has shown that, in the face of the COVID-19, it could adapt manufacturing processes to meet urgent needs.
The private sector can help eliminate period poverty through product innovation and by making changes in distribution strategies. The India-based Saral Designs, for example, is proving that by decentralizing the production of menstrual care products, issues of affordability and access in underserved markets can be addressed.
When approaching this journey, trial and error will be part of the process. We need to be risk-tolerant and willing to challenge our perceptions, dare to address social norms, and question traditions. By financing promising start-up and early-stage businesses, innovative capital can help them achieve both a positive societal impact and profitability.
Cristina Ljungberg (@Cristina_TCFH) is co-founder of The Case for Her, a philanthropic investment portfolio addressing the key women’s health issues of menstruation and female sexual health. Her combined expertise in business and health care has propelled a nearly two-decade journey in philanthropy.
Sue Coates (@WSSCCchief) serves as executive director ad interim of the Water Supply and Sanitation Collaborative Council. WSSCC is evolving into the Sanitation and Hygiene Fund, a scalable and global fund to support the world’s poorest and most left behind in achieving the sanitation, hygiene, and menstrual health (Sustainable Development Goal 6.2).