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Read this month’s featured article from our monthly newsletter, Health Promotion Connection/ Conexiones para la Promoción de la Salud/Connexion pour la Promotion de la Santé– Enjoy!

Gaps in Understanding and Implementation of Watsan Needs of Menstrual Hygiene Management – Neglected Facilities for Women in Urban Slums

By Sridevi Adivi, Public Health Consultant, ISECN Regional Coordinator for the Eastern Mediterranean Region

Background:

There still remains gender insensitivity in some countries in services offered by the Water and Sanitation (watsan) sector. Data from developing nations indicate that women constitute nearly 50% of the population with majority in the reproductive age.  On average, menarche for a woman lasts for 30-40 years and silence on the subject prevents dissemination of information on MHM (Menstrual Hygiene Management) even from mother to daughter. Every culture has taboos attached to this biological cycle, preventing girls to gain information or knowledge on the subject.  The lack of proper health care in developing countries aggravates the problem leading to poor physical and mental health.

The World Conference on Human Rights reaffirmed that the human rights of women throughout the life cycle are an integral and indivisible part of universal human rights.1 The WHO states that globally 1.1 billion people do not have access to improved water supply and 2.4 billion do not have access to any type of improved sanitation facility. Most affected is the urban poor and rural inhabitants.2

India, with the largest population in the world has 243 million adolescents between the ages of 10-19 years; 47% of this population is girls.3 Nearly 48 % of the population is women with the majority in their reproductive age with many living in marginalized communities.4

Marginalized communities have insufficient or shared watsan facilities in their households. Watsan facilities in schools are absent or inadequate promoting absenteeism of adolescent girls during their cycle. This often forces them to drop out of school in the longer duration and pushing them into cycle of lack of education, loss of productivity and poverty. Education in basic personal hygiene is absent in families for girl children. Meeting watsan needs for MHM is necessary taking into account that more than half the population is women of reproductive age.

Study Objectives and Method:

A community based cross-sectional study was conducted to elicit the knowledge on water and sanitation needs and MHM among adolescents and women. The study was conducted by the researcher for Kriya Sangh Society, a community based NGO registered in 2005.5 A pre-determined questionnaire was utilized for the focus group discussions for over a period of two months. Sixty women and adolescent girls from marginalized communities participated voluntarily in the study in an urban setting in the state of Telangana. Anonymity of the participants was vital and maintained as the study was to identify the needs of Watsan for MHM among the participating communities.

The study is a community based cross-sectional study among adolescent girls of 14-19 years and their mothers. The pre-determined questionnaire asked the women to share their cultural and traditional beliefs on menstruation, hygiene and their practices.

Results:

All participants affirmed their unpreparedness for the onset of menarche. Knowledge was limited to ‘a girl has period once every month’ and abdominal pain is common. Peers discussed the subject in whispers.  Mothers did not discuss the onset of menarche or MHM with daughters as they were embarrassed.

They all practice the age old customs of the families. Seclusion was not in practice among 40% of the respondents for tending to the needs of the family. 100 % of the women and girls mentioned that during menstruation they do not enter the room with altar, do not pray or attend family gatherings or festivities. Food and water are served separately with imposition of food restrictions. Women are prohibited from touching pickle jars during their monthly cycle to prevent pickle from getting spoilt, according to the cultural beliefs. They are not allowed to touch cows lest they make them infertile.

Women promoted usage of commercially available sanitary napkins for their daughters and they used cloth. They were unaware of other products like tampons and cups.

Quantity of water available was insufficient for the family’s daily needs so additional water for MHM purposes was not considered. Privacy of toilet facilities was restricted to usage after all men leave the premises and late at night. All respondents faced these challenges.

40% girls complained pain in abdomen, breast and lower back, cramping and 60% suffered from mood swings and bloating that lasted for a week. Medical attention was not sought and usage of pain medication was prevalent among adolescents.

Discussion:

Limited knowledge on menarche and MHM makes adolescent girls unprepared for the first period. Initial reaction is fear at the sight of blood and helplessness. Mothers silence daughters from discussing with its association to negative connotations and stigma.6

Women still sit in seclusion for the first three days of menstruation and girls forego school due to embarrassment. 70% of the women accepted that seclusion is not important yet avoid participation in festivals, family occasions or entering temples from habit and prohibition.

With changing times, women encouraged daughters to use commercially available sanitary napkins for convenience and comfort. Still only 12% of women used sanitary napkins as per the A C Nielsen survey.7 Cultural barriers, lack of information and affordability prevent use of tampons or cups. Cloth is dried in the dark corners away from eyes of boys and men and these may cause bacterial infections.

The socially marginalized live in crowded spaces         and share the water and sanitation facilities forcing them to often compromise their daily needs. Women are unable to fetch water for their family needs during their menstrual cycle and are forced to compromise on their personal needs as availability reduces more than regular.

Many share a common toilet or use public toilet and this prevents them to use till others have used the facilities or early morning and late at night. Lack of privacy makes them wait for long hours, limiting frequency of changing sanitary pads causing skin infections and may also lead to reproductive tract infections.8 Many families lack provision of private toilets in their homes and use the public toilets for a fee. Affordability of using public toilets also limits use of the facilities. 9

Adolescent girls often absent from school atleast for the first three days from lack of watsan facilties often forcing them to drop out of school.

Inadequate watsan facilities impact both physical and psychological health causing depression. Women usually use pain medication and avoid seeking medical help for other issues.

Although Governments are implementing sanitation campaigns, they lack user-friendly designs, especially for females. Sanitary napkins are distributed to adolescent girls in schools but disposal is an issue. These schemes are negligent to the basic needs of women affecting public health at large and burdening the health system.

Disposal poses a threat to environment as used products are disposed with other garbage and most of them do not wash them from ignorance and lack of water. Most survey respondents indicated that they were not aware that unwashed products can be a source of microbial growth and can spread infections.

WASH is essential for achievement of MDGs from universal education to gender equality, reduction of poverty, improvement of maternal health, reduction in infant/child mortality, environmental sustainability etc. Rights of women namely human dignity, non-discrimination, health, education, freedom and privacy are violated by the silence and want of information on MHM.

Conclusion:

With changing lifestyles, girls as young as 9-10 years are attaining puberty indicating the need to extend the MHM subject to them in school. Ensuring the subject is not omitted is essential for the preparation of the girls for menarche and understanding their needs. Schools can act as the primary source to dispel myths and cultural beliefs of menstruation by establishing peer support groups and counseling services.

The Supreme Court directive for provision of water and sanitation facilities in schools is still in implementation stages and the deadline has been postponed several times.10 The state governments and education department should work in coordination with the water and sanitation departments for provision of facilities to promote attendance of girl students.

Promoting corporate social responsibility in watsan can promote MHM and public health by providing affordable community toilets by involving women from design to implementation and maintenance for successful and sustainable utilization.

Distribution of sanitary pads or napkins through aanganwadi centres and vending machines in schools in urban and rural areas are in effectuation. Ngos are actively distributing low cost and reusable sanitary towels and pads. These initiatives are considered failure with absence of basic facilities like watsan. Some good practices and safe and reusable napkins can be achieved by addressing the issues of watsan.

It is suggested that more research is needed to evaluate the success of programs and measures implemented in promoting MHM at several levels resulting in behavioural change for improved women’s health and economic growth.

References
1.Fourth World Conference on Women, China ;1995 http://www.un.org/womenwatch/daw/beijing/platform/human.htm
2. Resolution on right to water, United Nations General Assembly, July 2010, General Comment No. 15. The right to water; Resolution A/RES/64/292; UN Committee on Economic, Social and Cultural Rights; November 2002. http://www.un.org/waterforlifedecade/human_right_to_water.shtm
3.India has the largest adolescent population in the world, Hindustan Times, India; February2011 http://www.hindustantimes.com/india-news/india-has-largest-adolescent-population-in-the-world/article1 667147.aspx
4. Population Data by country, Data survey by The World Bank;2013 http://data.worldbank.org/indicator/SP.POP.TOTL.FE.ZS
5. kriysanghsociety.org
6. Women and Wash: water, sanitation and hygiene for women’s rights and gender equality: Briefing Note for Water Aid by Shamila Jansz and Jane Wilbur; 2013 http://www.inclusivewash.org.au/resource-library-gender-women-and-girls
7. Vibeke Venema. The Indian sanitary pad revolutionary; BBC World Service, London; March 2013 http://www.bbc.com/news/magazine-26260978
8. Padma Das,Kelly K. Baker,Ambarish Dutta,Tapoja Swain,Sunita Sahoo,Bhabani Sankar Das,Bijay Panda,Arati Nayak,Mary Bara,Bibiana Bilung,Pravas Ranjan Mishra,Pinaki Panigrahi,Sandy Cairncross,Belen Torondel; Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India; June 30,2015; http://dx.doi.org/10.1371/journal.pone.0130777
9. Gold medalist’s family earns 5,000 a month, pays 2,000 for using toilet, The Times of India; October 8, 2014 http://timesofindia.indiatimes.com/city/rajkot/Gold-medalists-family-earns-5000-a-month-pays-2000-for using  toilet/articleshow/44688306.cms?intenttarget=no&utm_source=TOI_AShow_OBWidget&utm_medium=Int_Ref  &utm_campaign=TOI_AShow
10. Prakash Amatya. All government schools must have toilet by November end, Supreme Court of India;    Freshwater Action Network, India; October 2011  http://www.freshwateraction.net/content/all-govt-schools-must-have-toilet-november-end-supreme-court india

Published: May-August 2016, HPC

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