Menstrual hygiene management (MHM) or menstrual health and hygiene (MHH) is the access to menstrual hygiene products to absorb or collect the flow of blood during menstruation, privacy to change the materials, and access to facilities to dispose of used menstrual management materials. It can also include the "broader systemic factors that link menstruation with health, well-being, gender equality, education, equity, empowerment, and rights". Menstrual hygiene management can be particularly challenging for girls and women in developing countries, where clean water and toilet facilities are often inadequate. Menstrual waste is largely ignored in schools in developing countries, despite it being a significant problem. Menstruation can be a barrier to education for many girls, as a lack of effective sanitary products restricts girls' involvement in educational and social activities.
Terminology An accepted definition of menstrual hygiene management (MHM) is: "Women and adolescent girls use a clean material to absorb or collect menstrual blood, and this material can be changed in privacy as often as necessary for the duration of menstruation. MHM also includes using soap and water for washing the body as required; and having access to facilities to dispose of used menstrual management materials."UNICEF, Columbia University (2012). WASH in Schools - Empowers Girls' Education - Proceedings of Menstrual Hygiene Management in Schools Virtual Conferences. UNICEF and Columbia University, USA, p. 2 The "value chain" related to menstrual hygiene management includes four aspects: awareness, access, use as well as waste management. The CLTS Knowledge Hub gives a definition that accounts for these four aspects as well as social and cultural factors:
The term "menstrual health" is broader than menstrual hygiene. It encompasses both the menstrual hygiene management practices and the broader systemic factors that link menstruation with health, well-being, gender, education, equity, empowerment, and human rights (in particular the human right to water and sanitation).Keith, B. (2016). Girls' and women's right to menstrual health: Evidence and opportunities - Outlook on reproductive health. PATH, Seattle, USA, UNICEF now (since 2019) uses the term MHH for "menstrual health and hygiene".
These systematic factors include accurate and timely knowledge, available, safe, and affordable materials, informed and comfortable professionals, referral and access to health services, sanitation and washing facilities, positive social norms, safe and hygienic disposal, and advocacy and policy.
History The oldest known records of menstrual hygiene products date to ancient Egypt, where people utilized softened papyrus as a means of absorbing menstrual blood. In resource-constrained Indigenous communities, organic materials were likely employed for this purpose. There is speculation that Vikings used bog moss.
In the late 19th century, some suggest that menstruation was considered a form of illness. Doctor Edward Clark believed that attending school during menstruation could potentially delay the development of reproductive organs.
In 1897, Johnson & Johnson added sanitary napkins to its price list following a suggestion from Joseph Brown Cook. Despite limited acceptance of this product, it was the first commercially available sanitary protection product for women in the United States. These sanitary napkins were advertised minimally and in small print to maintain a sense of 'modesty'.
Sfag-Na-Kins, developed by the Sphagnum Moss Products Company, transformed sphagnum moss into sanitary napkins with the ability to absorb over 20 times their dry weight in fluids. In 1920, Johnson & Johnson introduced the discreetly named and plainly packaged Nupak brand, allowing women to make purchases inconspicuously.
The success of Kotex napkins in 1921 can be attributed to extensive advertising in women's magazines and the use of cellucotton enclosed within a gauze sheath. In 1928, Johnson & Johnson introduced silent purchase coupons in magazine ads for MODESS sanitary napkins, providing women with a discreet means of acquiring products without engaging with salespeople.
E.C. Haas filed a patent in 1931 for the Tampax tampons, featuring a paper-tube applicator. Tampons had initially been used in medical practice to control bleeding in deep wounds.
In 1957, Mary Davidson Kenner presented a patent for an adjustable sanitary belt designed to secure the pad, prevent menstrual blood leakage, and avoid stains. However, Kenner, a black woman, faced systemic barriers.
The popularity of belted sanitary napkins waned in the early 1980s with the advent of adhesive strips positioned on the bottom of sanitary pads, facilitating attachment to underwear linings. Since then, menstrual products have undergone substantial transformations, evolving to be more ergonomic, thinner, and incorporating diverse materials to enhance absorption.
Challenges
Menstrual hygiene management can be particularly challenging for girls and women in developing countries, where clean water and toilet facilities are often inadequate. In addition, traditional cultures make it difficult to discuss menstruation openly. This limits women's and adolescent girls' access to relevant and important information about the normal functions of their own body. This directly affects their health, education, and dignity. Access to information can be considered a human right.
Currently, there are about 3.73 billion women in the world. According to the World Health Organization (WHO), 52%, or 1.9 billion, of those women are of reproductive age, thus menstruating. Women at some point in their life will go through the reproductive age and thus, will experience menstruation. It has been estimated that daily 300 million women are menstruating; on average a woman will spend about 3,500 days during her life menstruating.Loughnan, Libbet C., Rob Bain, Rosemary Rop, Marni Sommer, and Tom Slaymaker. "What Can Existing Data on Water and Sanitation Tell Us About Menstrual Hygiene Management?" Waterlines 35.3 (2016): 228-44. Web.
Many adolescent girls and women of menstruating age live in poor socio-economic environments. 663 million people lack basic access to safe water, and 2.4 billion people lack adequate access to basic sanitary conditions. For women and girls, the lack of safe, accessible water, sanitation and hygiene (WASH) is particularly troubling during menstruation and childbirth. It has been estimated that half a billion (or 13%) of women lacked a place to defecate, have little to no privacy for menstrual hygiene management, and 3/4 of those lacked access to soap and water.Loughnan, Libbet. (2017, April 17). Retrieved from: https://blogs.worldbank.org/water/lack-access- toilet-and-handwashing-materials-hits-women-and-girls-hardest-especially-when
In a 2014 study conducted in India, the researchers found that as many as 42% of women who participated in the study did not know about sanitary pads or from where in their anatomy menstruation originated, and that "most of them were scared or worried on first menstruation." More recently, studies have shown that 50% of women in India have experienced a urinary tract infection (UTI) related to the inability to safely manage their period. When left untreated, UTIs can lead to kidney failure. Worldwide, in 2018, one in three women did not have access to a working toilet at all. Menstrual hygiene management issues have been ignored by professionals in the WASH sector, as well as in the health and education sectors.House, S., Mahon, T., Cavill, S. (2012). Menstrual hygiene matters - A resource for improving menstrual hygiene around the world. Wateraid, UK, p.8
Health and psycho-social aspects Poor MHM may affect the reproductive tract, but the specific infections, the strength of effect, and the route of transmission remain unclear. In India, a majority of girls are at risk for reproductive tract infections (RTI) because of poor MHM. RTI can lead to various disabilities if not treated early on and are the cause of 30–50% of prenatal infection. Due to prejudices surrounding the issue, some women in India do not eat or take showers during their menstruation.
Girls' self-image may be negatively impacted by adverse attitudes towards menstruation.
Sanitation facilities at schools
The onset of menstruation is challenging for school-aged girls in low-income settings. Impacts can include school absenteeism, missed class time, reduced participation, teasing, fear and shame, and risky adaptive behaviors. Further challenges that menstruating school girls face are a lack of knowledge, communication, and practical guidance prior to menarche and during menstruation; inadequate water, sanitation, and hygiene (WASH) facilities; and ineffective or unavailable menstrual management materials.
In many parts of sub-Saharan Africa, girls can miss up to 5 days of school a month or drop out entirely due to insufficient access to water, sanitation and hygiene (WASH) facilities and menstrual hygiene products. Improving access to WASH facilities can actually increase girls' attendance at school. A program for school sanitation in Bangladesh increased girls' enrollment at school by 11%.
Menstrual waste is largely ignored in schools in developing countries, despite it being a significant problem. Girls' access to water and sanitation at school is only available at 47% and 46% of all schools globally. Often, school toilets for girls (if they even exist) are missing bins for menstrual waste collection with the result that pads may be spread all around the school compound area.Kjellén, M., Pensulo, C., Nordqvist, P., Fogde, M. (2012). Global review of sanitation systems trends and interactions with menstrual management practices - Report for the menstrual management and sanitation systems project. Stockholm Environment Institute (SEI), Stockholm, Sweden, p. 25 This pollutes the environment and also causes embarrassment for the school girls.
In the United States, among other countries, girls who are unable to afford feminine hygiene products may miss school in order "to avoid the embarrassment of staining their clothes". According to a study done by INTIMINA surveying students across Ohio State University, University of Wisconsin at Madison, Harvard University, New York University, and University of Central Florida, 19% of female college students said they have felt forced to decide whether to buy period products or other necessities like food.
Period poverty
Period poverty is a term used to describe the lack of access to adequate menstrual hygiene management supplies and education, including sanitary products (e.g., tampons, pads, liners, menstrual cups), washing facilities, and disposal management. It also includes other constraints such as taboos and myths, movement and food restrictions, shame and stigma around impurity and dirt which all contribute to the menstruator having an experience which is not dignified. Period poverty is a global health issue that affects many individuals living in low- and middle-income countries, with many young adolescents using materials such as mud, leaves, old paper, cotton, or animal skin to manage their periods. The use of alternative products, or using products longer than intended, can lead to health complications, infections, and long-term health issues. "In a 2018 study commissioned by U by Kotex, one in four women surveyed struggled to purchase period products. In the same study, one in five low-wage women reported missing work, school or similar events due to lack of access to period supplies. These instances were linked to reported feelings of embarrassment, disappointment and depression."