The Case for Menstrual Health: PATH Works to Build Awareness, Commitment, and Access to Improved Menstrual Care

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M E N S T R U A L   H E A L T H   The  case  for  menstrual  health   Menstruation is a natural and routine part of life for healthy girls and women, but in many parts of the world, it is accompanied by shame and fear. Cultural taboos about menstruation and perceptions that women are unclean when they have their periods are barriers to open discussion and societal support. Without education from parents and teachers, girls often begin menarche in isolation, without any understanding of what is happening to their bodies. In many low-resource settings, this culture of silence is compounded by limited resources to help women manage their periods. Insufficient attention to menstrual care within gender and reproductive health education, a lack of access to affordable and appropriate menstrual care products, and an absence of appropriate sanitation and waste disposal systems limit women’s potential and perpetuate gender inequalities. Fortunately, there is a growing global movement to address these gaps. With increased support, these efforts have the potential to unlock tremendous health and opportunity for girls, women, and communities around the globe. THE  GLOBAL  COST  OF  POOR  MENSTRUAL  HEALTH     Poor menstrual health exacts a tremendous human and financial toll. A growing body of global research links menstruation with school absenteeism,1–3 engagement in transactional sex for money to buy sanitary pads,4 and lost workplace productivity.5 Menstrual care also presents unique challenges for women in humanitarian and fragile contexts and among women with disabilities. Studies in Kenya, Ghana, Malawi, Uganda, Lebanon, and elsewhere point to a positive association between the challenges of managing menstruation and girls’ performance and attendance in school. Research in Ghana3 showed that puberty education, coupled with provision of menstrual pads, significantly increased school attendance among girls between 12 and 18 years old. Recognizing that some research has also shown a weak association with school attendance, new studies also measure additional indicators, such as self-esteem, comfort, and classroom participation. Investment in further research is needed. Not surprisingly, there are also indications that menses- related absenteeism in the workplace leads to lost wages for women and lower productivity for businesses. A qualitative study in Pakistan revealed that female garment factory workers missed up to three days of work each month during their periods as a result of infections, embarrassment, and pain.5 Here too, research is needed to inform workplace policies and interventions. In addition, because sanitary napkins are prohibitively expensive in many low-resource settings, some women are reduced to using unhygienic alternatives, such as old rags, strips of mattress, leaves, or soil. Among other health concerns, emerging evidence suggests that these practices and poor menstrual hygiene, may be linked to bacterial vaginosis, which affects thousands of women in low- resource settings.6 The infection raises their risk of sexually transmitted infections, including HIV; miscarriage; preterm labor; and other negative health outcomes. INCREASING  MOMENTUM     Recognizing these costs, leaders, experts, and communities worldwide are joining a growing movement to address and improve menstrual health. In South Africa, Kenya, and India, national governments have committed to subsidizing sanitary pads for low-income girls and women in rural areas. Increasing numbers of entrepreneurs—many of them women—are developing affordable and appealing menstrual care products. In addition, innovative technologies such as the menstrual cup are providing women with new options. At the same time, many menstrual care products are still not available through mainstream markets, and prices remain too high for many of the low-income women who would benefit the most. There is also considerable need for educational curricula that can be adapted for different contexts and age groups; improved WASH (water, sanitation, and hygiene) services; waste disposal approaches PATH  works  to  build  awareness,  commitment,  and  access  to  improved  menstrual  care   PA TH /G le nn A us tin November  2015   STREET  ADDRESS   2201  Westlake  Avenue   Suite  200   Seattle,  WA  98121  USA     MAILING  ADDRESS   PO  Box  900922   Seattle,  WA  98109  USA   PATH  is  the  leader  in  global  health  innovation.  An  international  nonprofit  organization,   we  save  lives  and  improve  health,  especially  among  women  and  children.  We   accelerate  innovation  across  five  platforms—vaccines,  drugs,  diagnostics,  devices,  and   system  and  service  innovations—that  harness  our  entrepreneurial  insight,  scientific   and  public  health  expertise,  and  passion  for  health  equity.  By  mobilizing  partners   around  the  world,  we  take  innovation  to  scale,  working  alongside  countries  primarily  in   Africa  and  Asia  to  tackle  their  greatest  health  needs.  Together,  we  deliver  measurable   results  that  disrupt  the  cycle  of  poor  health.  Learn  more  at  www.path.org.   that allow women to manage menstruation safely and with dignity; better research about how menstruation affects women’s health and development; and increased awareness and advocacy. Meeting these needs will require innovative cross-sector partnerships to advance effective and sustainable solutions. PATH’S  VISION  FOR  MENSTRUAL  HEALTH   PATH, a leading international nonprofit health organization, is deeply invested in improving menstrual health for women worldwide. Our multidimensional approach includes increasing access to affordable, effective, and appealing menstrual care products; increasing education and awareness; and advocating for further investment. These efforts draw on our organizational expertise in user-centered product development, market shaping, behavior change, advocacy, and implementation science, and on long- standing relationships with governments and communities. Examples include: Improving data. In India and South Africa, PATH modeled the impact of disposable pads on sanitation and waste systems and engaged stakeholders to determine how to improve these facilities for women. As part of this project, we gave women disposable cameras and asked them to document how they managed their periods—easing communication about a sometimes sensitive topic. Menstrual cup research. Our global landscaping efforts explored the use and acceptability of this newer option, and identified possible design adjustments to increase its reach. Building a “better” pad. We seek out products that are appropriate, affordable, and acceptable to girls and women, develop new concepts where we see a gap, and look for partners interested in advancing them. For example, we are exploring a reusable and leak-resistant base, worn as underwear, that can be used with a variety of locally available absorbent materials. We have field-tested the pad in Cambodia and India and conducted qualitative research among adolescents in Rwanda, Kenya, India, and South Africa. We’ve also tested both existing and potential low- cost materials (such as agricultural byproducts) for safe use in pads. Spotlighting menstrual health. Through advocacy and awareness raising, we are ending the silence around menstruation and spotlighting solutions that help girls and women to manage their periods. For example, in Uttar Pradesh, India, our short video, developed with girls and women in the community,7 led community health volunteers to begin selling pads. And in India and Kenya, our Menstrual Hygiene Day activities broke through taboos and sparked critical new discussion. NEXT  STEPS     Now, PATH is working to expand and accelerate our work. Key focus areas include: • Identifying and validating innovative new menstrual health products for women in low-resource settings. • Developing and implementing a strategy to test market introduction of new products. • Expanding access through local and global markets. • Shaping a research agenda and contributing evidence on the impact of improved access to information and products on women’s health and development. • Integrating menstrual health programming into country- level reproductive health, WASH, maternal, newborn, and child health, and gender platforms. • Building awareness of and commitment to effective programming and policies. TO  CONTACT  PATH     Please email us: menstrual-health@path.org Visit our website: sites.path.org/water/menstrual-hygiene- management/ References   1. McMahon S, Winch PJ, Caruso BA, et al. ‘The girl with her period is the one to hang her head’: Reflections on menstrual management among schoolgirls in rural Kenya. BMC International Health and Human Rights. 2011;11(7):1–10. 2. African Population and Health Research Center (APHRC). Use of Menstrual Cup by Adolescent Girls and Women: Potential Benefits and Key Challenges. Policy Brief No. 22. APHRC; 2010. 3. Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary pad interventions for girls’ education in Ghana: a pilot study. PLoS One. 2012;7(10):e48274. 4. Phillips-Howard P. Menstrual needs and associations with sexual and reproductive risks in rural Kenyan females: a cross-sectional behavioral survey linked with HIV prevalence. Journal of Women’s Health. 2015;24(10):801–811. 5. Business for Social Responsibility (BSR). Investing in Women for a Better World. HERproject report. BSR; 2010. 6. Das P, Baker KK, Dutta A, et al. Menstrual hygiene practices, WASH access and the risk of urogenital infection in women from Odisha, India. PLoS One. 2015;10(6):e0130777. 7. Projecting Health. PATH website. Available at: http://www.path.org/publications/detail.php?i=2139. Accessed October 31, 2015. “I  had  my  first  period  at  school.  My  teacher  said  that  I   must  tell  them  at  home  and  do  not  come  to  school  the   following  day.  I  sat  and  did  not  go  to  school  for  the  whole   week…”  —PATH  study  participant,  South  Africa,  2012  

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