Sustainable Menstruation for Adolescent Schoolgirls in Rural Kenya

By Ragini Mae Gomonit Chengalath

Table of Contents:

1.    Introduction

2.    Problems Faced by Adolescent Schoolgirls in Rural Kenya 

3.    The Sustainability of Menstrual Cups

4.    Menstrual Health Education and Menstrual Cups: Considerations and Barriers

5.    Recommendations

6.    References

7.    Key Terms and Definitions 

8.    About the Author

1.    Introduction

Menstruation, the periodic discharge of blood and tissue from the uterus, is an important and often overlooked occurrence. In low-income settings, good menstrual hygiene can be a challenge that needs to be overcome as it createsproblems for school-going girls. Menstrual health education (MHE) covers menstrual health, hygiene,and reproductive health, and can be used to help prepare womenfor the onset of menstruation and the challenges it brings. 

In rural Kenya, adolescent schoolgirls face underlying problems when dealing with menstruation due to lack of quality MHE and lack of access to reusable feminine hygiene products. These in turn lead to a wide array of issues such as school absenteeism, mental and physical health problems, and negative environmental impact. MHE is therefore crucial in educating girls towards a more sustainable future. Furthermore, lack of MHE and hygiene services ultimately lead to gender inequality. 

Menstrual health is both explicitly and implicitly relevant to 5 out of the 17 United Nations 2030 Sustainable Development Goals (Keith, 2016). These include several targets such as 6.2 (adequate sanitation and hygiene, particularly for women and girls), 5.6 (universal access to reproductive health and rights), 4.5 (elimination of gender disparities in education), and 4.7 (acquisition of knowledge and skills to promote sustainable development through education for sustainable development) (UN, 2015). Countries should promote a sustainable approach to menstruation through culturally-sensitive MHE. Education should focus on reusable feminine hygiene products, empower girls and change attitudes towards menstruation within communities. 

This entry bringsto light some of the problems menstruating adolescent schoolgirls in rural Kenya often face and proposes a possible solution that includesthe use of menstrual cups and MHE. It also identifies barriers that exist which may influence the willingness to usemenstrual cups by schoolgirls and emphasises the importance of quality MHE to overcome these barriers. Although this entryfocuses on problems faced by schoolgirls in rural Kenya, itbeing a global issueisrelevant across the world. 

2.    Problems Faced by Adolescent Schoolgirls in Rural Kenya

In Kenya menstruationis viewed as ‘dirty’ (McMahon et al., 2011, p. 4) and sanitary pads are often referred to as ‘mud guards’ (p. 7). When girls have their period, they either go home during the school day or miss school altogether to avoid the risk of leakage that may stain their uniforms (Jewitt and Ryley, 2014), or having to clean themselves at school. Ultimately, lack of education and support as well as access to good sanitary products leaves girls at a disadvantage when compared to their male counterparts.

Lack of access to feminine hygiene products, which primarily is the result oftheir unaffordability is one concern. In low-income families, sanitary towels are viewed as a luxury item (Jewitt andRyley, 2014), forcing girls to use alternatives such as dry grass, leaves, and cotton (Keith, 2016). This increases risk of infections that may ultimately also lead to severe health issues if left untreated, including greater susceptibility to sexually transmitted infections (Keith, 2016). Reusable feminine hygiene products such as cloth sanitary pads and menstrual cups are a solution to the problem of cost. Nevertheless, there are still health risks associated with using reusable products without proper education. For example, reusable pads must be washed and dried after every use, however girls are often shy and unwilling to hang pads outside to dry in the open. Instead, they are left to dry improperly ‘hidden inside’ or ‘under the bed’ (Hennegan et. al, 2016, p. 4), increasing the risk of infection. These are issues that can be avoided through education, and it is therefore important to inform girls about the resources that are available and how to use them safely.

MHE is a necessary subject to teach to women and men as it includes the material aboutmenstruation, menstrual hygiene,and issues relating to menstruation,such as puberty, that cancreate apositive menstruation experience for girls. MHE must take placeinside and outside of school. According to Crichton et al. (2012), mothers, school teachers, and other relatives are the best sources of information about menstruation for girls. However, often these schoolgirls do not talk about menstruation at home or at school (McMahon et al., 2011). Lack of knowledge about menstruation leavesthem with feelings of fear, powerlessness, and shame. 

3.    The sustainability of menstrual cups

The menstrual cup is a bell-shaped, reusable feminine hygiene product made out of silicone. The cup is inserted into vagina where it collects menstrual fluid and is emptied and cleaned when necessary before reuse. Menstrual cups have economic, environmental,and health benefits that encourage more sustainable menstruation for girls and can be considered a possible solution to some of the problems they face. 

As menstrual cups are reusable, they produce significantly less waste and are more environmentally friendly than disposable products such as sanitary pads and tampons. Since disposable products must be changed several times a day, millions are disposed of daily, along with their plastic packaging. Furthermore, sanitary pads and tampons contain chemicals for fluid absorption and odour elimination, which can contaminate the environment after disposal. The high demand and production of non-renewable menstrual products has had a lasting, negative impact on the environment. However, depending on brand and upkeep, one menstrual cup can be used for approximately five years (Beksinska et al., 2015) making them far more environmentally friendly. 

The cost of menstrual hygiene products for these schoolgirls is an issue. A packet of sanitary pads in Kenya can cost 75 Kenyan Shillings (Rubli, 2014), which is more than half the daily income of an unskilled labourer. Over one menstrual cycle, a girl may go through two packets. However, only one menstrual cup is needed to replace years’ worth of sanitary pads and tampons. 

Menstrual cups also have health benefits when compared to other feminine hygiene products. First, they do not contain the chemicals found in sanitary pads and tampons (Silverman, 2015), as they are typically made of medical-grade silicone. This makes them safer than tampons, for example, where there is a risk of developing Toxic Shock Syndrome (Juma et al., 2017). Second, the fluid collected is held away from the cervix, reducing risk of infections that can be caused by using tampons (Kapitako, 2017). Third, menstrual cups can be safely worn for longer time periods, making them ideal for schoolgirls. Fourth, wearing menstrual cups does not result in the odour that often comes with wearing sanitary pads. (Silverman, 2015). Finally, menstrual cups can help women monitor menstrual blood flow, which can be helpful in detecting medical conditions such as menorrhagia (abnormally heavy menstrual bleeding) (Stewart et al., 2009; Kapitako, 2017).

4.    Menstrual health education and menstrual cups: Considerations and barriers

One major barrier is access to clean water, as menstrual cup cleanliness is vital for safe use. To do so, girls must ensure their hands and menstrual cups are clean when removing and reinserting, and cups should also be boiled after every cycle to avoid risk of infection. Safe spaces and sanitation facilities (UNESCO, 2014) to practice good menstrual hygiene are therefore necessary, both at home and at school. Another barrier is the initial cost of menstrual cups, which is significantly more than a single sanitary pad or tampon. The Ruby Cup for example, can cost between 27-55 euros (Ruby Cup, n/d). However, despite greater initial cost, menstrual cups can last several years, making them more cost effective long-term. Several organisations, such as Ruby Cup in Kenya,are working to provide menstrual cups free of charge (along with necessary MHE) to girls in need.

Perhaps some of the more difficult barriers to overcome concern culture and cultural taboos. In many African cultures, including in rural Kenya, the onset of menstruation brings about a number of values and beliefs embedded in the culture. One example is the understanding that one must remain silent about menstruation. McMahon et al. (2011) highlight the expectation upheld by society that menstruation should not be discussed, as girls believe that male relatives and classmates are ‘not supposed to know’ (Mason et al., 2013, p. 5) about menstruation. This perpetuates the aforementioned knowledge gap and further propagates the girls’ feelings of shame.

Second,patriarchal societies lead to prejudice against women. Greed (2014) argues that even in sanitation agendas such as toilet designs‘menstruation remains marginalized’(as cited in Jewitt andRyley, 2014, p. 139), resulting in women feeling a burden in their everyday lives. The nature of patriarchal societies also makes it difficult for girls to approach male teachers for assistance, and vice versa. (Jewitt and Ryley, 2014). Moreover, there is a ‘sexual dimension’ of menstruation (McMahon et al., 2011, p. 5), which is the perceived relationship between menstruation and sexual maturity. When a girl menstruates, she is no longer seen as a child, and this is often a signal for parents to begin considering marital prospects. 

Consequently, parents often pull their daughters out of school as they now see her education as ‘unnecessary’ (Jewittand Ryley, 2014, p. 4). Girls also feel pressure from the opposite sex once they begin menstruatingas they are viewed more sexually (Mason et al., 2013).Additionally, views on ‘virginity’ and how the menstrual cup may affect perceived virginity play a role, and menstrual cups are often viewed as a violation of virginity (Silverman, 2015).

Lastly, there is an understanding that menstruation is ‘dirty’ or ‘impure’a description applied to both menstrual blood and women (Keith, 2016, p. 5). Often, menstruating women are excluded from normal daily practices, such as cooking, dining with others (Keith, 2016; McMahon et al., 2011), or even being at home (Silverman, 2015). This exclusion can lead to the aforementioned feelings of shame they experience. 

Several problems also arise from lack of proper MHE. Without education on proper use and cleaning of menstrual cups arises health and hygiene risks, and improper cleaning can lead to bacteria growth such as E. Coli (Juma et al., 2017). There is also the vital need to educate the local community and reduce cultural barriers encountered. Stigma associated with menstruation needs to be tackled by educating the wider community, both at home and at school. There is a need for ‘increased attention to educating boys and male teachers on puberty in general and menstruation in particular, in order to create less stigmatized school environments for girls’ (UNESCO, 2014, p. 29). 

5.    Recommendations

It is difficult to come up with a single solution within the given context. However, it is safe to say that education can help overcomethe stigma surrounding menstruation and shameit creates. Several recommendations can therefore be suggested. 

First, MHE must be available in schools to ensure all schoolgirls have access, either organised internally or through partner organisations such as Ruby Cup, The Malkia Initiative Foundation, or Asante Africa Foundation. However, access is only the first step and quality education must be ensured. Educational material should be age appropriate, accurate and impartial, and be taught by suitable educators. Additionally, if menstrual cups are to be implemented, education relating specifically to menstrual cups must be included in the programmes. Second, learning should happen in a safe environment, where learners feel comfortable and are willing to ask questions. Third, education should not just cover menstruation, but include related subjects such as puberty and its sexual implications, for example,to help fight stigma (UNESCO, 2014). Fourth, boys and menmust also be educated to encourage positive perceptions on menstruation and create better school environments. Lastly, MHE must not happen only in school, but in informal settings too. For example, community programmes on MHE will encourage education for family members and the wider community.

Although it is a global problem, unique cultural aspects individualise it. It is also important to consider that menstrual cups may not be a suitable and sustainable solution in this context. One could argue that perhaps the advantages of menstrual cups do not outweigh the cultural barriers that may be encountered, and other solutions may be more appropriate (such as reusable menstrual pads). With more research will come more confidence and direction, however it is a starting point to begin a discussion on an often-overlooked problem, and to investigate what work is currently being done. What needs to be reiterated is the idea that quality MHE and sustainable feminine hygiene products must work together to create a sustainable menstrual future for adolescent schoolgirls in rural Kenya. 

6.    References

Beksinska, M. E., Smit, J., Greener, R., Todd, C. S., Lee, M. T., Maphumulo, V., Hoffmann, V. (2015). Acceptability and Performance of the Menstrual Cup in South Africa: A Randomized Crossover Trial Comparing the Menstrual Cup to Tampons or Sanitary Pads. Journal of Women’s Health, 24(2), 151-158. doi: 10.1089/jwh.2014.5021

Crichton, J., Ibisomi, L., Gyimah, O. (2012). Mother-Daughter Communication About Sexual Maturation, Abstinence and Unintended Pregnancy: Experiences from an Informal Settlement in Nairobi, Kenya. Journal of Adolescence, 35(1), 21-30. doi: 10.1016/j.adolescence.2011.06.008

Greed, C. (2014). Global Gendered Toilet Provision. Paper presented at the Association of American Geographers’ Annual Conference, Tampa, Florida (09.04.14).

Hennegan, J., Dolan, C., Wu, M., Scott, L., Montgomery, P. (2016). Measuring the Prevalence and Impact of Poor Menstrual Hygiene Management: A Quantitative Survey of Schoolgirls in Rural Uganda. BMJ Open, 6(12). doi: 10.1136/bmjopen-2016-012596

Jewitt, S., Ryley, H. (2014). It’s a Girl Thing: Menstruation, School Attendance, Spatial Mobility and Wider Gender Inequalities in Kenya. Geoforum, 56, 137-147. doi: 10.1016/j.geoforum.2014.07.006

Juma, J., Nyothach, E., Laserson, K. F., Oduor, C., Arita, L., Ouma, C., …Phillips-Howard, P. A. (2017). Examining the Safety of Menstrual Cups Among Rural Primary School Girls in Western Kenya: Observational Studies Nested in a Randomised Controlled Feasibility Study. BMJ Open, 7(4). doi:10.1136/bmjopen-2016-015429 

Kapitako, A. (2017, July 24). Namibia: Women Slowly Embracing Use of Menstrual Cup. New Era. Retrieved from https://www.newera.com.na/2017/07/24/women-slowly-embrace-use-of-menstrual-cup/

Keith, B. (2016). Girls and Women’s Right to Menstrual Health: Evidence and Opportunities.Outlook. 1-8

Mason, M., Nyothach, E., Alexander, K., Odhiambo, F. O., Eleveld, A., Vulule, J., …Phillips-Howard, P. A. (2013). ‘We Keep It Secret So No One Should Know’- A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation in Rural Western Kenya. PLoS ONE 8(11). doi: 10.1371/journal.pone.0079132

McMahon, S. A., Winch, P. J., Caruso, B. A., Obure, A. F., Ogutu, E. A., Ochari, I. A., Rheingans, R. D. (2011). ‘The Girl With Her Period Is The One To Hang Her Head’Reflections on Menstrual Management Among Schoolgirls in Rural Kenya. BMC International Health & Human Rights, 11(7). doi: 0.1186/1472-698X-11-7

Rubli, S. (2014, December 12). How Menstrual Cups are Changing Lives in East Africa. Huffpost.Retrieved from http://www.huffingtonpost.ca/sabrina-rubli/menstrual-cups-east-africa_b_6313436.html

Ruby Cup: Our Partners (n/d). Ruby Cup. Ruby Life Limited. Retrieved from http://rubycup.com/social-mission/ruby-cup-in-kenya/

Ruby Cup: How your donation helps (n/d).  Ruby Cup. Ruby Life Limited. Retrieved from http://rubycup.com/social-mission/how-ruby-cup-works/

Ruby Cup: Shop (n/d). Ruby Cup. Ruby Life Limited. Retrieved from http://shop.rubycup.com/

Silverman, C. A. (2015). Menstrual Management: Cameroon and Kenya. Monroe Freshman Research. 

Stewart, K., Powell, M., & Greer, R. (2009). An Alternative to Conventional Sanitary Protection: Would Women Use a Menstrual Cup? Journal of Obstetrics and Gynaecology 29(1): 49-52. doi: 10.1080/01443610802628841

United Nations Educational, Scientific and Cultural Organisation (UNESCO) (2014). Good Policy and Practice in Health Education. Booklet 9: Puberty Education & Menstrual Hygiene Management. UNESCO IIEP.

United Nations General Assembly (2015). Transforming Our World: The 2030 Agenda for Sustainable Development.A/RES/70/1. 21 October. 

7.    Key Terms and Definitions

Menstruation: The periodic discharge of blood and tissue from the uterus

Menstrual Health Education (MHE): Education about menstruation and related topics, particularly menstrual health and hygiene. 

Adolescent: A young person developing into an adult

About the author

Ragini Mae Gomonit Chengalath

MEd, The University of Hong Kong 

Email: raginimae@gmail.com