It has been four years since my friend Vyjayanthi and I started working on promoting Menstrual hygiene. We have travelled extensively across the state of Karnataka and interacted with thousands of adolescent girls from government schools and women from rural backgrounds, starting from the city of Bangalore to the tribal areas near Dandeli and the regions in North Karnataka like Gulbarga.
This write-up is an attempt to throw light at the reality of menstrual hygiene management (MHM) as experienced first hand by me. Although some of this information might apply to other parts of India, since I haven’t travelled enough to states outside Karnataka, I cannot vouch for its validity elsewhere.
Menstrual Hygiene is trending!
Suddenly, promoting menstrual hygiene is the “in thing”. For NGOs, CSRs, voluntary groups and others working in the social space, having a project on menstrual hygiene has become important. It is the easiest project to receive funding with all the articles going out of their way to describe the poor women in developing countries using straw, mud, ash and what not to absorb the menstrual flow. And with the perceived solution being as easy as distributing Sanitary Napkins, it seems to be fairly straightforward. If they have more money to throw away, then they will also put up a Sanitary Napkin manufacturing unit and – voila! – it becomes a great way for providing employment to these poor women who use straw, mud and ash!
While I am glad to see this issue being spoken about, highlighted and discussed like never before in India, I am also witnessing that much of the work happening in this direction is superficial. With so-called experts having little or no experience in actually interacting with rural girls and women, what is spoken about menstruation is more from perception rather than reality. Many a time, the entire issue gets reduced to programs promoting Sanitary Napkins.
Myth #1: Knowledge is everything!
I was once called to train a group of senior women leaders in a corporate set-up to conduct awareness sessions on menstrual hygiene in government schools, as part of their CSR. The group looked quite disinterested and in the beginning felt that there is nothing new to learn. Before I began, I asked them to share their personal experiences and embarrassing moments around menstruation. Suddenly, all the smart, confident women leaders looked distinctly uncomfortable and awkward. They thought educating others on menstruation was an impersonal monologue of doling out knowledge!
Training sessions for Menstrual Hygiene facilitators are often about giving them the knowledge, product information and sometimes, the trainers touch upon how the audience might be uncomfortable around this topic. It is rarely about the inhibition the facilitators might themselves have experienced dealing with their own periods. As I have experienced, unless we first help the facilitators overcome their own inhibitions about this topic, they will have a lot of trouble getting the girls/women to express freely and seek help when needed.
All women, inspite of their upbringing and economic background, do have a menstrual story to narrate – an embarrassing incident that makes them cringe even when they think about it. And that story is their gateway to make a difference in other women’s lives! If Vyjayanthi and I have been able to positively influence the attitudes of the girls and women we met, it was only because they could relate to our stories and realized that we, after all, are no different from them. Here is a glimpse of how we go about interacting with girls – Girls, lets talk about it!
Myth #2: Dismissing other’s beliefs =
Myth #2: Dismissing others’ beliefs = Empowerment
When I first started, I was advised to go to rural schools, teach them the biology of menstruation and distribute Sanitary Napkins. And so I did. So when a wide-eyed little girl would ask if she would indeed get a curse if she used a Sanitary Pad, I would say that it is all superstition. And then, there would be no more questions. Topic closed.
I later realized that whatever their beliefs and practices, it would yield far better results if I engaged them in conversations which would explore the origin of such beliefs. Once they see my willingness to hear their perspective, there would be a natural willingness on their part to hear my version. Their questions around religious beliefs are like them testing the waters to see if I can be trusted. If I deal with it correctly (without ridiculing or dismissing them), then come the real questions – the ones about white discharge, excessive bleeding, child marriage, sexual abuse and rape. It is not surprising that most of my sessions now are only a starting point for more serious discussions, beyond menstruation.
The same holds true for use of cloth. Dismissing it, without understanding when the usage of cloth can be harmful is like throwing the baby out with the bath water. Contrary to all the studies doing rounds, I have experienced that the reason most women/girls use cloth is because they prefer cloth to Sanitary Napkins. It is not the affordability or the lack of awareness of Sanitary Napkins in all cases. And no, I have not seen any woman who uses the straw, mud or ash in all my travels in Karnataka. The worst I have seen is that among tribal women, they used nothing and bled on their sarees, which is why they remained secluded in cow sheds during menstruation.
It is not the usage of cloth per se that causes menstrual problems, but rather how the cloth is used. If you want to know more about why menstrual hygiene is not about sanitary napkins, here is a blog I wrote on this topic Menstrual Hygiene is not about Sanitary Napkins
It is far more empowering for adolescent girls and women from rural backgrounds when we make an unbiased attempt to listen and learn from them and to help them improve (rather than change) their current practices, be it usage of cloth or pad. And when we do tell them about products they are unfamiliar with, let us leave it to them to pick what they prefer.
Myth #3: Entrepreneurship is the new answer to all menstrual hygiene problems
Recently, a well intentioned urban woman, excitedly told me how her group were planning to set up one of those Sanitary Napkin making machines, and asked me what I thought about it. In return, I asked her what her intention was? She mumbled something about women empowerment, self-employment and making pads affordable. And then I asked her what about menstrual hygiene? And she said: Oh yes, that too!
When I started my work on menstruation 4 years ago, I first explored the Sanitary pads made from the now famous Muruganathan’s “invention”. Mount Carmel college in Bangalore had a unit as part of their community initiative and we tied up with them. A few months into distributing these pads, here is what I found:
I tried these Sanitary Napkins myself and found the quality to be worse than the cheapest available commercial ones. The pads lasted for about 1.5 hours on the initial bleeding days. This was later confirmed by girls who simply refused to use it, saying they would rather spend a little more and buy better pads.
At that time, the price was Rs. 2 per pad, for a pack of 9 pads. After a few free distributions, Rotary tried to get the girls’ parents to pay Re.1 per pad. This led to the mothers picking up a fight with the school authorities saying that they are trying to sell cheap and poor quality pads to their daughters.
Mount Carmel college was having trouble sustaining the effort and breaking even was a struggle, let alone making a profit.
Different components of the machine regularly broke down, and we had to get our local electrician to try and fix it.
I mean no ill towards Mr. Muruganathan and certainly none towards Mount Carmel college who were very sincere in their effort. Mr. Muruganathan seemed to be a man with good intentions, rare courage and entrepreneur skills. But his approach is causing more problems than giving solutions. I have forgotten the number of organizations I have refused when they tried to rope me in to sell their new machine and the pads it produced, because there were no takers. The focus simply shifted from Menstrual Hygiene Management to marketing a product. Once the investments are made, organizations look for return on these investments. So they create an artificial need for a product even when women are perfectly happy using cloth or can afford commercially available Sanitary Napkins. Most often, organizations with money and little time to assess ground reality, will first create the solution and then attempt a reverse engineering to make the reality fit their solution.
If Hygiene is our focus, what we need is people who can spend time talking with girls and women about healthy menstrual practices, rather than business models.
Myth #4: Women in developing countries are suffering due to lack of Sanitary Napkins
There are rarely any positive stories around menstruation. Negativity about this topic sells like nothing else, and is suddenly the new find of several journalists world over. Developing countries have become the hotspot for these stories.
I had a brush with one such journalist two years ago. She was a freelance reporter for a German Broadcasting agency, and wanted to do a radio piece on the work I was doing on menstruation. Vyjayanthi and I thought it was best to let her experience it first hand, and so we invited her to witness our sessions in two rural government schools.
As is usually the case, our sessions are very lively, with plenty of laughter and positivity and it is anything but a grim situation full of sad faces and gloomy stories. Thrilled that the journalist would have a positive story to share, we started to head back to Bangalore. All of a sudden, to our great surprise, the journalist started sobbing saying that she couldn’t write this story. She said that if she didn’t get a sad story of girls dropping out of school due to menstruation, she would lose her job!
I, of course, refused to give her a false story. And she of course, found another NGO which helped her find one girl, somewhere in Bangalore, who had dropped out of school.
When I read most articles on Menstruation, I can almost visualize the conversation between the journalist and the girl/woman being questioned. I think it might be something like this:
Journalist: So what do you think about menstruation?
Woman (shrugs): what to think…
Journalist (with appropriate disgust in her expressions): So, do you use cloth?
Journalist (with sufficient sympathy): Oh you poor thing…
Woman (preferring sympathy to being called foolish): I wish I had access to Sanitary Pads, then even I would use it..
Journalist reports “Women in India are suffering due to poor access to Sanitary Napkins…”
If you ask my friend Ashok, a lawyer, he will tell you how you can pose questions to obtain exactly the type of answers you wish to hear!
I’m sure not all journalists are this way, but many of them do very little homework. Negative stories about menstruation not only makes for a good read, it also justifies the money being blown on distributing Sanitary Napkins in the name of Menstrual Hygiene Management.
Myth #5: Girls drop out of school once they attain puberty
This line features in every sad article on menstruation – “A study reveals that 23% girls are dropping out of school once they attain puberty.” This is followed by grand plans of making Sanitary Napkins available so that girls stop dropping out! It is the funniest connection that I have come across. I’ll tell you why…
Firstly, statistics from a survey done by Sarva Shiksha Abhiyaan show that
At the primary stage there is a similar dropout rate for boys and girls but at the upper primary stage there is a higher percentage of boys dropping out as compared to the girls.
At all states level, on an average the attendance rates of boys are more or less similar to girls in primary as well as upper primary grades. The percentage of girls present was more by 5% points than boys at the upper primary stage in the states of Kerala (94.1%, 83.6% respectively) and Uttarakhand (78.4%, 71.9% respectively)
In all the grades of primary and upper primary stages, number of boys who left the school was more than the number of girls in 2009-10: 28.1% boys and 25.5% girls in primary discontinued and 37.6% boys and 34.2% girls in upper primary discontinued.
The incidence of school leaving among girls is around 1.6 percentage points less than that of boys in 2008-09
So if we are concerned about dropouts, we need to shift our attention to poor boys instead!
Secondly, even when girls do drop out of school, it has no direct connection with non-availability of Sanitary pads and very little connection with lack of toilets. Here is the document of Sarva Shiksha Abhiyaan with all the data you need to understand why students drop out of school – Survey for assessment of dropout rates in 21 states. Especially interesting are pages 216 to 219 which capture the reasons why girls drop out of school.
From what I have experienced, the reasons they drop out are because in some places like Gulbarga, in order to avoid having to pay a fat dowry, parents get the girl married early to a relative. In places like Chamrajnagar, teenage pregnancies were high and therefore, parents feared their daughters would go astray and got them married. In some cases, it was because the parents migrated to another village, or the girl was simply not interested in school, or because she was needed at home to help with domestic work and looking after of younger siblings. So you see, even if we went all out and distributed Sanitary Napkins because 23% girls are dropping out of school, the dropout rate would not reduce.
Myth #6: Constructing toilets in itself will solve the problem of girls being absent during menstruation
My friend Anand is one of those rare species who declares to the group “I am going to pee, so please do not discuss anything important in my absence!” before he goes off to relieve himself.
Forget adolescent girls, there are so many of us adults (me included) who feel hesitant to make people around them know that they need to use the toilet. Now imagine, how much more difficult it would be for a menstruating girl, who has probably stained her skirt, to take a pad and some paper out of her bag, and walk to the toilet, in the presence of boys and male teachers. Add to it, the short recess hour of about 45 minutes where you need to also have your lunch, makes it difficult to change and dispose the pad in a relaxed manner. Even in schools with toilets and water, I have noticed that girls either feel very awkward to change in between school hours, or hurriedly try to get rid of the used pad and end up clogging the toilet. Therefore, building toilets alone may not create the necessary environment to change and dispose of sanitary products. Talking to the girls and helping them overcome their embarrassment in dealing with menstruation is a must for our plans to succeed.
So how do they manage when they don’t have toilets in a school? They go home, which is usually at a walking distance from the school in rural areas. And if not, they remain absent for a few days when they get their period. And going by the statistics, inspite of this monthly absenteeism, girls still have a better attendance when compared to boys! Even the teachers don’t mind this unless it is exam time, because they understand that it is OK for a girl to miss a few days of regular school when she is uncomfortable and perhaps in pain.
I once did a session for high school girls at a Government school in Bangalore. Their toilets were in an awful state due to improper disposal of Sanitary Napkins, and I was asked to help change their practices. We did a role play, taking girls through every stage of changing and disposing a used Sanitary Napkin. They were made to pause and think through each of their actions and decide what they wanted to do next. The session was followed by the girls getting together and cleaning up the toilet. At the end of it, the girls were so charged up that they convinced the school principal to renovate the toilet! With the existing schemes and government funds to construct toilets, getting a toilet built is not difficult. What it needs is a push from the women and girls, once they have realized its importance. And without this feeling of ownership from the user, the toilet might not be utilized as it should.
So, what is the real problem and what are the solutions in Menstrual Hygiene Management?
The problems we encountered and methods of addressing them are as follows:
Inhibition of girls/women – Unless you eat, sleep and dream menstruation like those of us working on this issue, in general, women are not OK to talk about it. Unless and until we normalize menstruation and everything that it comes with, we will not be addressing the issue at its root. If girls/women are not able to look at menstruation as something that is natural and normal, they will not respect their body enough to address its needs, be it in terms of hygiene or medical needs. The transformation in attitude begins with the ability of the facilitator to be comfortable about their own period and willingness to talk about it. Helping girls/women overcome inhibitions around menstruation is the prerequisite and important first step for any intervention in this direction to succeed.
Continuing conversations in absence of facilitator – Given the short time that most facilitators get to spend with girls/women talking about this topic, it is necessary to do so in groups. When girls and women find the courage to talk openly about menstruation with their peers, it creates a sense of normalcy around this topic and they realize that their problems are common. Such groups usually carry forward their conversations, menstrual stories and laughter, even in your absence. If this is done right, it will result in the group of girls/women having each other to share their problems with and find the courage to make decisions that will positively influence their health.
Lack of right knowledge of hygienic practices and biological basics – Once girls/women are comfortable talking about menstruation, we need to spend time understanding their current practices, without judgement. After all, we cannot help them if we are unaware of their wrong practices. Sharing with them the biological aspects of menstruation and how to maintain hygiene with the use of both cloth and pads, should help girls/women understand their body better and have clarity about safe and unsafe practices. At the end of the session, they should be able to suggest the changes they would need to make to improve their methods of maintaining hygiene, given the availability and accessibility of products and infrastructure in their surrounding.
Problems beyond menstruation – When done right, interactions on menstruation can open up all sorts of intimate conversations. Once girls/women get comfortable talking and sharing about their body and they begin to trust the group they are in, other important issues might come to light. In almost every school that we have visited in the last one year, the talk has extended to sexual abuse and rape. Also, it is not uncommon that the girls we address are made to work as domestic help or are being forced to get married soon after school. Therefore, it is important that the facilitator equip themselves with knowledge of handling these issues and awareness of child/woman helplines. The National helpline for children is 1098 and that for women in 1091.
Need for Sanitary Napkins or other menstrual products – It has been my experience that in most cases where after the session, girls/women feel the need for a better product, they express it and get it voluntarily. I remember one woman in Bahadarpur (Maharashtra) who suddenly realized that she had been using the same cloth for 10 years, and declared to the group that she would go and get a new cloth the very next day! There are similar cases of girls switching from cloth to pads and convincing their mothers to spend on it, just as there are girls and women who have a clear preference for cloth and wouldn’t switch over to a pad, even if it is given free of cost.
For those who still insist on distributing Sanitary Napkins, I would recommend the following checklist before you initiate the project:
Have you gone through steps 1 to 4 with the girls, and are they ready to talk to you openly about their menstrual needs?
Have the girls/women expressed, without pressure, that they wish to use Sanitary Napkins?
Have the girls/women said that they cannot afford to buy Sanitary Napkins?
What is your plan for sustaining the effort of donating free Sanitary Napkins? What happens once you stop distributing the free Napkins?
Have you used/tested the product that you will be distributing (for pads manufactured through decentralized machines) and is it comparable or better than the commercially available ones in terms of ability to absorb, environmental impact and disposal mechanism?
What are your suggestions to the girls/women for safe disposal of the used Sanitary Napkin?
Have you discussed with the women and village leaders about how introducing a new product will impact the environment in the village?
Lastly, no matter how many Sanitary Napkins we distribute, how many toilets we build and regardless of all the biology we use to educate girls and women in rural India, if we fail to connect with them on a personal level by relating our inhibitions; if we fail to listen, share and laugh together, our attempts on Menstrual Hygiene Management will remain a struggle. For those who are interested to work on this issue, it is extremely important to step on the ground and do a reality check of every assumption that is made. There is a dearth of those who can actually spend time and effort to work on the ground, and always an excess of arm-chair intellectuals.