What’s missing in MHM? Moving beyond hygiene in menstrual hygiene management

Introduction

Menstruation is having a moment. 2015 was dubbed the “Year of the Period” by National Public Radio in the United States and “the year the period went public” in Cosmopolitan (p.96).¹ The widespread discussion of the “tampon tax” and “period poverty” has resulted in legal change around the taxing of menstrual products in multiple states in the United States and the introduction of free sanitary products in schools in England from 2020. Menstruation has also become a focus in international development and the concept of menstrual hygiene management (MHM) is now established. Yet, work in this area largely remains dominated by WASH (water and sanitary health) bodies. Drawing in part on original research conducted in mid-western Nepal, we argue for a broader understanding of menstruation than that which is currently presented in mainstream international development discourse. In line with emerging ideas within both the NGO sector and academic literature, we propose a definition centred instead on rights as opposed to hygiene. Such a reframing would have positive implications for policy on menstruation across the globe.

What is(n’t) MHM?

Research and interest in menstruation started to emerge in the mid-2000s.^1,2 Sommer et al.² link the coinage of MHM to a roundtable in Oxford in 2005 hosted by UNICEF, although uptake appears to have been slow until around 2010. In 2012, the Joint Monitoring Programme of the WHO and UNICEF decided to “add MHM in schools and health facilities as a global advocacy issue in the lobbying effort for the post-2015 sustainability goals” (p.1308).² They also defined MHM clearly for the first time, as the process where:

“Women and adolescent girls are using a clean menstrual management material to absorb or collect blood that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.”(p.1557)³

As Sommer et al. note, a definition is important in advocacy as it provides “a center around which efforts can coalesce” (p.1308).² MHM’s growing popularity as a term “reflected the power of the word ‘hygiene’ to neutralise the otherwise alarming reference to menstruation” (p.1305).² MHM has become the central way in which work around menstruation is framed and measured.

Yet this approach to menstruation excludes as much as it includes. While menstrual products and adequate sanitation are clearly important, there are other factors to consider in policy. Bobel¹ notes that pain management, the wider community within which the menstruating woman/girl exists, and taboos and stigmas surrounding menstruation, are not covered in this definition. Neither is the woman/girl’s understanding of menstruation and the reproductive cycle, nor her own reproductive and sexual health. The definition’s silence on taboos and stigma is particularly striking, given how central these are to an understanding of menstruation in all contexts, and the severe impact that these can have on women and girls’ rights, dignity and well-being.⁴ The definition also excludes transgender men and others who menstruate, a group facing specific challenges related to menstruation.⁵

Furthermore, the definition frames the issue of menstruation firmly within the boundaries of sanitation and hygiene. This reflects the dominant role that the WASH sector has played in bringing menstruation onto the international development agenda. MHM largely has its origins in work focussing on girls’ education, beginning from the early 2000s^1,2 and the WASH sector, which began to pay attention to the issue several years later.¹ The early role that these two areas have had in framing this issue remains, with the WASH sector continuing to dominate. Indeed, other voices that we might expect to be involved in this conversation – those of the SRHR, gender, and women’s and girls’ rights sectors, in particular – are noticeably absent.²

Reflecting this definition, interventions focus mainly on technical solutions – access to sanitation but also provision of pads or other menstrual materials. Multiple NGOs and charities have sprung up with a focus on providing menstrual materials, including reusable options. Private companies that manufacture menstrual products have also been key here, partly through a desire to grow their own markets.² Although education or public awareness elements are sometimes included, “the bulk of MHM interventions rely too much on individual intervention through product provision and too little on structural and societal change” (p.7).¹ Product provision may well be helpful but cannot on its own challenge the power structures which generate and reinforce menstrual stigmas, or the economic structures which prevent recipients from being able to access appropriate sanitary products in the first place.

Evidence from our study

In April 2019, we conducted research in one rural municipality (Bhairabi) and one urban municipality (Dullu) of Dailekh district, Karnali Province, in mid-western Nepal. We collected quantitative data from 400 adolescent girls aged 14–19 years using cluster random sampling. To obtain understanding of the issues surrounding menstruation, we also conducted eight focus group discussions, four with adolescent girls and four with adult women aged 25–45 years (8–10 participants in each group). Men and boys were not invited because of the sensitive nature and taboos around menstruation, although we acknowledge that involving them is important.

Beyond hygiene, our study shed light on multiple issues which girls and women faced when menstruating. Underpinning most of their experiences were strong taboos and stigma. Girls frequently reported not being permitted to touch male family members, attend temple, join in celebrations, cook or enter their kitchens, eat many normal foods (such as dairy products), or sleep in their own bed. These practices appeared to be most keenly enforced by elders within their family and community, including mothers, grandmothers, and other senior women. Girls also frequently cited the role of religious leaders and traditional healers reinforcing them.

We were particularly interested in the practice of chhaupadi, which is prevalent in mid- and far-western Nepal, especially in light of its criminalisation by the Nepali government in late 2018. Chhaupadi involves sleeping away from the home in specially built chhau huts whilst menstruating or in animal sheds or in the open. Within our study, 77% of girls practiced chhaupadi. Although 60% of the girls we surveyed knew it was illegal, girls who knew this were just as likely to practice chhaupadi as those who did not. Girls from urban, wealthier households were less likely to practice chhaupadi, although prevalence was still 66% in the richest wealth quintile; Dalits were also more likely to practice. While most girls had access (albeit restricted and normally at some distance) to water and soap during menstruation (meaning that good menstrual hygiene could still feasibly be practiced), chhaupadi comes with a range of broader issues. Huts might be too cold in winter or have insufficient ventilation. Girls repeatedly discussed fears about the dangers of snake bites and other animals or the potential of being attacked by strangers. If they do not have access to a chhau hut, or it has been damaged or destroyed, they may sleep outside, open to the elements, or with animals. This was often accompanied by feelings of stress, anxiety, and disempowerment.

Civil society actors in Kathmandu highlighted that there were difficulties in policy coordination by the Nepali government. Multiple ministries (including WASH, Health, Women and Education) were involved in developing policy around MHM but it appeared unclear who bore the overall responsibility. There appeared a possibility that the issue would fall between the gaps of the various ministries, with the danger that policy implementation would be slow or blocked due to this uncertainty.

Conclusion: expanding MHM?

Menstrual taboos clearly have a substantial impact on well-being yet are unaccounted for in the current working definition of MHM. A more holistic approach is needed. Actors beyond the WASH and education sectors are beginning to push at these boundaries. In May 2019, the International Women’s Health Coalition, Marie Stopes International, the IPPF, Simavi and Wateraid published a document entitled “A Shared Agenda,” proposing, among other things, to “increase the focus on menstrual health as a critical pathway to improving SRHR” and stating that “WASH and SRHR actors can leverage one another’s efforts for a greater impact on improving menstrual health.”* In 2017, the Menstrual Health Hub, an online platform for research and practitioners, was launched. It defines the issue broadly:

“Menstrual health is a CROSS-SECTOR ISSUE … . we see menstrual health as a more holistic and encompassing term that includes both MHM as well as the broader systemic factors that link menstruation with health, well-being, the environment and equity.”⁶

In March 2018, the Agreed Conclusions of the United Nations Commission on the Status of Women stated that governments and civil society should “take steps to promote educational and health practices in order to foster a culture in which menstruation is recognized as healthy and natural and in which girls are not stigmatized on this basis” (p.4).¹

While we acknowledge that this cross-sectoral work is important, we argue that this issue might gain further traction and energy if centred in a rights-based approach. In the remit of the above short study of Nepal alone, we see multiple rights being ignored – notably rights to safety, security and dignity. We argue in a similar vein to Winkler and Roaf that

“The human rights framework and the links between menstrual hygiene and these varied human rights highlight the need for a holistic understanding of menstrual hygiene. It is not just an infrastructure issue, it is at least as much an issue of having the voice and space to articulate and meet one’s needs. It requires access to accurate and pragmatic information and raising the awareness and confidence of women and girls to manage menstruation with safety, privacy, and dignity.” (p.21)^7,8

A move to a rights-based understanding of menstruation would also help with many of the criticisms concerning its current emphasis as a hygiene issue. Menstruation is more than hygiene (and it is not unhygienic, as the MHM definition almost implicitly asserts). It is an undeniable fact of biology for the majority of human beings globally for at least part of their lives. Framing the issue as being about the right to safe, healthy and dignified menstruation moves it from being a negative problem to be solved, and instead an affirmative principle through which the facts of women and girls’ lives are acknowledged and validated.

Our study in Nepal highlighted a broad range of issues around menstruation beyond hygiene – questions of security, safety, stigma, taboo, and policy ownership were all central. Reframing menstruation as a question of rights can help to bring these various facets under one clear umbrella. A focus on rights emphasises both the naturalness of menstruation and the individual girl or woman as a rights-bearing agent. This reorientation can help to begin to shed the stigma around menstruation, and also to act as a catalyst to bring new voices into the global movement for better menstrual practices.

ORCID

Jennifer Thomson http://orcid.org/0000-0001-5518-9849

Melanie Channon http://orcid.org/0000-0003-4820-0928