By Estelle Monique Sidze, Associate Research Scientist and Salome Wawire, Post-doctoral Fellow, APHRC
In Kenya, girls in grades 4-8, who have reached puberty, miss on average 6 learning weeks/year due to menses (i.e. one and half school months in a year) (MoE, 2011). A girl in grade 4 will miss up to 30 weeks by the time she completes grade 8. This contributes to an increase in the existing gender disparities in access, retention, transition and achievements in education. What does this mean? Young girls are missing school because they are on their period.
APHRC’s engagement to achieve universal access to hygienic menstrual management products by adolescent girls in Kenya
As a result of this serious problem, in November, 2010, the African Population and Health Research Center (APHRC), through the Population Dynamics and Reproductive Health Program, completed the implementation of a research study to explore menstrual practices among adolescent girls and women in Nairobi, and to investigate the feasibility and suitability of the menstrual cup in managing menstruation. The ultimate goal of the project was to promote the reproductive health and education rights of adolescent girls and women by tackling problems associated with menstruation, and by improving access to appropriate menstrual products. The study sought to provide policymakers with a better understanding of menstruation and associated practices of adolescent girls and young women in Nairobi, including their experiences and attitudes as well as the problems they encounter during this period.
The research was conducted in two phases. Phase 1 explored beliefs, attitudes, practices and problems associated with menstruation among women and girls in informal settlements and other urban areas of Nairobi. Based on the Phase 1 findings, Phase 2 was designed as a pilot study to assess the cultural, practical and health-related appropriateness and feasibility of the menstrual cup (a small reusable soft silicon cup that is inserted like a tampon that can be used in lieu of pads or tampons) as a method for managing menstrual flows. During Phase 2 we collected data from 60 girls and 36 women from two localities of Nairobi before the women and girls used the menstrual cup and compared that to data collected after the women and girls had used the cup for four months.
What did we find?
Sanitary towels were described by almost all participants as their preferred method for managing menstruation. Because pads are not always available, many participants said people in their community used cotton wool, cloths (including socks), tampons, tissue paper, and even pages torn from school exercise books, and pieces of sponge torn from mattresses.
What happened in response to this new information?
Shocked by the severity of the issue, the Government of Kenya set aside two hundred and forty one million Kenyan shillings (almost 3 million U.S. dollars) for the 2011/2012 year for the purchase of sanitary towels to distribute to targeted pupils across the country. In May 2012, the Kenyan Ministry of Education launched a Sanitary Towels Program (STP) in public primary schools. A total of 443,858 (class 4-8) needy girls in 4,114 primary schools drawn from 82 districts are expected to benefit from this program. The districts where schools are drawn from were identified using criteria which took into account the national poverty index, the gender parity index, ASAL characteristics and needy areas based on Provincial Director’s of Education reports. The overall objective of the government intervention is to increase the opportunity to learn for adolescent girls by: reducing school absenteeism among girls, improving self-esteem & participation during instruction.
Is the Menstrual Cup Part of the Solution?
Based on the evidence from the APHRC study, the menstrual cup could play an important role in mitigating menstrual problems for women and girls. Prior to using the cup, many girls reported that they were so worried about staining their clothes, that they had trouble concentrating in school, whereas after using the cup they reported forgetting they were menstruating at all and were able and willing to participate in all of the class activities. In fact, before using the cups 47% of the girls reported having trouble concentrating because of their period, whereas after using the cup only 29% reported still have trouble concentrating.
Acceptability of the menstrual cup:
At the first attempt of trying on the menstrual cup, most participants encountered discomfort. Some complained that they could feel the cup (an indication, as explained by the project nurse, that the cup was not properly inserted). This opened up the opportunity for further explanations and directions on how to use the cup. Acceptability of using the menstrual cup increased with more awareness and knowledge of how to use the cup. Some women mentioned that as a result of the education sessions they understood their bodies better and had gained experience using the cup after every subsequent use.
Could there be economic benefits to using the cup?
Again, more research is needed, but the pilot study results do show a slight reduction in women’s productivity loss from menstruation as a result of using the cup. Before using the cup 28% of the women reported that their period prevented them from doing their everyday activities, whereas only 17% reported the same problem after using the cup. Women also commented that the cup reduced the monthly cost to women because they no longer had to purchase pads on a monthly basis. The women also reported that they used less water to clean the cup than to clean other materials they had previously been using to prevent leakage and staining.
What about hygiene?
Women who wore the cup in the correct way reported no external skin irritations and that there was no smell from menstruation. Therefore women felt that the cup was more hygienic than using other methods.
Socially empowering women:
Since the major social implication of menstruation mentioned by the participants was the fear of embarrassment from staining their clothes while on their period, the menstrual cup was particularly successful in relieving the social stress around menstruating. Because of how the cup is worn, the chances for leakage are very small and women felt less burdened by menstruation and more free to carry on with their normal activities, such as work and schooling. Therefore using the cup also reduced the opportunity for women and girls being victimized or stigmatized.
While the study shed light on the challenges faced by school girls and women living in Nairobi, and also showed that the menstrual cup could be part of the solution, there are a number of questions that remain to be answered, and which limit the generalizability of the findings, given the small sample size and study area (Nairobi). These revolve around access to clean water (to clean the cup) and sanitation facilities, social and cultural beliefs and taboos around menstruation and the acceptability and use given the cultural questions around the use of intra-vaginal devices in virgin girls, and health-related risks such as Toxic Shock Syndrome (TSS), among others. Other questions include production costs and cost effectiveness and delivery mechanisms.
To address these issues, APHRC, in collaboration with Liverpool School of Tropical Medicine, KEMRI/CDC and the Division of Reproductive Health, among others, is conducting a proof of concept study to quantify cultural acceptance, use and satisfaction with menstrual products (the menstrual cup, sanitary pads and ‘usual practice’) with at least 750 school girls in western Kenya. This study also examines the cost-effectiveness of these menstrual products. The results from this study will be used to further inform current policy on menstrual management products to improve education for girls.