Menstrual health rituals -
The significance of ceremonies marking menarche was reported in two anthropological studies [ 34 , 42 ] conducted in Fiji. These authors reported the menarcheal ceremonies or rituals facilitate gender identity and preparation of girls for womanhood.
Apart from preparation of womanhood, Jenkins explicitly explained that due to the belief that open communication about sexuality may pique curiosity leading to earlier or greater experimentation with sex , menarcheal rituals or initiations are traditionally used by parents to control the flow of information about sexuality, sex and reproduction to young women [ 38 , p.
This ceremony typically involves mothers, grandmothers and aunties in teaching and advising young girls about SRH topics. However, this ceremony no longer occurs regularly due to changes in the traditional ways of life and education [ 34 , 38 , 42 ].
Some women continue to observe traditional beliefs around menstruation which exclude them from community, social participation and sexual activities.
The study in Samoa reported that menstruation is not considered a taboo concept or polluting and the restrictive belief systems and resulting changes in behaviour are individual choices [ 35 ].
While menstruating women paid attention to personal hygiene there was no elaborative evidence about MHM. However, men perceived that pre-menarcheal coitus is a pre-requisite for menarche to begin and coitus after childbirth for resumption of postpartum menstruation. No study explicitly reported major policy issues such as policy review, budget provisions or minimum standards for addressing MHH practices.
Quality assessment of the 11 studies on Table 3 resulted in four studies meeting the criteria, five partially meeting the criteria as far as were reported and two did not meet all criteria as outlined in the CASP tools.
This review found that research on MHH is very limited in the PICTs, certainly beyond the anthropological literature about beliefs and practices around menarche and subsequent menstruation.
This finding is consistent with a recent unpublished literature review on menstrual hygiene in the Pacific [ 44 ]. This review found that research on MHH in the PICTs is largely externally driven and lacks critical indigenous and epistemological perspectives from Pacific Islanders.
Furthermore, the research lacks approaches that empower participants with lived experience to have control over the research agenda, the process and actions to address their felt issues [ 45 ]. Despite different settings and populations, the synthesis of descriptive evidence from a few countries PNG, SI, Fiji, Kiribati and Samoa reflects common themes relating to MHH with manifestations that differ in response to context between and within countries.
Using the Socio-Ecological Framework SEF , this synthesis highlights multiple challenges faced by women in PICTs at menarche and throughout their reproductive life relating to MHH. These challenges have important implications for addressing sexual and reproductive health issues specifically those relating to menstruation in the PICTs.
These implications are now discussed at individual, institutional and societal levels [ 46 ]. Pre-menarche girls generally lacked menstrual knowledge, and menstruation management skills—often leaving them unprepared for menstruation in both urban and rural areas.
Mothers are considered a primary source of support for their daughters, however many of them lacked proper knowledge about menstruation and menstrual health.
Consequently, mothers felt ashamed and lacked confidence to assist their daughters resulting in fear, shame and confusion. Women living in rural and isolated communities with limited access to education tend to face more difficulties [ 46 , 47 , 48 , 49 ]. Inability to effectively manage menstruation due to lack of skills and menstrual management materials were also reported in Sierra Leone leading to shame and embarrassment [ 43 ].
Restrictive practices can also potentially impact on a range of personal factors such as pre-menarcheal awareness and preparation, self-esteem and psychological wellbeing, and MHH practices [ 14 , 50 , 51 ]. This review found lack of proper WASH facilities in schools, workplaces and communities in both urban and rural areas.
This finding is consistent with many studies conducted on WASH and MHH in the urban and rural areas in LMICs [ 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. Lack of WASH facilities often left women feeling ashamed and embarrassed. This review found girls absenting from schools as a result of lack of proper toilet and sanitation facilities.
The structural challenges at school such as inadequate bathrooms also cause difficulties for girls to manage menstruation effectively in school [ 52 , 53 , 54 , 55 ].
Although the review found disparity in menstrual beliefs and practices between countries and between rural and urban areas, the findings suggest that these beliefs are ingrained in the cultural beliefs and perceptions of menstruation including menstrual blood [ 57 , 58 , 59 ] and may continue to influence MHH practices of women in the PICTs.
Curiosity, shame and gender-bound secrecy were also found to influence behavioural practices such as bullying and teasing from male figures, and the inability of male teachers to effectively support female students during menstruation in schools.
Inadequate knowledge of boys about SRH and menstruation have been found to help promote and perpetuate stigma, acts of teasing, and bullying of women during menstruation [ 47 , 63 , 64 , 65 ]. Taboo and stigma against menstruating women leading to restricted SRH communication and menstruation, social and community participation, education and work, are considered forms of gender-based violence induced by patriarchal perceptions of menstrual blood [ 64 , 66 ].
Stigma, shame and secrecy around menstruation are linked to menstrual taboos [ 7 , 58 , 67 , 68 , 69 ]. Myths and rumours about menstruation found in this review lead to fear, shame and self-isolation [ 41 ]. They were also found in studies conducted in India [ 70 ] and Ghana [ 71 ], leading to psychological distress in menstruating women.
The use of the Socio-Ecological Framework in this analysis has highlighted important challenges and multiple focus areas for interventions.
A multi-level approach is required in order to facilitate and create a supportive environment for a positive menstruation experience. The majority of evidence related to the implications of traditional social and cultural norms, beliefs and practices on MHM.
Policy related evidence relating to MHH was minimal; this may infer lack of evidence informing practice or a mere lack of consideration for gender-specific issues due to subordination of women, cultural taboos, shame and secrecy.
Negative norms, beliefs and practices that condition the experiences of women and girls at menarche result from the predominant patriarchal social and cultural environment within PICTs.
Despite disparities in experience between countries, rural and urban contextual settings, following actions are recommended; planning to include males in SRH education programs in an effort to influence their perceptions about menstruation is paramount [ 8 , 19 , 36 , 37 , 38 , 39 , 40 , 41 , 61 ].
WASH facilities should be considered beyond schools to include work environments, public spaces, rural and urban settings [ 19 , 36 , 37 , 38 , 39 , 40 , 41 ]. The menarcheal ceremonies provide an important alternative to SRH communication due to taboo and secrecy relating to menstruation and menstrual blood.
The menarcheal ceremonies reported in Fijian are traditional cultural systems practices by i-Taukei Fijian group to prepare young women for womanhood. These practices assist young women to assume gendered roles and responsibilities required in the society they belong to [ 34 ].
These menarche ceremonies are also found among the Navajo tribe of America [ 72 ], and Maasai and Bemba tribes Rhodesia of Africa to prepare girls for womanhood [ 73 , 74 ]. The elements of the menarche ceremonies could be explored further to inform the development of an alternative communication strategy for menstruation and SRH for girls in transition to womanhood.
Developing menarcheal ceremonies into a contemporary learning hub for teaching SRH topics to adolescent females in the Pacific holds promise. Country-specific research around menstruation is a necessary first step for PICTs and the author has gone onto conduct relevant MHH research in PNG [ 19 ].
Furthermore, because menstruation is deeply embedded in the social and cultural context of PICTs, research done by local researchers using socially and culturally situated approach is important to ensure the knowledge that is created is relevant.
Leaders in PICTs must prioritise research that promotes an understanding of local socio-cultural norms around menstruation because menstrual experiences are contextual; given the diversity of social and cultural contexts in the PICTs, local contextual knowledge is paramount.
Consistent with indigenous epistemological standpoints, this review was led by a Pacific Island research scholar as part of her PhD studies. Conducted from an Australian university, this review had good access to peer-reviewed and grey literature and relevant worldwide websites.
The author group included researchers conducting research on menstruation in PICTs and with international organizations. Most research about MHM in PICTs apart from anthropological studies mostly commenced only a few years ago. Hence, the number of studies conducted thus far is insufficient to fully understand the factors influencing MHM and the broader implications of menstruation on the wellbeing of girls and women.
Articles published in languages other than English were excluded, which may have excluded relevant literature from French-speaking Pacific islands and territories. Menstruating girls and women have the right to manage menstruation effectively and with dignity.
It is evident from this review that societal, environmental, interpersonal and personal factors impact on the experiences of girls and women around menstruation. Of these four factors, socio-cultural norms, beliefs and practices appear to be extremely important underlying determinants that require locally-relevant action.
Furthermore, because menstruation is deeply embedded in the social and cultural context of PICTs, research done by local researchers must use socially and culturally situated approaches to ensure the knowledge that is created is relevant.
Consideration should be given to utilising socially and culturally relevant approaches to understand country-specific issues around menstruation.
Keith B. Google Scholar. Hennegan J. Menstrual hygiene management and human rights: the case for an evidence-based approach. Womens Reprod Health. Article Google Scholar. Winkler IT. Human rights shine a light on unmet menstrual health needs and menstruation at the margins.
DiVall SA, Radovick S. Pubertal development and menarche. Ann N Y Acad Sci. Article CAS PubMed Google Scholar. Phillips-Howard PA, Hennegan J, Weiss HA, Hytti L, Sommer M. Inclusion of menstrual health in sexual and reproductive health and rights.
Lancet Child Adolesc Health. Article PubMed Google Scholar. Rembeck GI, Moller M, Gunnarsson RK. Attitudes and feelings towards menstruation and womanhood in girls at menarche. Acta Paediatr.
Dammery S. First blood: a cultural study of menarche. Clayton: Monash University Publishing; Hennegan J, Winkler IT, Bobel C, Keiser D, Hampton J, Larsson G, Chandra-Mouli V, Plesons M, Mahon T.
Menstrual health: a definition for policy, practice, and research. Sex Reprod Health Matters. PubMed PubMed Central Google Scholar. Sommer M, Vasquez E, Worthington N, Sahin M, editors. Guide to menstrual hygiene materials. New York: UNICEF; Hennegan J, Shannon AK, Rubli J, Schwab KJ, Melendez-Torres GJ.
PLoS Med. Article PubMed PubMed Central Google Scholar. Sommer M, Chandraratna S, Cavill S, Mahon T, Phillips-Howard P. Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries.
Int J Equity Health. Thakur H, Aronsson A, Bansode S, Lundborg CS, Dalvie S, Faxelid E. Knowledge, practices, and restrictions related to menstruation among young women from low socioeconomic community in Mumbai, India.
Front Public Health. Sommer M, Hirsch JS, Nathanson C, Parker RG. Comfortably, safely, and without shame: defining menstrual hygiene management as a public health issue. Am J Public Health.
Mohamed Y, Durrant K, Huggett C, Davis J, Macintyre A, Menu S, et al. A qualitative exploration of menstruation-related restrictive practices in Fiji, Solomon Islands and Papua New Guinea.
PLoS ONE. Article CAS PubMed PubMed Central Google Scholar. Farage MA, Miller KW, Davis A. Cultural aspects of menstruation and menstrual hygiene in adolescents. Expert Rev Obstet Gynecol. Sumpter C, Torondel B. A systematic review of the health and social effects of menstrual hygiene management.
Lutkehaus N, Roscoe PB. Gender rituals: female initiation in Melanesia. New York: Routledge; Maulingin-Gumbaketi E, Larkins S, Gunnarsson R, Rembeck G, Whittaker M, Redman-MacLaren M. Sommer M, Caruso B, Sahin M, Calderon T, Cavill S, Mahon T, et al.
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Vallely A, Fitzgerald L, Fiya V, Aeno H, Kelly A, Sauk J, et al. Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting.
BMC Res Notes. Sniekers M. From little girl to young woman: the menarche ceremony in Fiji. Fijian Stud. Fitzgerald MH. The interplay of culture and symptoms: menstrual symptoms among Samoans. Med Anthropol.
Francois MC, Lauff A, Yamakoshi B. Huggett C, Natoli L. The last taboo: research on menstrual hygiene management in the Pacific.
Fiji final report. Jenkins C. Knowledge and events before marriage. In: Jenkins CL, editor. National study of sexual and reproductive knowledge and behaviour in Papua New Guinea.
Goroka: Papua New Guinea Institute of Medical Research; Natoli L, Huggett C. The Solomon Islands final report. Mohamed Y, Natoli L. Papua New Guinea final report.
Breaking down barriers: coming of age, becoming the change. Case study on the knowledge, attitudes and practices of menstrual hygiene management in Kiribati schools.
Clauson A. San Luis: California Polytechnic State University; Caruso B, Fehr A, Inden K, Sahin M, Ellis A, Andes K. New York, USA: UNICEF; Burnet Institute.
Literature review on the last taboo: research on managing menstruation in the Pacific. Bergold J, Thomas S. Participatory research methods: a methodological approach in motion. Hist Soc Res. For generations of girls and women, poor menstrual health and hygiene is exacerbating social and economic inequalities, negatively impacting their education, health, safety, and human development.
The multi-dimensional issues that menstruators face require multi-sectoral interventions. WASH professionals alone cannot come up with all of the solutions to tackle the intersecting issues of inadequate sanitary facilities, lack of information and knowledge, lack of access to affordable and quality menstrual hygiene products, and the stigma and social norms associated with menstruation.
Research has shown that approaches that can effectively combine information and education with appropriate infrastructure and menstrual products, in a conducive policy environment, are more successful in avoiding the negative effects of poor MHH — in short, a holistic approach requiring collaborative and multi-dimensional responses.
Priority Areas. In low-income countries, half of the schools lack adequate water, sanitation, and hygiene services crucial to enable girls and female teachers to manage menstruation UNICEF Schools that have female-friendly facilities and incorporate information on menstruation into the curriculum for both girls and boys can reduce stigma and contribute to better education and health outcomes.
When girls and women have access to safe and affordable sanitary materials to manage their menstruation, they decrease their risk of infections. This can have cascading effects on overall sexual and reproductive health, including reducing teen pregnancy, maternal outcomes, and fertility.
Poor menstrual hygiene, however, can pose serious health risks, like reproductive and urinary tract infections which can result in future infertility and birth complications. Neglecting to wash hands after changing menstrual products can spread infections, such as hepatitis B and thrush.
Awareness of MHH contributes to building an enabling environment of nondiscrimination and gender equality in which female voices are heard, girls have choices about their future, and women have options to become leaders and managers.
In addition, feminine hygiene products are a multibillion-dollar industry, which, if properly tapped into, can generate income for many and significantly boost economic growth. Disposable sanitary products contribute to large amounts of global waste.
Ensuring women and girls have access to sustainable and quality products, and improving the management of the disposal of menstrual products, can make a big difference to the environment.
In India alone, roughly million women and girls use an average of eight disposable and non-compostable pads per month, generating 1.
Country Examples. Enhancing opportunities for women to access adequate menstrual health and hygiene is central to the World Bank Group in achieving its development outcomes. In addition, the project is facilitating behavior change sessions and training on the importance of menstrual hygiene and safely managed WASH facilities.
Access to finance will be provided to women entrepreneurs to help them market and sell soaps, disinfectants and menstrual hygiene products at household doorsteps.
This will improve menstrual hygiene practices, especially among those who are too shy and reluctant to purchase them at public markets. Close menu. Menstrual underwear. Washable pads Menstrual cups Intimate soap Menstrual Diary [French Only] Gift Card.
Our unique concept. Get money back! Kits of undies. Group orders. Monthly events. sangdéchet Movement. Log in. Instagram Facebook YouTube LinkedIn. Language English Français English. Moontime rituals are one of my most treasured ways of connecting to my womb while menstruating.
So much so, that I often find myself looking forward to my next bleed. Connection and ease As you begin to establish a monthly Moontime ritual, an unquestionable connection is cultivated.
Here are 3 Moontime rituals to help you get started: WELCOME YOUR BLEED If this is your first time connecting to a Moontime ritual - this is a great place to start.
The words we use when we bleed matters. The way we respond when we bleed matters. Every cell in our body receives that information. Here are some ways to Welcome your bleed: Light a candle Burn incense or sage Say a short prayer, meditate or say a mantra. Share Share on Facebook Tweet Tweet on Twitter Pin it Pin on Pinterest.
Blood Menstrual health rituals have been Menstrual health rituals into the rituuals fabric Menstrual health rituals all of our Skin rejuvenation therapy stories, of our westernized religions, and into the fairytales that Menstruxl to us the mysteries of the heaoth forgotten, shamed, Quenching dry mouth demonized MMenstrual river of consciousness. Ritals was deeply respected and understood. In fact, it is not only possible, but the right of every woman to experience menstruation as ecstatic, blissful, profound, deeply healing, and even orgasmic. The surest way to disconnect a woman from her own power is to convince her that this power is inherently impure and separate from God. There is an ancient Hopi prophecy that goes,"When the women give their blood back to the earth, men will come home from war and earth shall find peace. The significance High-Quality Citrus Concentrate menstruation varies substantially among different Mesntrual and Meenstrual groups. For example, in the Cherokee Nation, menstruating women were Menstruzl sacred Menstrual health rituals powerful. However, this positive view Mfnstrual a rare Menatrual, and in many parts of the world, menstruation is unfortunately regarded as dirty, impure, and taboo. Today some Brahmin Hindu women are secluded during menstruation and do not participate in normal domestic activities. In some forms of Judaism women participate in ritual bathing at the end of the menstrual period called Mikvah, prior to resuming sexual relations. Many religious or cultural practices forbid menstruating women from participating in religious ceremonies, or engaging in physical intimacy.Menstrual health rituals -
Changing the natural pH balance of your vagina by washing or using chemicals to cleanse out the vagina can be harmful and may result in a yeast infection or bacterial vaginosis. Use unscented toilet paper, tampons, or pads.
Scented hygiene products can irritate the skin and impact your natural pH balance. Drink enough liquids. This can help wash out your urinary tract and help prevent infections, like vaginal candidiasis. Track and monitor your period. Your menstrual cycle is a valuable marker for your overall health.
Irregular periods can be a sign of conditions like diabetes, thyroid dysfunction, and celiac disease. You can track your period on a calendar or with an app on your phone designed for this purpose. Visit a healthcare provider for your annual check-up. An annual well-woman exam is a full check-up that includes a pap smear , a pelvic exam, and a breast exam.
These exams are essential for good reproductive health as they can catch early signs of cancer or other health issues. Menstrual Hygiene Day — May 28 Each year on May 28, Menstrual Hygiene Day is observed to highlight good menstrual hygiene practices during your period and to raise awareness about the importance of access to menstrual products, period education, and sanitation facilities.
What You Can Do Everyone can participate in Menstrual Hygiene Day by: Spreading awareness in your community about the importance of good menstrual hygiene habits.
Joining a worldwide conversation on social media using MHDay Learning more about other hygiene practices to keep you healthy. Share messages on social media! To download image, right click on the large image and click "Save picture as".
Changing the orientation of your bed. We know — the last thing you probably want to do on your heaviest day is move heavy furniture, but even just a small change can create some fresh alignment to go along with your new fresh lining and help you feel secure and strong in your period ritual.
And remember, you can always change everything back tomorrow. Self-care takes many forms, and incorporating menstruation rituals into your monthly period routine can promote a healthier cycle and a more comfortable experience.
Keeping in touch with your menstrual cycle can help you nourish yourself, strengthen your mind-body awareness, and gain new perspectives. Karina Primelles is the CEO and co-founder of Xula Herbs. Her research focuses on the clinical and historical uses of medicinal herbs and cannabis, with a particular focus on how they can influence and support the female reproductive system.
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Xula Herbs, "Herbal Index. Why We Need to Change the Way We Talk About Periods. Creating a Better Future For All Who Menstruate. How the Alliance for Period Supplies is Breaking the Cycle of Period Poverty. This is a carousel containing website messages.
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Home Periodical Voices 3 Easy Ways to Ritualize Your Period Week. This systematic review identifies knowledge gaps and targets for future research and interventions. Studies from Nepal that examined factors contributing to menstrual health and hygiene were identified through searches across six databases Medline, CINAHL, Web of Science, PsychInfo, Nepal Journals Online and Kathmandu University Medical Journal in January The SEM is a public health framework that describes how health is impacted at multiple levels including the individual, interpersonal, community, organizational and policy levels.
Key themes were identified, and factors contributing to menstrual health and hygiene were categorized as per the level of socio-ecological model SEM. After a comprehensive literature review, twenty peer-reviewed publications, published between and January were included in this review.
Eighteen studies were descriptive and two were interventional. The main outcomes reported were reproductive health concerns and menstrual hygiene practices.
Nine studies focused on knowledge, attitude, and practices regarding menstruation, seven studies highlighted reproductive health issues, three studies focused on prevalence of culturally restrictive practices, and one on school absenteeism and intimate partner violence.
Lack of awareness regarding menstrual health and hygiene, inadequate WASH facilities, no sex education and culturally restrictive practices makes menstruation a challenge for Nepali women.
There are gaps in the evidence for high quality interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address needs identified at all levels of the SEM. Menstrual health and hygiene are major public health and social issues in Nepal, due to a lack of health and education infrastructure, gender-based disparities and restrictive cultural and social norms.
This study reviewed the current state of research on menstrual health and hygiene in Nepal. The socio-ecological model SEM —a public health framework that examines individual, interpersonal, community, organizational, and policy impacts on health—was employed to describe impacts on menstrual health and hygiene.
After a comprehensive literature review, 20 papers were included in this analysis, of which 18 were descriptive and two were interventional.
The primary menstrual health and hygiene outcomes reported were reproductive health concerns and menstrual hygiene practices. Key themes identified were knowledge, attitude, and practices regarding menstruation, reproductive health issues, prevalence of culturally restrictive practices, school absenteeism and intimate partner violence.
The study results indicated lower menstrual health and hygiene challenges arose from lack of education around menstruation, lack of proper water, sanitation, and hygiene WASH facilities, poor sex education, and culturally restrictive practices.
There is need for high quality, effective interventions to improve menstrual health and hygiene in Nepal. Future research and interventions should address improvements in menstrual health and hygiene at all levels of the socio-ecological model. Peer Review reports. Menstruation is a natural physiological process that most women experience during their reproductive years [ 1 ].
The Joint Monitoring Program JMP of the World Health Organization WHO and the United Nations International Children's Emergency Fund UNICEF highlight the importance of managing menstruation hygienically and with dignity. In order to accomplish this, women and girls must have access to clean menstrual management materials, that can be changed as frequently as necessary, privacy, access to water and soap for washing, and access to appropriate disposal facilities [ 2 ].
For women and girls to live a healthy, productive and dignified life, effective menstrual health and hygiene is essential [ 3 ]. Menstrual hygiene management is an important health and social issue in Nepal. Nepal is a predominantly Hindu country [ 4 ].
Although it is not explicitly stated in any Hindu scriptures, many Hindus believe that menstruating women and girls are impure [ 4 ]. Due to religious beliefs about the impurity of women during menstruation, many women and girls are excluded from participation in typical daily and community activities during menstruation.
Nine out of ten women and girls in Nepal report restrictions during menstruation including being prohibited from entering prayer rooms, temples and kitchens, touching their male family members, sleeping in their own bed, and going to school [ 4 ]. In Nepal, gender discrimination is frequently exercised in the name of religious, cultural and social norms [ 5 ].
Women are often not involved in decision making for household matters and are uncomfortable challenge harmful cultural and religious practices [ 3 ]. Restrictions placed on women and girls during their menses are more likely to be practiced in rural and remote areas of Nepal.
Chhaupadi is a tradition in which women are banished to outdoor sheds often where animals are kept during their menses, and are considered impure and untouchable. Although the Chhaupadi tradition was legally abolished by the government of Nepal in and criminalized in , it is still widely practiced in these areas, with menstruating women ostracized for about seven days every month [ 6 ].
Local residents believe that stopping this tradition would be offensive to the Gods and would bring bad luck and misfortune [ 7 ]. Literature pertaining to menstrual hygiene in Nepal is lacking [ 8 ]. Menstrual health and hygiene has not previously been examined to understand its impact at individual, interpersonal, community, organizational and policy levels.
The social ecological model SEM is a paradigm used to guide public health research and practice [ 9 ]. The model describes how individual and environmental characteristics influence health outcomes. Examining a public health problem using the SEM shows that health is impacted by factors on multiple levels including the individual, interpersonal, community, organizational and policy levels [ 10 ].
Thus, the SEM is a useful framework for examining menstrual health and hygiene in the developing world [ 11 ]. For example, on an individual level, women and girls may lack knowledge about menstruation.
Poor knowledge on menstruation leads to misconceptions that perpetuate stigma and cultural restrictions as well as poor hygiene [ 3 ]. On an interpersonal level, they may face various restrictions during their menses due to cultural beliefs [ 12 ]. These cultural beliefs not only hinder proper menstrual health and hygiene but also lower the self-esteem of women and girls.
On the policy level, there may be a lack of programs to promote menstrual health and hygiene such as ensuring water, sanitation and hygiene WASH in schools [ 11 ]. Lack of proper WASH facilities in schools lead to school absenteeism among menstruating adolescent girls [ 11 ].
Although most menstrual health and hygiene research and interventions have been focused on individual and interpersonal levels, exploration of factors affecting menstrual health and hygiene at all levels of the SEM is important [ 13 ].
Poor menstrual health and hygiene has gained global attention in recent years. Academics, non-governmental organizations NGOs , the United Nations UN and other international agencies have called for an end to the gender gap in school education. Promoting menstrual health and hygiene is one promising means to achieve this goal, as menstruation contributes to this gender gap; girls face challenges to ful participating in school due to limitations regarding menstrual management in school environments [ 12 ].
The objectives of this paper are 1 to review the current state of knowledge on menstrual health and hygiene in Nepal by employing a socio-ecological perspective and 2 to understand the challenges, barriers and facilitators to optimizing menstrual health and hygiene.
A literature search was conducted on January, in five databases: Medline, CINAHL, Web of Science, Nepal Journals Online NepJOL and Kathmandu University Medical Journal KUMJ. An example of the search strategy is as follows: menstruation OR chaupadi OR chhaupadi AND Nepal.
The inclusion and exclusion criteria were defined before the literature search and followed strictly. The inclusion criteria were: 1 papers that included women of reproductive age [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ] in Nepal, and 2 studies that examined factors contributing to menstrual health and hygiene.
Study designs included in the articles reviewed were qualitative, quantitative and mixed methods. Only papers published in English were included. Organizational reports, policy statements and training manuals were excluded from this review a priori. The titles and abstracts of all papers identified during the literature search were reviewed to check relevance and appropriateness.
Duplicates were removed manually. The reference lists of all identified articles were reviewed to identify additional manuscripts that may have been missed during the initial search. After the full review of the final list of all selected titles and abstracts, a quality appraisal was conducted for all the papers.
Quality assessment was conducted using the approach described by Banks et al. Each paper was given a quality score using the modified version of the Strengthening The Reporting of Observational Studies in Epidemiology STROBE and the Qualitative Research Review Guidelines RATS quality assessment tools [ 14 ].
The papers were assessed to have either high risk of bias, medium risk of bias, or low risk of bias, based on their study design, sampling methods, data collection, data analysis and interpretation.
The studies were considered low risk of bias if most of the criteria in the quality assessment tool were met; medium risk of bias if some of the criteria were met; and high risk of bias if few or none of the criteria were met Additional file 1.
Due to variation in the study designs of the papers included in this review we developed a data abstraction form to abstract important elements from each paper.
The abstraction form included: the type of study, author s , title, journal or publication, years published and conducted, research objectives, participants characteristics, study design, setting, sampling size and methods, data collection methods, ethical considerations, data analysis techniques, outcomes measured, key findings and study limitations.
We identified three key menstrual health and hygiene categories that were examined in the papers: reproductive health concerns, menstrual hygiene practices and mental health concerns.
After identifying key themes from each paper, factors contributing to menstrual health and hygiene were categorized as per the level of SEM and described in detail. The interactions between levels in SEM were then examined. The SEM was adopted from the Maternal, Newborn, Child Health and Nutrition Guide Module on Social Ecological Model developed by UNICEF [ 15 ].
The interpersonal level includes social networks, social support systems and customs and traditions [ 15 ]. The community level includes built environment, village associations, community leaders, local businesses and transportation [ 15 ].
The organizational level includes organizations and social institutions that affect how or how well services are provided to an individual or group [ 15 ]. A total of papers were identified through database searches.
Thirty duplicates were found and removed. Ninety-nine papers were removed after screening titles and abstracts. Twenty papers were assessed for quality. Although the limitations and biases of all papers were examined, none of the papers were excluded from this study.
A total of twenty papers were included in this literature review Fig. Search strategy with PRISMA flow diagram [ 16 ]. The description of the studies included in this review have been summarized and presented in Table 1.
These characteristics include study design, methods, location, year of publication, and primary outcomes assessed. Twenty studies that met inclusion criteria were identified. Studies were published between and ; most were published in and Provincial Map of Nepal [ 17 ]. Fifteen studies were quantitative; one study was qualitative and three were mixed methods.
Of the twenty studies, nine focused on knowledge, attitude and practices regarding menstruation, seven focused on reproductive health issues associated with menstruation, three on prevalence and experiences with cultural rituals and restrictive practices during menstruation such as Chhaupadi, one on school absenteeism and one on intimate partner violence.
The study characteristics are shown in Table 2. As per the quality assessment, six studies were identified as having low risk of bias, twelve as medium risk of bias and one as high risk of bias.
Potential biases included response rates not reported, potential confounders not taken into consideration, study samples not representative of the broader population, and tests for statistical significance that were not undertaken.
Due to limited studies in menstrual health and hygiene in Nepal, we included all the studies regardless of their risk of bias. The three main menstrual health and hygiene outcomes reported in the papers were reproductive health concerns, menstrual hygiene practices and mental health concerns.
Reproductive health concerns reported included menstrual cycle irregularities, dysmenorrhea and other genitourinary complaints such as burning during micturition, abnormal discharge, genital itching, pain, and foul smelling menstruation [ 8 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ].
Menstrual hygiene practices described by the papers included use of sanitary products such as commercial pads, homemade reusable pads and menstrual cups, bathing and cleaning perineal areas during menstruation, frequency of changing menstrual pads during the day, washing hands after changing pads, washing and drying of reusable menstrual pads and various restrictions faced during menstruation [ 6 , 19 , 23 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ].
Mental health concerns described by the studies encompassed confusion, stress, shame, pain, fear of leakage and teasing [ 18 , 25 , 27 , 33 , 35 ]. On an individual level, factors that impacted menstrual health and hygiene were demographics age, education, residence, economic status, and marital status , knowledge of menstruation, and negative experiences related to menstruation.
Six papers reported on age in association with menarche, dysmenorrhea, irregular menstrual bleeding and sanitary pad use [ 18 , 23 , 24 , 30 , 32 , 34 ]. Liu et al. They also reported that every year increase in age led to decreased odds of using commercial pads compared to reusable towels [ 19 ].
Sharma et al. Amatya et al. Four studies reported on educational factors including types of school, level of education and school absenteeism [ 19 , 20 , 24 , 31 ]. Findings from Sharma et al. Another cause for school absenteeism reported by Rajbhandari et al. Oster et al.
The study reported that Residence impacted several aspects of menstrual health and hygiene [ 8 , 19 ]. Ranabhat et al. The two districts are adjacent and both have migrants from places where Chhaupadi is practiced [ 8 ].
Women with poor economic status had significantly higher reproductive health problems than more economically advantaged women [ 8 ]. In one study, economic status did not have any statistically significant difference among people who practiced menstrual exile and those who did not [ 6 ].
Marital status was reported only by Amatya et al. However, they did not find any statistically significant difference in marital status among people who practiced menstrual exile and those who did not.
Eight papers reported on knowledge of menstruation, including understanding the physiology of menstruation, knowledge of menstrual hygiene practices such as use of sanitary pads, frequency in changing pads, bathing and cleaning genital areas during menstruation, and appropriate disposal of used sanitary pads [ 23 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].
Rajbhandari et al. Overall, the studies that reported knowledge on menstruation reported poor or insufficient knowledge of menstruation and menstrual hygiene among participants [ 23 , 29 , 30 , 31 , 32 , 33 , 34 ].
Parajuli et al. Five papers reported on negative experiences related to menstruation [ 18 , 25 , 27 , 33 , 35 ]. Two studies stated that women and girls perceived menarche as confusing, stressful and inconvenient [ 27 , 35 ]. Similarly, Yadav et al.
Dysmenorrhea and stress were shown to be positively correlated in studies conducted by Pramanik et al. Factors identified on the interpersonal level affecting menstrual health and hygiene included ethnicity, education level of husbands, family members as source information about menstruation, culturally restrictive practices, and intimate partner violence.
Three papers reported on ethnicity and its association with menstrual health and hygiene [ 8 , 24 , 26 ]. The study called for further research on disparities among ethnic groups regarding menstrual regularity [ 24 ].
On the contrary, Ranabhat et al. Similarly, Cardosa et al. Three studies reported that women and girls mostly received information on menstruation from their mothers and friends [ 23 , 30 , 35 ]. The information received included restrictions and impurity associated with menstruation, cramps, how to sit to avoid stains, and how to fold and clean menstrual cloths.
Girls received conflicting information from mothers, teachers and friends regarding menstruation [ 35 ]. In one study, the majority of the girls received information regarding menstruation from their teachers.
Teachers taught girls about menstruation when teaching about sexually transmitted diseases, infections and cervical cancer [ 35 ].
Thirteen studies reported on various culturally restrictive practices faced by women and girls during menstruation [ 6 , 8 , 20 , 21 , 23 , 26 , 27 , 29 , 30 , 32 , 33 , 34 , 35 ].
Restrictions include abstaining from going to the kitchen, prayer rooms and temples, eating certain foods, taking a bath and touching men including their husbands, not attending school and living outside the house in seclusion i.
Culturally restrictive practices were followed due to various superstitions. It was believed that menstruating girls would curse their house with just a look [ 35 ]. Girls also believed that they would fail their exams, fall sick or become infertile if they prayed during their menstruation [ 35 ].
Women and girls believed that refraining from these restrictions would anger the Gods and bring bad luck to their families [ 6 , 33 ]. Reproductive health problems were significantly higher among women who faced food, water and bathing restrictions or stayed in Chhaupadi sheds compared to those who did not [ 8 ].
Of note, Cardosa et al. The study recommended further research to assess menstrual restrictions and their potential association with IPV. In contrast, Amatya et al. Findings on the community level were sparse. Two studies reported on community level factors affecting menstrual health and hygiene.
Budhathoki et al. Organizational factors related to menstrual health and hygiene that were reported included the educational system, WASH facilities in schools, information on menstruation through mass media, the role of NGOs in providing menstruation hygiene management education and training, and access to transportation.
Three studies reported on the need for improved sex education [ 26 , 33 , 34 ]. Women in the Crawford et al. According to Yadav et al. Ninety-eight percent of the girls in the Adhikari et al. The study recommended motivating teachers and health workers to improve their knowledge on menstrual health and hygiene in order to help adolescent girls [ 34 ].
Three studies reported on inadequate WASH facilities in schools [ 31 , 33 , 35 ]. Out of eleven schools observed by Yadav et al. Morrison et al. Only three out of twelve schools had waste disposal facilities [ 35 ]. Two studies reported on mass media as a source of information for women and girls regarding menstrual health and hygiene [ 6 , 27 , 31 , 33 ].
Yadav et al. Crawford et al. Five studies reported that NGOs played a major role in providing menstrual hygiene education and training [ 6 , 28 , 30 , 33 , 35 ].
According to Parajuli et al. In August , the Government of Nepal passed a criminal code criminalizing Chhaupadi. Budathoki et al. Only one study reported on the role of access to transportation in menstrual health and hygiene [ 19 ].
There were no papers that described the impact of a policy change on menstrual health and hygiene. Three papers described policy recommendations based on their findings [ 8 , 26 , 34 ]. Adhikari et al. Integration of menstrual hygiene management efforts with the sustainable development goals SDGs was recommended by Cardosa et al.
The SDGs are global goals set by United Nations Development Programme UNDP that recommend all governments to prioritize ending poverty, protecting the planet, and ensuring peace and prosperity for all. This systematic review examined studies of menstrual health and hygiene practices in Nepal.
Twenty studies met our review criteria. Studies differed in quality and outcomes reported.
November 1, November 15, 3 min Menstrual health rituals By Daily food and activity log Srri. Have you seen Mebstrual of those Msnstrual where a woman is on her Mentsrual and is just Riruals without a care in the world? Who is she? I want to shed some light on some of the period health rituals and celebrations that South Asian cultures have practised for centuries, that we have now forgotten. Well, guess what? Those commercials are actually not wrong. That is how happy menstruation can be.
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