Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal

Menstruation is a naturally occurring physiological phenomenon in adolescent girls and pre-menopausal women [1]. Menstrual Hygiene Management (MHM) is defined as ‘Women and adolescent girls 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’. Menstruation necessitates the availability of material resources to absorb or collect menstrual blood, facilitate personal hygiene and dispose of waste, ideally with adequate privacy [2]. Women and girls in low income settings have low awareness on hygienic practices and lack culturally appropriate materials for menstrual hygiene management (MHM) practices [3–5]. Menstruation and associated activities are surrounded by silence, shame and social taboos that are further manifested in social practices that restrict mobility, freedom and access to normal activities in India and Nepal. For instance, drinking milk, preparing food, interacting with people or refraining from performing religious rituals are restrictions found in many cultures [5–9].

The materials used as adsorbents during menstruation in low income countries including Nepal, vary from reusable towels (cloth torn from dresses of women and cotton fabric) to commercially available disposable sanitary pads [6, 10–15]. Practical, sustainable and culturally acceptable methods are recommended for addressing the menstrual hygiene needs of women in low income countries [4, 16]. Types of adsorbents used, hygienic practices and cultural restrictions during menstruation are associated with negative clinical and psychosocial outcomes including reproductive and urinary tract infections, anemia, school absenteeism, and social isolation [1, 6, 15, 17, 18].

Young adolescent girls tend to be less prepared for MHM and suffer from anxiety, apprehensions, fear and shame during their menses [12, 19]. In addition, pre-existing social taboos and cultural restraints during menstruation mean that managing menstruation is a greater challenge during disasters [20–22]. Further, there is limited access to reproductive health services and safe menstrual hygiene materials during disasters [23]. Menstrual hygiene needs are not only specific and pressing to women and girls in reproductive age but also require access to same management of the menstrual period, a basic reproductive health right. In emergencies, the usual lifestyles of affected individuals change and they are confronted with additional stress that could worsen their physical and psychological well-being. Provision of fundamental human requirements such as shelter, food, clean water and medicines is prioritised, however other needs such as safe menstrual hygiene management that can have profound psychosocial impact if unmet are often neglected [22, 24].

On 25^thApril 2015, Nepal was affected by a 7.8 Richter scale magnitude earthquake killing almost 9000 people and displaced 3.5 million people [25]. Compared to men, more women survived [26] and although emergency relief and rescue operations swiftly began addressing essential humanitarian needs, there seemed to be a lack of attention to menstrual hygiene needs of adolescent girls and women [13, 27]. Although increasingly considered, menstrual hygiene continues to be overlooked during disasters, even in community level responses [22, 28, 29]. Nepal is frequently affected by disasters, both natural as well as manmade leading to displacement of the population into temporary shelters [25, 30].

Menstrual hygiene is a need of menstruating women & girls. Although, there are some studies on menstrual hygiene management in Nepal, there is limited evidence on menstrual hygiene management especially in the aftermath of the earthquake in Nepal [12, 13, 21, 31]. Therefore, we conducted this study to explore the perceptions and the lived experience of women and young girls regarding menstrual hygiene management in the aftermath of the earthquake in Nepal.

This mixed methods study highlights the experiences of women and young girls related to menstrual hygiene management in the aftermath of the recent earthquake in Nepal. Although menstrual hygiene management needs are only specific to a subgroup of the population, they appear as an immediate pressing requisite for the women affected and as such, they should be seen as another core need even in post-disaster scenarios. The quantitate findings reveal that MHM as a priority that was not immediately addressed, however women and girls also list MHM material as less pressing compared to other general needs in immediate post-earthquake situation. The qualitative data presents evidence that for the menstruating women, it indeed was a challenge in timely accessing the material as well as availability of private space for the MHM activities. Our study reiterates the importance of MHM activities for women and adolescent girls and highlights the necessity to design culturally appropriate and sustainable interventions embedded within well-planned interventions in disaster relief efforts to support women and young girls.

Our findings indicate that whilst MHM activities are felt as important priorities for women and girls, they are often overlooked during disasters. Ensuring access to an essential amount of water available for personal use, provision of ready-made hygienic kits containing essential medicines, first aid and sanitary pads, and ensuring women’s safety and dignity in using toilets and wash areas are fundamental rights of every woman during disasters and must therefore be safeguarded.

While further participatory research methods could enrich the existing evidence-base, particularly around personal preferences and socio-cultural aspects of menstrual hygiene management, our use of in-depth interviews illuminated the findings from the quantitative data and facilitated its understanding.

In this study, most respondents did not receive any menstrual hygiene adsorbents in the relief materials during the first month post-earthquake. Hence, women had to improvise by making reusable sanitary towels from sarees or cloths, or obtain through their own networks of friends and relatives. While this seems to be the only option during emergencies, these adsorbents might not be hygienic and could potentially lead to infections [3, 18]. Only half of the respondents in this study received soaps as relief material in the first month following earthquake. Availability of a safe, private space for changing was not available for more than half of the respondents. Safe disposal of sanitary pads was also a concerning issue, echoing the findings reported among displaced girls and women in Myanmar and Lebanon, where some women disposed of used pads together with household waste in dark colored plastic bags [35]. Women and girls in India also report disposal of used sanitary pads in inappropriate places [16].

Our finding on the use of reusable sanitary towels is in concordance with practices reported by others in rural areas of Nepal [12]. In immediate post-disaster situations, most women and girls who menstruate during such events may perceive MHM activities as an immediate, peremptory need. Our findings corroborate with news reports from Nepal [27, 36] and from literature which indicate that menstrual hygiene management is often not prioritized in relief works [22]. Such low attention could also point to societal taboos and inadequate sensitivity on MHM within the wider society [9, 19, 37]. Research from elsewhere also supports that menstrual hygiene being exclusively a feminine need is lesser priority in humanitarian responses whereas, the food and security needs expressed by participants are the fundamental immediate needs for everyone [24]. The underlying reasons for the lack of adsorbents within standard relief materials supplied to earthquake victims and survivors on the first month would require further research among the humanitarian workers, logisticians and agencies.

Immediate measures during disasters are considered possible using locally available cloth as adsorbents [13]. The efforts need to emphasize the need for private spaces for women focusing on menstrual hygiene management apart from the toilets. Availability of a toilet still leaves an unmet need for addressing the women’s need for menstruation related privacy [38]. Safe disposal of sanitary pads is also essential [39]. The menstruating girl not being able to discuss the need for materials to manage her periods expressed in this study is an example of how silent the women and girls are about menstruation and related matters. The inability of women to freely talk about menstruation within their communities suggests that there are still taboos associated with menstruation [40]. In the south Asian context especially in India and Nepal, menstruation comes with many social restrictions including for religious rituals [9, 12, 38].

Lessons from Myanmar and Lebanon suggests that, women and girls’ choice of adsorbents in emergency settings depend on the availability of the materials, privacy for changing the pads and availability of private space for washing and drying the reusable towels or disposing of pads [35]. Most respondents in our study referred using reusable instead of disposable sanitary pads, as these were unavailable despite being more convenient, a predicament also reported by authors in other settings [35]. Reusable sanitary towels seem to be more easily available, and are perhaps a sustainable and culturally suitable alternative in the Nepalese context.

The current study has certain limitations. It was conducted in one earthquake-affected district of Nepal and may not therefore be generalizable to all other areas of Nepal. As our study setting was predominantly rural, our findings may be particularly unsuitable to urban areas of the country. Further, we specifically asked questions related to the first menstrual period management after the earthquake, and as the study was conducted 3 months after the earthquake potential recall bias cannot be overlooked.

The study brings evidence that MHM activities are lesser prioritized in immediate relief works. As menstruation comes along with cultural and religious taboo, the MHM needs is present as a silent need, which is addressed by the use of local materials and resources in immediate post-disaster situations. The choice of materials for adsorbents is made based on the availability of materials and the privacy for MHM activities While disposable pads are considered more convenient and hygienic, the use of culturally appropriate, local materials and gender sensitive methods of reusable sanitary towels could be considered by relief workers as sustainable and environmental friendly method.