Why Hygienic Management of Menstruation is Essential for Girls
Empowering Girls: Menstruation, Education and Health
Von Linda B Jackson
Menstruation can be a major barrier for girls, affecting school attendance and health outcomes. ACESWorld listens to girls’ experiences and works to empower them with reproductive health information and supplies to manage their periods with dignity. These projects have a far-reaching impact on the health of girls, their wellbeing, and their communities. Approximately 400 girls in Uganda, Ghana and Colombia have participated in Pads4Learning (P4L).
Pads4Learnng participants in Ghana learning to hand-sew pads. Photo by Robert Mbongo.
Forty-nine percent of the population of Uganda is under age the age of 15. School enrollment in the early primary levels slightly favors girls, but girls face many challenges to continuing their education. Girls are expected to work at home, helping with younger siblings and household tasks, and to care for the ill. In rural areas girls experience additional challenges. Girls must walk long distances to school unaccompanied and are at risk along the way. They are offered rides by men and are exposed to sexual assault. Even in the classroom girls experience harassment by male teachers and classmates and must manage their periods without adequate sanitary facilities at school. In addition, poverty is a barrier to education for both boys and girls. Although education is free in Uganda, it does not include the cost of uniforms, shoes, school supplies, etc. Girls are required to shave their heads to attend school, and girls reported that this was also a barrier (Pads4Learning Survey, Kampala, 2018).
Government data is available on school enrollment, but less is available on attendance, especially disaggregated by gender. While girls are enrolled in schools, they often miss days because parents cannot pay school fees. When poor families must decide whether to pay fees for sons or daughters, they favor the son. In families living in extreme poverty, feeding, clothing, and educating girls is costly, and they eventually leave the household. Families can recover this investment through a bride price. In Uganda, 10% of girls are married by age 15 and 40% of girls are married before age 18 (Girls Not Brides).
Child brides tend to be from families with little or no education and living in extreme poverty. Marriage is often viewed to provide for the girl. Some families marry off their daughters to protect them from early sexual encounters. Other girls marry to gain access to sanitary products to manage periods. Whatever the drivers of child marriage in Uganda and other countries, there is a direct relationship between child marriage, health and education. Girls who marry generally do not continue their education, and girls who can continue school are able to delay marriage. The longer a girl stays in school, the less likely she is to be married and have children during her teenage years. In many communities around the globe, menstruation is a barrier to education. A lack of sanitary supplies, misinformation, and cultural stigma are factors negatively impacting girls and keeping them out of school.
Girls Education and Health Outcomes
A UNESCO (2014) report estimates that one in ten girls in Sub-Saharan Africa miss school during their menstrual cycle. By some estimates, this equals as much as twenty percent of a given school year (Lusk-Stover et al 2016). Girls’ school attendance is inextricably linked to better health outcomes, such as reduced child marriage and early pregnancy. A 15 years old is twice as likely to die during childbirth compared to those aged 20 years and above (UNFPA 2019). Maternal schooling plays a key role in determining children’s chances of survival in low- and middle-income countries. In Uganda, the odds of dying for children of women with one additional year of education are 16.6 % lower (Andriano & Monden 2019).
Pads4Learning participant with Afripads in Uganda. Photo by Ithungu Peregia.
Accessing Reproductive Health Information
Girls often suffer in silence and are uncomfortable talking to the adults about their lives. Most girls do not understand the menstrual cycle, ovulation, female anatomy nor the risks associated with sexual intercourse, especially with older, more promiscuous men. Girls have reported being ridiculed by teachers when they are menstruating and not being allowed to leave class to change. ACESWorld P4L provides access to adequate information, preparation, and support for girls to manage menstruation to continue their education with dignity in Uganda, Ghana and Colombia.
The P4L program begins with a baseline survey. The baseline P4L survey categories include:
- Age, menarche onset, knowledge of reproductive health information
- School attendance and menstruation
- Materials used to manage menstruation
- Impact of menstruation on daily life
- Family attitudes toward menstruation
P4L reproductive health education is based on the ABC’s of Being a Girl curriculum, a resource from UNICEF (2015) presenting simple and accessible lessons on menstrual hygiene. Each girl receives a period calendar and there is an open forum for questions related to reproductive health. P4L does not specifically address contraception, but staff answers any questions the girls or teachers pose. Girls learn to sew or receive reusable sanitary pads. Lessons also include the importance of not sharing the pads, drying the pads between uses in the sun and changing the pads frequently. When adequate facilities are not available in school to change pads, girls are given strategies to manage. Girls who have access to effective resources to manage periods can participate fully in daily life and continue their education, to better avoid child marriage and early pregnancy.
100 girls between ages 13 and 16 participated in P4L in the Rwenzori region of Uganda. The baseline survey was administered to the 100 girls who received manufactured reusable pads. An evaluation survey was conducted 6 months later to evaluate the project. The girls indicated they benefited from all aspects of the project goals. The direct benefits of the projects assessed included the extent to which the training influenced girls’ decision making with respect to reproductive health and the multiplier effect on knowledge in their communities.
Pads4Learning Evaluation Survey, Rwenzori region of Uganda, September 2019 N=100
Reproductive Health Education - How Girls Empower Others
Beyond our target group and the direct impact experienced by the 100 girls, reproductive health education was spread within the larger community. Based on an evaluation survey question asking how many family members, friends, and/or classmates students shared the information learned fromP4L, this impact was assessed and identified as having a multiplier effect. Information is disseminated by teenagers, who become the agents of change rather than ACESWorld personnel, and knowledge spreads as education is provided to the larger community and continued after the project ends.
Students in P4L reproductive health class in Colombia. Photo by Adrian Palomino
Girls’ ability to make decisions regarding their reproductive health has important implications for their health and well-being. Assessing the extent to which reproductive health education influences decision making, a positive impact was reported with each participant experiencing at least some level of influence.
Pads4Learning Evaluation Survey, Rwenzori region of Uganda, September 2019 N=100
The Need for More Support for Menstrual Hygiene
In the baseline survey, 56% of girls attending a rural Ugandan school reported lack of access to adequate menstrual hygiene products. The girls reported wanting to buy disposable sanitary products but being unable to do so. When girls don’t have access to hygienic sanitary supplies, they may manage their periods with available materials such as cotton, mattresses and leaves, which can lead to respiratory and urinary tract infections and negatively affect reproductive health (Baisley et al 2009).
Pads4Learning Baseline Survey, Kampala, Uganda, July 2018 N=100
New research from the School of Oriental and African Studies, University of London, shows that sanitary care and reproductive health education improved girls' attendance at school by 17% in rural Uganda. In Uganda, only 22% of girls are enrolled in secondary schools compared with 91% in primary schools, while those living in rural areas are the least likely group to go to school (Tofaris 2018). Researchers believe that the cost of hygiene products and the difficulties in managing periods play a key role in keeping girls out of school. Up to 40% P4L participants report missing school days the last time they had their period.
The Benefit of Menstrual Health Management Trainings
P4L addresses community needs by providing knowledge and tangible resources. Schools welcome the opportunity to provide sanitary pads. Since P4L gives girls pads, schools generally accept the reproductive health education. We focus the training on anatomy, menstruation and menstrual hygiene and management but answer any reproductive health questions. P4L supplies girls with reusable manufactured pads that last about one year, and teaches them to hand-sew pads. The knowledge from these sewing classes leads to more sustainable outcomes, as sewn pads can be replaced when they are no longer effective. Girls share the knowledge of making pads with other women and peers in their community, and even poor families can cover the relatively low cost of purchasing materials.
ACESWorld’s Pads4Learning projects help girls’ health directly through promoting hygienic practices and reproductive health education and indirectly through supporting school attendance,helping to delay marriage and providing knowledge of reproductive health. Pads4Learning continues to listen to girls to better understand their challenges, to improve health outcomes for the girls and their future children and to prevent child marriage.
Students in Ghana celebrating the completion of P4L with their cloth pads. Photo by Adrian Palomino.
- Andriano, Liliana, and Christiaan Monden. “The Causal Effect of Maternal Education on Child Mortality: From a Quasi-Experiment in Malawi and Uganda.” Demography Christiaan W. S. Monden, vol. 56, no. 5, Oct. 2019, pp. 1765–1790. https://link.springer.com/article/10.1007/s13524-019-00812-3
- Baisley, K, et al. “Bacterial Vaginosis in Female Facility Workers in North-Western Tanzania: Prevalence and Risk Factors.” Sex Transm Infect, vol. 85, no. 5, Sept. 2009, pp. 370–375. https://www.ncbi.nlm.nih.gov/pubmed/19473997
- Cleland, J G, and J K Van Ginneken. “Maternal Education and Child Survival in Developing Countries: the Search for Pathways of Influence.” Social Science & Medicine, vol. 27, no. 12, 1988, pp. 1357–1368. https://psycnet.apa.org/record/1989-25980-001
- Lusk-Stover, Oni, et al. “Globally, Periods Are Causing Girls to Be Absent from School.” Education for Global Development, The World Bank, 27 June 2016, https://blogs.worldbank.org/education/globally-periods-are-causing-girls-be-absent-school.
- Tofaris, Elizabeth. “Can Better Sanitary Care Help Keep Girls in School?” Global Partnership for Education, The World Bank, 18 Apr. 2018, https://www.globalpartnership.org/blog/can-better-sanitary-care-help-keep-african-girls-school.
- United Nations Children's Fund (UNICEF). ABCs of Being a Girl, 2015, https://www.unicef.org/wash/schools/files/UNICEF-MenstrualHygiene-PRINT-27May15.pdf.
- United Nations Educational, Scientific and Cultural Organization (UNESCO). Puberty Education & Menstrual Hygiene Management, 2014, https://unesdoc.unesco.org/ark:/48223/pf0000226792.
- United Nations Population Fund (UNFPA), “Adolescent Pregnancy.” UNFPA ESARO, 17 Nov. 2019, https://esaro.unfpa.org/en/topics/adolescent-pregnancy.
- World Health Organization, “Adolescent Pregnancy Fact Sheet.” 23 Feb. 2018, https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy.
To Learn more about Pads4Learning visit www.ACESWorld.org.
Linda B Jackson is a native Washingtonian and an explorer. That exploration has taken her to many countries, but her work has been in Colombia, Haiti, Uganda, and Ghana helping teachers improve the quality of education for children living in extreme poverty and helping adolescents navigate reproductive health. As CEO of the Association of Community Empowerment Solutions, she manages ACESWorld programs and develops strategic partnerships with like-minded people and organizations to promote Sustainable Development Goals. She has conducted teacher and staff development workshops in the US, Haiti and in Uganda and continues to liaise and consult with several US-based and international organizations. Email