Menstruation, a unique event in the life of developing females, is one of the milestones of puberty. It involves the cyclical shedding of the inner lining of the uterus which is controlled by the hormones produced by the hypothalamus and pituitary glands located in the brain(1).
Menstrual hygiene refers to personal hygiene practices during menstruation. This personal hygiene management starts with the choice of best sanitary materials, its proper utilization, disposal and body cleanliness(2). Menstruation is still regarded as something unclean or dirty in society. Seclusion of the menstruating girls/women and restrictions being imposed on them in the family not to participate in a different activity while on menses have reinforced a negative attitude towards this phenomenon(3).
Worldwide, nearly 52% of the female population (26% of the total population) is of reproductive age. The majority of these women and girls will menstruate each month for between two and seven days. Despite the challenges related to menstrual hygiene management, menstrual hygiene has been routinely ignored by professionals in the water sector, and in the health and education sectors too(4).
In Ethiopia, like in many parts of the African Countries, menstrual hygiene management is one of the critical problems adolescent girls facing while they are in school. This is mainly due to lack of infrastructure as well as poor management of the existing facilities which are important for the management of menstrual hygiene. Menstrual hygiene practices are clouded by taboos and socio-cultural restrictions even today, resulting from ignorance of the scientific facts and hygienic health practices, necessary for maintaining positive reproductive health(5).
Though menstruation is a naturally occurring event, it is associated with misconceptions, poor practices, and challenges among girls in developing countries. However, much is not documented; class-absenteeism and poor menstrual hygiene practices are common problems among adolescent girls.
In Ethiopia, 11% of girls change their menstrual cloths once a day. Girls commonly use rags torn from old clothes and use their dress tied in a knot to keep the sanitary cloths in place. Most girls rinse their rags in water without using soap; dry them under the bed; hang them in hidden, often unhealthy places in the house or on the roof, where they can grow mold. Such practices may increase susceptibility to infection(2).
Poor menstrual hygiene and inadequate self-care are major determinants of morbidity and other complications among the younger age group. Some of these problems include reproductive tract infections, urinary tract infections, scabies in the vaginal area, abdominal pain, absence from school, and complications during pregnancy(6).
In spite of these issues, menstrual hygiene has been largely neglected by the sector and other sectors focusing on sexual and reproductive health, and education. Even though the specific infections, the strength of the effect, and the route of transmission, remain unclear, it is plausible that poor MHM can affect the reproductive tract. Studies revealed that women who frequently use the reusable type of pad, and less frequently wash their genital during menses were at risk for lower reproductive tract infection, especially for bacterial vaginosis. Also, Baislye et. al reported that using cloths or cotton wool for menstrual hygiene is also a single most predictive for bacterial vaginosis infection(6)(7).
In a study conducted in Uganda among school girls, Julia et.al reported that about 90% of the schoolgirls didn’t meet the minimal criteria for safe MHM, which indicates the issue needs urgent responses from the concerned body. On the other way, the rate of genital irritation, discharge, and concern of malodor is higher among poor MHM girls. In addition to resulting in missing school, poor MHM also leads to a feeling of shame, worrying that odor may disturb the class and low self-esteem, which may results in psychological problems like depression during menses(8).
In the absence of parental and school support, girls cope, sometimes alone, with menses in practical and sometimes hazardous ways. Due to economic constraints or because of the females thought that it is taboo to ask parents for money to buy sanitary pads, they turn to transactional sex to get money for buying sanitary pads(9).
Menstruation is a silent issue in girl’s life which is further affected by the teacher’s perception and school resources. Because of this, many girls remain absent from schools during menstruation and sex education is also often neglected from the school curriculum which negatively impacts the student’s life. Educational policy analysis in lower and middle-income countries indicated that out of the 20 countries’ educational policy included in the study, the MHM didn’t get focus and even not mentioned in the all educational policy and in many of the countries’ school curriculum(10). In most of the schools, both male and female teachers are not ready to discuss menstruation and menstrual hygiene management with students. Many of the schools are male dominant and female teachers are not available. Teachers often skip such topics in books as they do not want any open discussion in the class or to escape from the questions asked by students. Also many were reported being absent from school due to lack of disposal system, broken lock/doors of toilets, lack of water tap, bucket, and poor water supply (11)(12).
The type of absorbents used during menses depends on the awareness of the existing materials, economic status, cultural acceptability, availability in the local market and personal preferences. Ideally recommended sanitary material for safe MHM is commercially available sanitary pads. However, though female reports they were using pads just not to be stigmatized, the most commonly mentioned alternatives were old clothes (rags), blanket or pieces of (bedding) mattress. Panties, socks, towel, cotton wool or tissue paper were also sometimes reported as absorbents for menses blood. When girls’ menses start unexpectedly, grass or leaves plucked from the ground around the schoolyard was reported to be the only option that schoolgirls have once they faced menses at school(9).
Proper disposal of used menstrual material is still a challenge for many countries of the world. Because of this, most of the women dispose of their sanitary pads or other menstrual articles into household solid wastes or garbage bins that ultimately become a part of solid waste. In countryside areas, most women use reusable and non-commercial sanitary materials like reusable pads or cloths. Thus, they generate a lesser amount of menstrual waste as compared to women in urban areas who rely on commercial disposable pads(13). While they are in the schools, due to the lack of hygienic facilities like dust bins, girls throw their pads in the toilets. In some cases, girls threw away their used menstrual clothes without washing them. As sanitation systems were designed with urine and feces in mind, they are unable to cope with the menstrual absorption materials and will block the sewerage and causes blockage or backflow(12).
In general, different studies were conducted on the issue related to menstruation and menstrual hygiene management among school females in Ethiopia. However, the way they measured the hygienic practice of menstrual hygiene varies. Many of the studies use practice assessing questions and based on the number of items they grouped MHM as good or bad or as poor or good. We believe that such classification is not objective, not comprehensive and it doesn’t meet with the actual/standard definition of menstrual hygiene management. Because of this, it is even difficult to compare or to conclude the extent of poor menstrual hygiene management with the currently existing works of literature in the country.
So, this study assessed practices of menstrual hygiene management and associated factors among high school Females in Ambo Town West Showa Zone, Ethiopia, using the four major areas of the MHM which is in line with the internationally recognized definition of MHM with the following specific objectives.
- What extents of high school females were practicing unsafe MHM?
- What are the underlying determinants of MHM practices among high school Females?