Out of the 25 papers included in this study, 20 papers (80%) were from South Asia (India, Bangladesh, Nepal) and Africa (Ethiopia, South Africa, Kenya, Malawi, Ghana, Honduras, Mali, Mozambique, Niger, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe). Only 4 (16%) studies are from other regions: Taiwan, Korea, Argentina and Australia. In terms of developed and developing countries: 21 (84%) studies are from developing countries while only 3 studies (12%) are from developed countries. 1 study did not mention any geographic location.
3.1 Studies focused on awareness about menstruation and menstrual health.
The studies dealing with awareness around the menstrual process and health and hygiene aspects focus on understanding the MHM needs in rural schools [17]. Studies have considered many factors leading to MHM disparities among girls in rural and urban areas. E.g., a study conducted in Ethiopia [12] explored the disparities between rural and urban areas and investigated variables like age, religion, ethnicity, education of parents, occupation of parents, knowledge of menstrual hygiene, source of information about menstrual hygiene, school environment-related issues, knowledge about menstrual hygiene, good MHM practice, functional toilet compartment in school, discussing menstrual hygiene with parents. It found that there is variability, and the performance in the urban areas was better. Two significant reasons are: accessibility of sanitary materials, which is available more in urban areas, and sexual and reproductive discussion with parents is high in urban areas. Also, the study highlighted that the girls in urban areas have access to media, which helps them gather more information on MHM practices than rural girls.
Afiaz and Biswas (2021) reported that the factors influencing modern methods of managing MHM depend on the status of women’s education and their access to media [13]. Accordingly, women with better access to media and higher education status were more likely to have better MHM practices. Future intervention-based studies using the media platforms should focus on providing access and knowledge regarding MHM to improve MHM practices. Studies should have more target-oriented research and generate specific data to evaluate the respondents’ level of awareness while understanding the direct impact of media and mobile phone use [13]. There is a lack of awareness on keeping track of the menstrual cycle; therefore, there is a need for in-depth education about the basic biology behind menstruation [18].
Roxburgh et al. (2020) reported on the medicinal aspect of menstrual blood. The study revealed that menstrual blood is viewed as a powerful substance used in traditional medicine. The study found that several women preserved their menstrual clothes to be used when required in case of illness or injury of a family member, even after the cloth was worn out and no longer used. A study reported that a woman even obtained permission from her husband before discarding her used menstrual cloths, which were considered valuable. Women took great care to keep their menstrual clothes secure and hidden at home, so they were not vulnerable to ufiti (witchcraft) [19]. Burning and discarding the used pads in pit latrines were considered the safest options. Due to the secrecy around menstruation, many women preferred disposing of pads and burning used cloth. Further research is recommended to improve the availability and manufacturing standards of high-quality reusable sanitary pads [14].
Women face logistical challenges in storing and transporting menstrual products as secrecy around purchasing sanitary items, overcrowded housing, living across multiple residences, high financial costs, lack of privacy for safe keeping of personal items, sufficient female-friendly infrastructure (e.g., working toilets, accessible disposal facilities, privacy) [5]. The MHH content and material should be dealt with the sensitivity and should be made available to all genders. Additionally, vending machines that provide free MHH products may improve access for girls while in school. Still, more evidence is needed to inform knowledge of the effectiveness and implementation of the strategy before scaling up [5]. It is assumed that young girls learn about their menstruation from their mothers. Still, studies show a need for in-depth education about the basic biology behind menstruation [18].
A multi – African country study was conducted in Ethiopia, Uganda, South Sudan, Tanzania, and Zimbabwe to understand the existing MHM practices and ascertain the feasibility of introducing sustainable menstrual practices like cups and reusable pads[20]. In all five countries, it was found that menstrual exclusion practices are still in practice, and menstruation is considered a taboo; thus, there is silence around the topic. Menstruating women are considered impure and unclean, which affects their access to MHH.
The study also indicated that
“the materials used during menstruation range from nothing to disposable pads, cloths/rags, commercial sanitary pads (disposable and reusable), toilet paper, magazines, cotton, pieces of mattress, natural materials (leaves, tree bark), digging a hole, goat skin, cow dung, ash, and sand are the main materials used in managing menstruation in the five countries” [20].McMahon et al., 2011 studied the Kenyan Schoolgirls’ perceptions and practices related to menstruation. The study was conducted in six rural schools. Data from 48 primary school students and nine teachers was collected through focused group discussions, in-depth interviews, and field notes. The respondent girls expressed fear, distractions, and shame around the topic of menstruation. The study recommends encouraging sustainable menstrual practices after considering practical and culturally acceptable practices.
3.2 Studies on the feasibility and acceptability of the menstrual products
Studies focussing on the feasibility and acceptability of reusable and sustainable menstrual products highlighted key points such as a need to consider upscaling such products. For e.g., In India, a study [21] on Banana fiber pads, a market-ready product, has less leakage compared to disposable pads, are largely biodegradable and, CO2 emission is less than 0.01 kg (compare to one disposable sanitary pad is 0.041 kg), abundantly available, have suitable mechanical properties and ease of production and manufacturing. Banana fiber pads need prior soaking before washing. The paper pointed out that during COVID restrictions, the re-usability features of menstrual products have catered to the needs of women and helped in reducing menstrual poverty.
Studies have shown that women attach importance to comfort, volume, and duration of blood absorption in the selection of menstrual products [22].
“Among women’s attitudes regarding eco-friendly menstrual products, menstrual cloth pads and menstrual cups are the main trends, followed by menstrual underpants, while menstrual pads and tampons account for the market majority of menstrual products. While tampons are superior to menstrual pads in all aspects, women prefer the latter, as the former are invasive, and people are afraid of pain and have a misunderstanding of a “damaged hymen”” [22]
A study on the acceptability of the menstrual cup among students in higher education institutions reported problems and experiences on ease of insertion and removal on first use and advised future studies to compare the use of menstrual cup with other alternative products and study the changes over time [23]. The amount spent on purchasing menstrual products should be collected and measured in the menstrual health management programmes that offer various products.
Girls and women were happy with the introduction of menstrual product interventions (both disposable and reusable), especially in schools and considered reusable pads and menstrual cups a better option in terms of affordability and disposal [24]. Reusable pads and menstrual cups were a one-time investment, as the products can be reused multiple times depending on the type of material and can be used for several years. Future studies need to explore the barriers that prevent women from using sustainable menstrual products [24]
Studies reported that patriarchal society and socio-cultural taboos reinforce menstruating women to restrict their choices of accepting Sustainable Menstrual Products (SMPs). Even though women were pro-environment, they were forced to continue with discomfort and constrained choices and resist change. The study provides powerful evidence for attitude-behaviour inconsistency in consumption decisions toward sustainable products [25].
Several studies have been conducted in African countries focusing on sustainable menstrual practice [20]. In western rural Kenya [26], a study was conducted to find out adolescent schoolgirls’ experience with the acceptability of menstrual cups and reusable pads. Initially, the uptake of the cup was slow, but once the girls switched to the cup, they preferred it compared to other menstrual products. Once they were comfortable with cups and pads, they were free from embarrassing leakages and odours. The girl’s school absenteeism reduced as they switched to cups and pads.
3.3 Studies exploring innovations around menstrual products
‘The pad project’ is a global initiative to unite women to educate them about the menstrual cycle and hygiene. This project was initiated by a nurse from the USA (United States of America) who resides in India. Through this initiative, sustainable menstrual hygiene kits are provided to women when they come to attend menstrual education talks. Every kit contains six washable, reusable pads, underwear, two panty liners, a washcloth, two safety pins, a soap, and laundry detergent [27]. Jatan Sansthan, an NGO from Rajasthan, claims to have pioneered stitched cloth pads named ‘Uger pads’ in India [28].
A study in Argentina [29] highlights how technologies and users co-construct each other in menstrual activism, working for the empowerment, de-stigmatisation, and sustainability. The study recommends involving women’s agencies in this cause. The study found that shifting to environmentally friendly menstrual products is a gradual process, and concern for the environment is the main reason for the shift. The respondents sought information about sustainable menstrual products from websites.
3.4 Studies focussing on menstrual waste disposal and management issues
A primary survey study conducted in Vanuatu found that during menstruation, it is the responsibility of the menstruators to collect their water, wash their reusable menstrual cloth, and use a separate latrine and bathing shelter [30].
A study on the disposal of menstrual waste found that the girls from rural schools do not use menstrual clothes during school hours as there is no room for changing and washing. And those who used menstrual clothes did not reuse them. They either buried or disposed of used clothes and pads. The study reported that girls missed school during menstruation, and others did not change sanitary pads during school hours due to a lack of supportive facilities. Menstrual waste was not managed efficiently due to inadequate toilet disposal facilities. Girls from urban and rural schools refrained from using school toilets, especially during menstruation, as they had to wait in a queue and lacked privacy and facilities to change or dispose of the used products. The most recommended facilities by girls in the study were: separate toilet and washroom, provision of toilet paper, sanitary pad and disposal bin in the toilet, and stored water and soap for handwashing. Students perceived puberty and menstruation as a matter of shame and should not be discussed with the opposite sex to avoid teasing. The school curriculum lacks sufficient information about puberty and menstruation; therefore, they fail to develop a clear understanding of MHM and the irresponsible attitude of teachers towards puberty and menstruation-related classes by advising students to read about these topics at home on their own [31].
In Asian countries, especially in India, there have been several menstrual activisms towards sustainable menstruation in recent times, and likewise, academic research studies have also been carried out [32] [27] [33] [28]. Imperfect Information in Menstrual Health and the Role of Informed Choice study by Tanya Mahajan, 2019, compare menstrual cups, reusable pads and disposable pads and understands how media influences our choices on menstrual products. Her study suggests that informed product choice can become a tool for enhancing women’s agency further and can improve menstrual health [32].
Nepal experienced an earthquake in 2015, post-earthquake, there was an intervention to help women and girls to switch to reusable pads. This initiative helped meet the women’s immediate needs, and Nepalese women and girls welcomed reusable pads. The study recommends the promotion of reusable pads at the national level by the government is required [33].