Better Understanding Menstruation Helps Girls and Women
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A community educator shows adolescent girls in India how to make their own reusable, hygienic menstrual pads using inexpensive and readily available materials. Photo: Lakshimi Murthy/Vikalpdesign
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Menstruation is a natural event throughout much of a woman's life. Yet menstruation is often a taboo topic and seldom openly discussed. Thus many women lack sufficient or accurate knowledge about it. They often have misunderstandings and mistaken beliefs passed on by family and community (3, 23, 91, 154).
Many women do not understand the purpose of menstruation, what happens in their bodies during menstruation, or—most important for avoiding or achieving pregnancy—when they are likely to be fertile during the menstrual cycle. Fertilization of a woman's egg by sperm normally takes place in the fallopian tubes, which lead from the ovaries to the womb. A woman can become pregnant only while the egg is in the tube and there are sperm there to meet it. Ovulation (release of an egg into a fallopian tube by an ovary) usually occurs about midway between two menstrual periods. Because sperm can live in the cervical mucus for several days, sexual intercourse does not have to take place very close to the time of ovulation to result in pregnancy. A woman's fertile phase begins five days before ovulation. It ends 24 hours after ovulation (67).
Across 47 countries, most in sub-Saharan Africa, only 22% of women ages 15 to 49 know that a woman is fertile generally about midway between two menstrual periods. This statistic is an unweighted average1 derived from findings compiled by the Demographic and Health Surveys (DHS) (see Web Table 1). In only one of these countries, Jordan, do more than half of surveyed women know when the fertile time usually occurs. Most commonly, women say that they do not know when the fertile time occurs.
DHS data on men ages 15 to 49, available for seven sub-Saharan African countries, Haiti, and Bolivia, show that, on average, 18% know that a woman is fertile generally in the middle of the cycle. About 26% say that they do not know.
Smaller, in-depth studies find that adolescents' knowledge of fertility, of menstruation, and of hygienic practices during menstruation is poor in many countries (81, 104). For example, in Dakar, Senegal, two-thirds of adolescent girls and boys ages 15 to 19 could not identify the midpoint in the menstrual cycle as the time when a woman is most likely to get pregnant (78). In Ile-Ife, Nigeria, some 40% of school girls surveyed did not know the meaning or cause of menstruation (1). Among school girls ages 12 to 17 in Tamil Nadu, India, more than half of girls who used an old cloth, napkin, or only their undergarments as a menstrual product washed them only once or twice a day, rather than four or five times a day, as is best. Rather than learning about hygiene, much of what these girls had learned concerned restrictions to their mobility and behavior during menstruation and superstitions about their being "polluting" to others who touch them or their used menstrual cloths (96).
Programs Teach Girls About Menstruation
Education about menstruation needs to start at an early age, before girls reach puberty. When taught beforehand, girls are better prepared emotionally for the experience of menstruation and have fewer negative reactions (136, 159). They also are better able to care for themselves during menstruation. Especially important is learning about hygienic practices since a common taboo is for women to either avoid washing themselves or their genital area during menstruation (96, 154). In fact, washing the genital area daily is important for maintaining hygiene during menstruation, as is changing menstrual pads or cloths at least four to five times a day, and washing used menstrual cloths as soon as possible and drying them completely. These practices can help avoid problems such as burning during urination and genital itching.
Programs that involve women, their partners, and communities are equally important. Teaching the facts about menstruation—what it means and what it does not mean—and about hygienic menstrual practices enables parents to better inform their daughters. Also, boys often have questions about menstruation. Improving their knowledge of menstruation and of puberty is just as important as improving that of girls. Since puberty affects both girls and boys but in different ways, they should each understand what the other is going through and that the changes are not shameful or harmful. Understanding the physiology of menstruation can help dispel misconceptions about it, help change taboos against talking about bleeding, and in some cases even help ease restrictions on women's lives around the time of menstruation.
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The Champa Kit, Stories of Yoni, and Know Yourself communication materials provide creative and interactive approaches to educate girls about puberty and menstruation.© 2004, Thoughtshop Foundation; Johns Hopkins' CCP.
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Stories, visual aids offer creative approaches. Storybooks with fictional characters and situations help girls connect to the characters' experiences and understand emotions and behavior. Posters and providers' communication aids are a good way to visually explain the menstrual cycle and ovulation. Many programs worldwide employ these approaches. For instance, an edition from a popular comic book series in Bolivia called The stories of Yoni, "A new awakening: The story of a young girl discovering the changes in her body" (Las historias de Yoni, "Un nuevo despertar: La historia de una muchacha que descubre los cambios de su cuerpo") features a 12-year-old girl, Carina, going through puberty. One morning Carina wakes up and finds blood on her sheets. She is afraid to tell her mother, but she does tell a teacher. The teacher explains to Carina about her body and menstruation (114).
Similarly, in Bangladesh a set of communication materials for girls called Nijeke Jano, or Know Yourself, features a comic book issue in which two young cousins, Shanu and Nasima, deal with menstruation and puberty. With information and help from their family and friends, Shanu and Nasima overcome their concerns and fears. The comic book also debunks common misperceptions, such as one that restricts a girl's diet during her monthly bleeding (14). In addition to using comic books, the Bangladesh communication program engaged adolescents and their families with interactive videos and group discussions.
In Bengal, India, a toolkit of games, stories, pictures, and models known as the Champa Kit helps make reproductive health education come alive for young people in the community. The kit is based on a story. The 12-year-old girl Champa is its central character. A flipchart in the menstruation module of the kit uses Champa's story to explore myths about menstruation, to help young women deal with menstrual pain and hygiene, and to explain low, heavy, and irregular blood flow. The module includes an activity book that describes the process of menstruation and the natural changes that take place during the cycle (137) (For more information, see http://www.thoughtshopfoundation.org/ChampaKit.html).
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Left: The Mahawari Chaka (or menstruation wheel), a handmade education tool, helps educators explain the various stages of the menstrual cycle to adolescent girls in India. © Lakshmi Murthy/Vikalpdesign
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School and community programs can succeed. Teaching girls about menstruation as part of adolescent and reproductive health education in school has succeeded in Zimbabwe. Among urban and rural secondary-school girls and boys who were part of a health education program, knowledge of the correct meaning of menstruation and of hygienic practices during menstruation rose from about 80% before the program to 98% after. Among girls in their first year of secondary education, those in the program were twice as likely to know that ovulation generally occurs in the middle of the menstrual cycle as their counterparts who were not in the program. Also, both boys' and girls' attitudes towards menstruation improved. After the lessons more of the students understood that menstruation is not an illness, not dirty, and not a punishment of women (89). School-based programs are conducted in other countries, too; the program in Zimbabwe is among the best documented (42, 46, 54).
Community-based education efforts can reach adolescents who are not in school as well as parents—important since most girls learn about menstruation from their mothers and other family members (1, 11, 26, 42, 93). The Adolescent Girls Initiate for Their Reproductive Health project in Nepal has had particular success in educating girls not enrolled in school and in reaching parents (see Spotlight). Another creative program is carried out by the communication organization Vikalpdesign in Udaipur, India. Community educators use three-dimensional media to teach rural girls ages 10 to 19 about puberty, menstruation, and hygiene during menstrual bleeding. A Mahawari Chaka, or menstruation wheel (see picture above) helps explain the phases of menstruation. Paper patterns are used to teach girls how to make washable menstrual pads (see photo above), and paper doll show girls how to wear the pads (51, 95).
1 An unweighted average does not reflect differences in population among the countries.
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See companion INFO Reports, "Key Facts About the Menstrual Cycle