project report assessing the menstrual hygiene management

Education about menstruation changes everything

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Project Report

Assessing the Menstrual Hygiene Management Practices in Urban and Rural

areas of Madhya Pradesh

2018

Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis


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Project Team

Project Coordinator and Author

Dr. Kanika Sharma, Deputy Advisor, State Health Resource Center

Under the guidance of

Akhilesh Argal, Director, AIGGPA

Madan Mohan Upadhyay, Principal Advisor, Center for Social Sector

Development, AIGGPA


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Contents Project Team ........................................................................................................................................... 2

Executive Summary ................................................................................................................................. 5

1. Introduction .................................................................................................................................... 6

1.1 Menstrual Hygiene Management Practices (MHMP) in India .................................................... 7

1.2 MHMP in Madhya Pradesh ....................................................................................................... 8

1.3 Demographics and Religious Affiliations of districts in the study .................................................... 8

2. Literature Review .......................................................................................................................... 10

2.1 Other studies on MHM ................................................................................................................ 10

2.2 Other organizations working on MHM in India ............................................................................. 11

2.3 Government schemes and initiatives on MHM ............................................................................. 11

2.4 Commercially available sanitary napkins and other products of female hygiene ........................... 12

2.5 Arunchalam Muruganantham: Indian Superhero “Padman” ......................................................... 13

2.6 Extraordinary Story in MP ............................................................................................................ 14

3. Objectives and Methodology ......................................................................................................... 16

3.1 Objectives of the study ........................................................................................................... 16

3.2 Methodology ......................................................................................................................... 16

3.3 Limitations of the study .......................................................................................................... 17

3.4 Internal and External Validity of the study.................................................................................... 17

4. Findings ......................................................................................................................................... 19

4.1 Adolescent girls specific ......................................................................................................... 19

4.2 Adult women specific ............................................................................................................. 22

5. Conclusion ..................................................................................................................................... 26

6. Recommendations ......................................................................................................................... 30

7. References ........................................................................................................................................ 32


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Executive Summary

Menstruation is a biological and physiological process which naturally occurs in healthy

adolescent girls and premenopausal women. The process of menstruation is one of the key

determinants of human reproduction and consequently parenthood. The age for menarche and

menopause varies by geographical region, race and ethnicity, and other determinants but research

evidence suggests that the average age of menarche in Indian female population is 13.46 years(1).

Similarly, the average age for menopause is 46.8 years. Rounding off these figures, it can be

calculated that an average Indian female menstruates for about 2040 days in her lifetime between

menarche and menopause.

The process of menstruation should concern men and women alike, but unfortunately it is not the

case. In some communities of the Indian society, menstruation is still considered a taboo, and

women are considered “impure” during this time of the month by many societies, sometimes

even educated ones. Due to various religious, cultural and social norms, there has been

unbreakable silence on the matter until recently. Poor menstrual hygiene creates a huge impact

on the woman’s vulnerability to uro-genital tract infections.

Previous research in the field also points to the severe information and knowledge gap that exists

between girls in urban and rural areas(2). Therefore, one of the research hypothesis attempted to

be studied via this exercise is examining the role of education against various socio-cultural and

religious practices in the region.The primary aim of this study was to gauge the magnitude of

influence of socio-cultural and religious practices on women’s menstrual hygiene management

practices in the selected region of study. Secondary aim of the study was to examine the role of

education in enabling the adolescent girls to choose better health practices. And tertiary aim of

the study was to examine if there exists a correlation between distributions of low cost sanitary

napkins to women and if that translates to adoption of better and safe menstrual hygiene

management practices.

Based on the findings of the study, it is strongly recommended that the adolescent girls and

women be educated about the facts of menstruation. Lack of adoption of better practices is also

compounded by the traditional beliefs, traditional knowledge, religious and social practices,

taboos and misconceptions. Mothers and older women in the family should be encouraged to

break their inhibitions when it comes to discussing sex education and safe management during

menstruation, and that dialogue about the issue should promote inclusivity of the male members

of the family as well.


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1. Introduction

The world transitioning from Millennium Development Goals (MDGs) to Sustainable

Development Goals (SDGs), has witnessed the widening inclusion of menstrual hygiene

management as a crucial component of sanitation and environmental health. Most health

initiatives, including sanitation and environmental health, are aimed at reducing morbidity and

mortality in children by controlling agents that cause diseases such as pathogens, environmental

hazards and other such things. This is where the interplay between the importance of menstrual

hygiene management and health comes to surface.

Women, in general, spend about 2000 days of their lives menstruating. And, contrary to that, the

subject of menstruation and menstrual hygiene is neglected the most in developing countries, like

ours, owing to myths and misconceptions, religious and socio-cultural practices. Only recently

have we, as a society, been able to talk about such issues when Mr. Arunachalam

Muruganantham, a mechanic from the south of India, revolutionized the sanitary napkin

manufacturing industry to a point where his innovation earned him a prestigious national award.

India still doesn’t fare well when it comes to menstrual hygiene management.

With many debates and discussions came about the initiative wherein the government distributed

low-cost sanitary napkins to women in need in rural areas, but was that the solution to the myriad

of problems faced by such women when it comes to menstrual hygiene management? That’s a

critical question that needs to be asked, and, in addition, the case for maintaining individual

dignity of such women needs to be addressed. Apart from the need of a mechanism for ensuring

good quality of the sanitary product and a mechanism to address the environmental issues that

play along with the issue, this study also advocates for a change in the attitude of the society

towards menstruation as a taboo as well.

While designing the study, it was borne in mind that it’s crucial to take into account the

contemporary beliefs and practices of women in the state, including rural and urban areas.

Therefore, a study of 1200 participants (600 school going adolescent girls and 600 adult women)

was designed within 6 districts of the state, viz. Bhopal, Indore, Balaghat, Bhind, Rewa and

Jhabua. Inclusion criteria of the study included adolescent girls who have attained menarche and

are school going. For the adult women, we only asked married women. Using strategic random

sampling in the selection of adolescent girls in grade 8th through grade 12th in schools, we asked

every 3rd girl student to be a respondent for the survey, only after obtaining the consent from the

school. For adult women, we used the random sampling technique and the women were included

as participants after obtaining the consent.


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1.1 Menstrual Hygiene Management Practices (MHMP) in India As a developing nation, we come across many socio-cultural practices in the country that are

not scientifically supported as in the western parts of the world. It is often said that superstitious

beliefs disguised as science work in the west and science disguised as magic works well in most

parts of the rest of the world. The socio-cultural, sometimes religious and often superstitious

practices pose a serious conundrum to the overall well being of the society when it’s met with

negative health outcomes and when the repercussions are sometimes even fatal.

One such muddle that’s often seen within India is the unhygienic and unsafe menstrual hygiene

management practices. Owing to the vast inter-state diversity in the country and secularity, the

MHMP differ from state to state and are also influenced based on the urban-rural setting of the

community. Other factors that influence MHMP in the country are affordability of the sanitary

hygiene product, accessibility to the product, knowledge about availability of such products,

correct usage and disposal and even educational status of the individual, mother and family

altogether in case of adolescent girls. This issue also requires immediate addressal as poor

water, sanitation and hygiene (WASH) facilities in school and in rural areas of India sometimes

even violate the right of a women to individual dignity as in non-availability of a proper place

to change herself during that time of the month, resulting in menstruation being a shameful and

embarrassing experience for the females.

As stated earlier, India is a country with wealth related disparities, gender related disparities,

owing to which there exists a significant variation in social indicators among girls between

various regions of the country. Of the 113 million adolescent girls, 68 million girls attend about

1.4 million schools, with cultural practices and taboos pertaining to MHM acting as

impediments to their attendance of the schools(3). Numerous studies have been conducted across

the country, examining the prevalence of unsafe MHM practices, their causes and implications.

One such study(4) conducted in Haryana concluded that feeling of sickness followed by

irritability and emotional disturbance was most commonly experienced by the adolescent girls

while on their periods. Also, it was found in the same study that more than 45% of the

respondents were not allowed to worship and cook in the kitchen and one-fourth followed

dietary restrictions. More than 16% of the respondents thought of menstruation as a sign of

onset of a severe disease and around 7% thought of it as a “curse”.

Another similar study(5) conducted in states of northern India found that the awareness of

menstruation before menarche was reported by 60% of the respondents and that awareness was

significantly associated with age. Another similar study from Gujarat (10), found that almost

50% of the girls had to sit separately during menstruation, 89% were restricted in what they

could touch, including worship material and cooking materials, almost half of the respondents

experienced changes in the behavior of their family members and almost a third of them were

not allowed to go outside alone during their periods.


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Another study that sheds more light on the issue at hand was conducted by the University of

Mysore(11) which found that the choice of sanitary napkin, storage place of the napkin, change

during night, school and college hours, safe disposal of the napkins were all a function the

socio-economic status of their family.

1.2 MHMP in Madhya Pradesh The state of MP doesn’t fare well when it comes to safe and hygienic MHM practices by

adolescent girls and adult women in the state. In a study conducted by Amity Business

School(6), Gwalior, it was found that most of the respondents answered that menstruation was a

curse from God, along with other things, such as they were asked to restrict their activities

while on their periods every month, ranging from simply not being allowed to step out of the

house alone to not touching the males of the house. Another study assessing the menstrual

hygiene management practices of women in urban areas of Jabalpur district (13) found that out of

the 200 adolescent girls surveyed for the study, approximately 70% of the respondents used

sanitary pads and the remainder used old cloth as an absorbent, and reused the same cloth for

consequent period without washing it properly.

According to a study published in the JMSCR, conducted in Jabalpur district of Madhya

Pradesh, the most common social changes that came along after the onset of menarche for the

adolescent girl in the family was the increased strictness by the mother imposed upon the

daughter, cessation of schooling and initiation of marriage talks.

In another prospective study conducted by the National Institute of Public Cooperation and

Child Development (NIPCCD) in the year 2007 and repeated again 2012, it was concluded that

respondents from Delhi had significantly higher awareness and knowledge about menstruation

before menarche than that of the other districts in the study, viz. Dhar (Madhya Pradesh),

Barbanki (Uttar Pradesh), Kamrup (Assam) and Mysore (Karnataka).

A study conducted by the Department of Community Medicine, Vasantrao Medical College,

Maharashtra, reported that there is a stark difference in awareness and knowledge about

menstruation and hygiene management practices between urban and rural areas of the state.

1.3 Demographics and Religious Affiliations of districts in the study Bhopal: District Bhopal serves as the administrative headquarters for the state of Madhya

Pradesh. According to the 2011 census, the total population of the district is 2,371,061, with

literacy rate of 80.37% and sex ratio of 918 for every 1000 males. Average literacy rate of the

distirct stands at 80.37% with male literacy rate and female literacy rate at 85.42 and 75.87

respectively. Religious affiliations in the district range from about 74% Hindus and 22.16%

Muslims to about 1% Christians and 1.09% Jains.

Indore: Indore is the most urbanized and populous district of the state, with a population of

3,276,697. The literacy rate in the district is 87.38%, with male and female literacy rates of


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91.84% and 82.55% respectively. About 84% of the total population of the district subscribes to

and practices Hindu religion, followed by 12.67% Muslims, 2.19% Jains and 0.78% Sikhs.

25.19% of the population of the district lives in rural areas.

Balaghat: According to Census 2011, the total population of the district is 1,701,198 with

842,178 males and 859,520 males. Sex ratio is at 1021 females per 1000 males. Female literacy

rate stands at 69.04% while the overall literacy rate is 77.09%. Out of the total population of the

district, about 14.39% of the population lives in urban regions of the district.

Rewa: Total population of the district is 2,365,106 with a sex ratio of 931females for 1000

males. Average literacy rate of the district stands at 71.62% with female and male literacy rates

at 81.43% and 61.06% respectively. It is interesting to note that the female literacy rate is

significantly lower than that of males in the district. A considerable part of the population, i.e.

95.93% subscribes to Hindu religion, followed by 3.61% Muslims and 0.08% Christians.

Jhabua: Jhabua district constitutes about 1.41% of the entire population of MP, with a total

population of 1,025,048. Population in this area is predominantly tribal. Average literacy rate is

43.30% with male and female literacy rates at 52.85% and 33.77% respectively. Similar to

Rewa, the literacy rate in the district is significantly lower. Also, the overall literacy rate of the

district is substantially lower than the state average which stands at 70.06%. About 94% of the

population is Hindu, 1.53% Muslims, 3.75% Christians and 0.87% Jains.

Bhind: The total population of Bhind district is 1,703,005, which constitutes about 2.5% of the

population of MP. Average literacy rate of the distirct is 75.26% with male and female literacy

rate at 85.40% and 63.14%, respectively. 93.68% of the population is Hindu, with Muslims,

Sikhs and Jains at 3.92%, 0.24% and 1.17%, respectively.

Based on the above characteristics of the population of individual districts, it can be inferred

that female literacy in the state is a challenge owing to various reasons. The etiology for this

scenario is compounded by many factors, viz. socio-economic status, religion, and other

cultural beliefs. It will be interesting to find out if the association between low education level

and practice of unsafe methods for MHM really exists.


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2. Literature Review Knowledge gap and poor personal hygiene practiced by women in India during menstruation has

been a subject of interest for academicians. Also, what has been particularly interesting is the

disparity between urban and rural areas pertaining to MHM knowledge, practices, behaviors and

attitudes. A few of such studies and their findings are discussed below.

2.1 Other studies on MHM While MHM has increasingly become an issue of paramount importance, it has led to intensive

actions by the public and private sectors. Recent initiatives at the global level, include an inter-

sectoral meeting convened by the Water Supply and Sanitation Collaborative Council (WSSCC)

in March 2013, release of first comprehensive manual on MHM by WaterAid foundation in

2012, titled “Menstrual Hygiene Matters: A resource for improving menstrual hygiene around

the world”. In September 2012, an online workshop on MHM was conducted by UNICEF in 13

countries, including India. A study by Sommer et. al. in 2013 found that girls attendance in

schools is directly proportional to availability of adequate sanitation facilities in school, for

instance, gender-segregated toilets, private washing and disposal facilities etc.

Most of the studies pertaining to MHM have been in geographically specific and small regions.

One large scale study was conducted by the center for global safe water and Emory University in

Georgia. In 2012, this collaboration began a multinational study in Bolivia, Philippines, Rwanda

and Sierra Leone. The theoretical design of the study focuses on societal, environmental and

religious factors influencing MHMP. In 2013, the project was expanded to include Mali. The

project yielded evidence-based programmatic recommendations to reduce MHM barriers and

challenges faced by school going girls.

Nationally, in the year 2010, a study was conducted in Saoner, Nagpur District in Maharashtra,

examining the knowledge and menstrual hygiene management practices of adolescent school

going girls in 8th and 9thstandard. The study reported that only about 37% of the girls in the study

knew about menstruation before menarche and the major source of this information was reported

to be their mothers. More than 75% of the girls had no clue about the cause and the source of

bleeding. About 50% of the girls knew about and used commercially available sanitary napkins.

Satisfactory cleaning of the external genitalia was practiced only by 33% of the participant

adolescent girls. Another similar study conducted in Dehradun, Uttarakhand reports that 64% of

girls were about menstruation before menarche, however, awareness amongst the rural

population was found to be more than that of the urban girls. In about 32% of the cases, the

primary informant was found to be a friend from school. Also, majority of the girls did not know

about the cause and source of bleeding during menstruation.

Beyond all this, there still exists a significant gap in knowledge and understanding of MHMP in

the state of Madhya Pradesh.


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2.2 Other organizations working on MHM in India Many corporate and non-governmental organizations are doing their part towards the betterment

of MHM status of adolescent girls and women in India. Usually corporate sector does it under

the Corporate Social Responsibility (CSR) project. Since the revolutionary manufacturing of low

cost sanitary napkins, introduced by Mr. Arunachalam Muruganantham, there is a whole range of

organizations, working independently and with the governments, to procure, produce and

promote the usage of these low cost sanitary napkins. A few such initiatives include, Anandi

Pads by Aakar Innovations, Mukti Pads by Society for Rural Industrialization, Sasodashi by

Corporate Social Responsibility Project by Jindal Power and Steel Plant, and Freedays by

Government of India, that have catered to smaller pockets across the country.

Following is a summary of certain prominent organizations working towards MHM in India:

1. WaterAid: An NGO, with a mission “to transform the lives of the poorest and the most

marginalized people by improving access to Water, Sanitation and Hygiene

(WASH)”.WaterAid India recognizes that menstrual hygiene is fundamental to individual

dignity and well-being of adolescent girls and adult women. They employ the approach

of generating awareness amongst the adolescent girls and their families and providing

low-cost simple solutions which are locally appropriate. On international Menstrual

Hygiene Day, observed on May 28th every year, WaterAid, India launched a campaign

called “Thunderclap” to advocate for better menstrual hygiene. The primary objective of

the campaign was to address the menstruation related taboos, enhance the advocacy about

this issue to the governments and feminine hygiene product makers.

The campaign came with a hashtag “#noshameinmesntruation”.

2. Healthy Living Development Society (HLDS): V-care is a joint Initiative of Healthy

living Development Society (HLDS) and Women & Child Development (WCD) Indore,

which took place in 2011 by establishing sanitary napkin production unit Under SABLA

scheme of GOI. The main objective of their mission is to provide beneficiaries with

affordable, hygienic and convenient sanitary napkins.

2.3 Government schemes and initiatives on MHM UDITA program was launched by the Government of Madhya Pradesh (GoMP) in 2015, to

assuage the culture of silence and social taboos around the subject of menstruation in the society,

to raise awareness about this matter which directly correlates with the individual dignity of

adolescent girls and women of the state, and to provide access to affordable sanitary napkins.

Under the Pradhan Mantri Bharatiya Jan aushadhi Pariyojana, Government of India (GoI)

launched “Janaushadhi Suvidha – Oxo biodegradable sanitary napkins”, in June 2018. The

affordable sanitary napkins will now become available at over 3600 Janaushadhi Kendras

functional in 33 States/UTs across India, as promised by Union Minister, Chemical & Fertilizers


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and Parliamentary Affairs, Shri Ananthkumar on March 8, 2018 (World Women’s day). These

suvidha sanitary napkins are priced at Rs. 2.50/pad.

This unique product would ensure Affordability, Hygiene as well as Ease of use and disposal for

them. Jan Aushadhi Suvidha comes with a special additive, which makes it biodegradable when

it comes in contact with oxygen after being discarded. This would ensure ‘Swachhta, Swasthya

and Suvidha’ for the underprivileged women of India and go a long way in the achievement of

Prime Minster Shri Narendra Modi’s vision of Affordable and Quality Healthcare for All.

2.4 Commercially available sanitary napkins and other products of female hygiene A study conducted in Rajasthan by the Indian Institute of Health Management found direct

correlation between unsafe sanitation practices and prevalence/incidence of Reproductive Tract

Infections (RTIs). A whole range of sanitary napkins or pads (as they are commonly named) is

available in the market ranging from Rs. 20 to Rs 85 per packet. Some of the commercially

successful names include Whisper, Stayfree, Sofy, and Kotex.

Currently, the sanitary napkin market base in India and the state divides the product into three

categories, viz. disposable menstrual pads, cloth menstrual pads and biodegradable menstrual

pads, and from the three categories, disposable menstrual pads accounts for the majority of the

total share in the market.

The market is also segmented on a regional basis, predominantly functional in the urban states,

with the highest penetration in states of Maharashtra, Delhi NCR, and Tamil Nadu respectively.

The key players include Proctor and Gamble, Johnson & Johnson, Emami and Unicharm.

Some of the most common varieties commonly found on the shelves of the shops/stores in India

and the state are as follows:

S.

No.

Brand Name Type No. of pads/pack Cost (In Rupees)

1 Whisper Ultra Clean 15 165

2 Stayfree Dry-Max All-Night 7 70

3 Sofy Side-walls 15 120

4 Stayfree Dry-Max Ultra-Thin 8 80

5 Whisper Ultra Nights 15 175

6 Whisper Regular Wings 8 26

7 Kotex Soft Smooth 8 25

It is noteworthy here that besides the last two names mentioned in the table, rest of the products

seem unaffordable by a lower-middle class family.

The cost implications are an important factor to consider as a study conducted by the AC

Nielsen, a marketing research firm, titled “Sanitary Protection: Every Woman’s Right”,


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concluded that the biggest barrier to using sanitary napkins by women is the affordability.

About 70% of women in India say that they resort to using unsanitary cloth because they

themselves or their family cannot afford to buy commercially available sanitary napkins.

The study surveyed 1,033 adult women and 151 gynecologists across the country. It is to be

noted that 97% of the gynecologists in the study said that use of sanitary napkins lowered the

risk of severe RTIs and 68% said that the use of sanitary napkins reduces the risk of cervical

cancer.

2.5 Arunchalam Muruganantham: Indian Superhero “Padman” The man behind the first low-cost pad making machine is now a famously known social

entrepreneur, internationally and nationally. The extraordinary story began in 1998 when he

noticed his wife using an old rag during her time of the month. Determined to help her, he put in

many years of research (to the extent of wearing a sanitary napkin himself where he fashioned

an artificial uterus made of rubber and animal blood) and manufacturing trials and eventually

came up with a machine that can make up to 3,000 sanitary pads/day. This low-cost machine

can be operated with minimal training.

Mr. Muruganantham has developed a set of four different small machines namely de-fiberation

unit, core forming unit, sealing unit and UV sanitizing unit, which reduce the cost of production

making Sanitary Napkins affordable to all. In the first stage, by using de-fiberation unit, the raw

material in the form of wood fiber is de-fibred to produce soft pulp. In second stage, de-fibered

pulp is given required shape of the napkin in core forming units operated by a foot pedal. The

third stage involves sealing the pads. The fourth stage involves passing the sealed pads through

a dedicated Sterilization unit. Once the sterilization is complete, the pads are ready for the

finishing operations consisting of trimming, position strip fixing, packing and dispatch.

His invention revolutionized the sanitary napkin manufacturing industry as this machine costs

only about Rs. 65,000 (US$950) as opposed to commercially used machines, which cost around

Rs. 3,50,00,000 (US$ 500,000). His invention is widely praised across the nation and the world

as it substantially changed women’s lives in India, particularly in rural India. He has currently

sold 1300 machines across 27 states in India and to other developing countries as well.

He won some substantial accolades and awards for his absolutely worth invention including a

mention in the most influential people’s list of 2014 by TIME magazine. Mr. Muruganantham

was also conferred upon Padma Shri in the year 2016.


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Mr. Muruganantham also gave a TED talk on the subject which earned him much more

recognition around the world. His story was the subject of a prize-winning documentary titled

“Menstrual Man”. In the picture above, he is shown receiving the highest national award by the

Honorable President of India, Shri. Pranab Mukherjee.

2.6 Extraordinary Story in MP Maya Vishwakarma, also commonly and dearly known as the padwoman of MP, hails from a

village in Narsinghpur district in MP. She’s a fine example to illustrate the taboos surrounding

menstruation in India as in an interview to New Indian Express she confessed that she hadn’t

heard of sanitary napkins until the age of 26. Coming from a family of agriculture farm

laborers, the family was struggling to make ends meet and for her first period she was asked to

use an old cloth by a female relative of the family.

Because Maya received full support from her family to study and was not rushed into marriage,

which is why she landed a research stint in AIIMS, New Delhi and then got a chance to work in

the US where she worked as a cancer researcher for Leukemia.

Maya started the “SUKARMA” foundation in her hometown two years before after her return

to India. This foundation manufactures sanitary napkins at low and affordable costs and sells it

to women in the area. In the two years since the beginning of the work of this foundation, they

have changed the lives of about 2,000 women. In another interview to the New Indian Express,

she told “the money of the machine and the unit was sourced through crowd funding, personal

savings and from friends working abroad for the California and India chapter of the Sukarma


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Foundation founded by me. It was while scouting for the best and cost-efficient machinery for

producing sanitary pads that I met the real ‘Padman’ (Muruganantham) two years ago and saw

the machine being used by him”.

In the picture above, Maya Vishwakarma, is shown in action at Sukarma Foundation.


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3. Objectives and Methodology

3.1 Objectives of the study The fundamental purpose for the conception of the study was to have an enhanced

understanding of the various religious and socio-cultural practices pertaining to Menstrual

Hygiene Management Practices (MHMP). Keeping that in mind, the following objectives were

formulated:

1. To examine the role of education against various religious and socio-cultural practices in the

select districts of Madhya Pradesh.

2. To examine the existence of a correlation, if any, between the distribution of low-cost

sanitary napkins and the change to adoption of better menstrual hygiene management

practices.

3. To ascertain if women in rural areas have any knowledge of menstruation as a biological

and physiological process essential for reproduction.

The study also aims to add to the growing body of research in the field and help guide the

decisions of policy makers in the area. Also, if the study reaches the intended audience, i.e.

adolescent girls and adult women, it will educate them and directly impact their empowerment.

The secondary literature review for the study, includes, inter-alia:

1. National Guidelines for Menstrual Hygiene Management Practices, Drinking Water and

Sanitation Department, Government of India

2. Various studies in the area reflecting on the issues and concerns

3. Socio-cultural beliefs and taboos surrounding the subject

4. WASH indicators from Sustainable Development Goals

5. Current menstrual hygiene management practices

The study also aims at highlighting this issue of grave concern which can ipso facto lower the

burden on the healthcare economy of the state. Only when the healthcare governance is at

center stage in policy making can we really nip the problem in the bud. Peripherally, the study

also aims to understand the current provisions of menstrual hygiene management and

availability of sanitary products in the state run schools, or lack thereof.

This report looks into the current MHM practices among adolescent girls and adult females in

the 6 districts of MP, namely, Bhopal, Indore, Balaghat, Rewa, Jhabua and Bhind, and proposes

recommendations to alleviate the incidence and prevalence of uro-genital tract infections in the

female population in the area.

3.2 Methodology The study was cross-sectional, block level, questionnaire based. From the identified target

population (N = 2,18,43,686 )[4], the sample population (n = 1200) was identified using random

sampling for identification of blocks and villages, and systematic random sampling for


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respondents in each village, keeping the Confidence Interval at 95%. The sample covered

adolescent girls and adult females. The distribution of the survey and data collection on the field

was assisted by a female Field Investigator (FI) in each block. The survey was primarily

focused on knowledge, attitude and behavior of women about menstruation in the selected

geographical areas. The sample covered the entire spectrum of targeted women beginning from

13 years to 47 years (rounded off from average age of menarche in India i.e. 13.46 years and

average age of menopause in India i.e. 46.2 years [5]). The sample was distributed among rural

and urban areas equally. The urban population was picked up from (Bhopal Block) Bhopal

District and (Indore Block) Indore District and the rural population will be from (Meghnagar

Block) Jhabua District, (Balaghat Block) Balaghat District, Gohad (Bhind District) and

(Hanumana Block) Rewa District. 200 respondents (100 adolescent girls and 100 adult women)

were picked up from all the six blocks/districts each.

Nodal Point for dissemination of surveys to adolescent girls was the schools run by government

in each block, and that for the adult women was the Aanganwadi centers. Timeline for

dissemination of surveys and completion of data collection was 1 month. The data was collected

using android supported mobile application called “e-sanchay” developed by the Department of

Economics & Statistics. The data was coded in Excel 2013 and data analysis was completed

using SPSS 18.

3.3 Limitations of the study

There is tremendous amount of research available on the issue of MHM in India. However, the

literature that studies the transformation of behavior, knowledge and attitude from unsafe to

safe menstrual hygiene management practices brought about by a scheme wherein low-cost

sanitary napkins were distributed, is scarce. Therefore, this study used an exploratory study

design.

Also, the study had to rely on the survey administering ability of the female field investigators

(FIs) for data collection, for which, the FIs had to visit government schools in the region. It was

reported that when the permission to leave the class to take the survey was obtained from a male

teacher, the student seemed uneasy while answering the questions on the survey.

We missed to include non-school going girls in this study. We also missed to ask the

respondents if they knew of the source of bleeding during menstruation, and there was

ambivalence in the question wherein we asked the respondents if they did or did not feel

embarrassed around male members of their family.

3.4 Internal and External Validity of the study Internal validity refers to whether the results obtained in a study are due to the manipulation of

the independent variables or due to some other unknown variable. No threats to internal validity

of this study came across as the “Maturation” was fixed by shortening the duration of the

study to 4 months, “Diffusion of Information” may have been a possibility as the respondent

samples were taken from the same grade in the same school.


18

External validity refers to the extent to which the findings of a study can be generalized to other

situations and other people. “Sample characteristics” is no threat to the external validity of

this study as the rural-urban population is covered so the findings can be replicated to another

state with similar population and demographics. “Reactivity of study arrangements” can

potentially alter the way the respondent answers the questions on the survey as being aware of

participation in a study can greatly influence the way they think they should answer the

questions. “Selection bias” was not a threat to the external validity of the study as every 5 th

adolescent girl from grade 8th through grade 12th was selected and every 3rd adult women at the

Aanganwadi center was selected as a respondent for the study.


19

4. Findings

4.1 Adolescent girls specific To meet every objective of the study, various hypotheses were formulated. The individual

objective and the hypotheses under it are described in the following section:

Objective 1: To examine the role of education against various religious and socio-cultural

practices in the select districts of Madhya Pradesh.

Hypothesis 1: Girls who knew about menstruation prior to menarche used sanitary napkins

only as an absorbent during menstruation.

Finding: We ran Cramer's V as the statistical tool of choice to determine the correlation

between the Independent Variable (knowledge prior to menarche) and the Dependent Variable

(Type of absorbent used during menstruation). Therefore, it can be safely inferred that

educating adolescent girls about menstruation during school years, and as a part of their school

curriculum leads to adoption of safe menstrual hygiene management practices.

Cramer's V correlation was found to be significantly strong with the value of 0.440 and α <0.05.

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .440 .000

Cramer's V .440 .000

N of Valid Cases 600

Hypothesis 2: Educational status of the mother of the adolescent girls was inversely

proportional to attitude towards menstruation in it being considered a “curse from God”.

Finding: Cramer's V as the statistical tool of choice was used to determine the correlation

between the Independent Variable (mother's educational status) and the Dependent Variable

(knowledge of cause of menstruation).

Cramer's V correlation was found to be significant with the value of 0.144 and α <0.05.

However, the value of the correlation coefficient signifies a moderately weak correlation. Albeit

weak, the correlation directs us to inferring that adolescent girls with mothers with better

educational status knew that menstruation is not a “curse from God”.


20

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .203 .046



Hypothesis 3: Girls with educated mothers did not feel embarrassed in the presence of their

male friends or family members while they were on their period.

Finding: Pearson’s correlation coefficient was the statistical tool of choice to determine the

magnitude of correlation between the independent variable (Mother's educational status) and

dependent variable (feeling of embarrassment), as the dependent variable is placed in true

dichotomy.

The correlation is found to be significant with the Pearson coefficient value at 0.178 and α

<0.05. The correlation however is found to be weak.

Correlations

Medu

embarrasseda

roundmalefa

mily

Medu Pearson

Correlation

1 .178**

Sig. (2-tailed) .000

N 600 600

embarrassedaroundma

lefamily

Pearson

Correlation

.178** 1

Sig. (2-tailed) .000

N 600 600

**. Correlation is significant at the 0.01 level (2-tailed).


21

Objective 2: To examine the existence of a correlation, if any, between the distribution of low-

cost sanitary napkins and the change to adoption of better menstrual hygiene management

practices.

Hypothesis 1: Girls who knew of UDITA scheme didn’t use rags anymore while on their

period.

Finding: The correlation coefficient obtained is strong and statistically significant (Cramer's V

0.386 and α<0.05).

It is essential to point out here that only 7.6% of the respondents in the study knew of UDITA

program and majority of those who knew were from Bhopal district.

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .386 .000



Hypothesis 2: Girls who knew of UDITA scheme maintained cleanliness of external genitalia.

Finding: Correlation coefficient shows a negligible value with p value insignificant at α>0.05,

which suggests that adolescent girls did not clean there external genitalia even if they knew of

the UDITA scheme.

Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

biological and physiological process essential for reproduction.

Hypothesis 1: Urban girls knew of menstruation as a process essential for reproduction better

than their rural counterparts.

Finding: Based on the Chi Square value (ᵡ2 – 56.37) and p<0.05, it can be inferred that the

knowledge of menstruation as a physiological process essential for reproduction is a function of

residential area being rural or urban.

Hypothesis 2: Urban girls have better knowledge than rural girls about maintaining cleanliness

of the external genitalia well during menstruation.


22

Finding: According to the Cramer’s V correlation coefficient value, and p<0.05, there exists a

correlation between maintaining cleanliness of the external genitalia well during menstruation

and the residential area being urban or rural, implying that urban girls practiced better MHM.

4.2 Adult women specific Objective 1: To examine the role of education against various religious and socio-cultural

practices in the select districts of Madhya Pradesh.

Hypothesis1: Women with better educational status practiced better MHM via using sanitary

napkins only.

Findings: Using Cramer's V as the statistical tool of choice to elucidate the correlation between

respondent's educational status and the absorbent commonly used by them during menstruation,

the correlation coefficient is found to be significant (Cramer's V - 0.283 and α<0.05), implying

that education does play a key role in empowering women to make better choices pertaining to

safe and hygienic MHM.

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .567 .000



Hypothesis 2: Educated women didn't feel embarrassed to be around their male colleagues or

male family members during the time they were on their menses.

Findings: Women's educational status has a direct influence on the feeling of embarrassment

during menstruation while around their male colleagues and family members (Cramer's V -

0.361 and α<0.05), which directs us to the inference that education combats socio-cultural and

religious notions of “state of impurity” during menstruation thereby alleviating the feeling of

embarrassment.

Symmetric Measures

Value

Approx.

Sig.


23

Nominal by

Nominal

Phi .361 .000



Hypothesis 3: Educated women are aware of the cause of menstruation and did not consider it a

curse from God.

Findings: Correlation coefficient between educational status of women and menstruation being

considered a curse from God is significant but the coefficient value signifies extremely low

correlation (Cramer's V - 0.195, although α<0.05). This points to the fact that even if these

women as girls were not educated about menstruation in school, attaining higher education led

them to the understanding that menstruation is not a “curse from God”.

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .390 .000



Objective 2: To examine the existence of a correlation, if any, between the distribution of low-

cost sanitary napkins and the change to adoption of better menstrual hygiene management

practices.

Hypothesis 1: Women who knew of UDITA scheme didn’t use rags anymore while on their

period.

Findings: Correlation coefficient holds moderately strong at 0.354 and significant at α<0.05,

implying that due to the remarkable outreach and innovative strategies of UDITA program,

adult women did adopt better menstrual hygiene management practices. Also, it can be safely

inferred that this correlation stands true for the target population as well. It should especially

noted here that the maximum penetration of UDITA outreach to the community was found in

Meghnagar Block of Jhabua District, whereas the awareness regarding the scheme in other

districts of the study was considerably nil.


24

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .354 .000



Hypothesis 2: Women who knew of UDITA scheme maintained cleanliness of external

genitalia.

Finding: Correlation coefficient shows a negligible value with p value insignificant at α>0.05,

which suggests that women did not clean there external genitalia even if they knew of the

UDITA scheme. The p value insignificance implies that this finding cannot be replicated to a

larger population.

Symmetric Measures

Value

Approx.

Sig.

Nominal by

Nominal

Phi .022 .575


Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

biological and physiological process essential for reproduction.

Hypothesis 1: Urban women knew of menstruation as a process essential for reproduction

better than their rural counterparts.

Finding: As depicted by the Asymptotic Significance (p) which is <0.05, knowledge of

menstruation as a process essential for reproduction is a function of the residential area being

urban or rural, meaning that women in urban areas have better means of gaining knowledge on

the subject.


25

Chi-Square Tests

Value df

Asymp. Sig.

(2-sided)

Exact Sig. (2-

sided)

Exact Sig.

(1-sided)

Pearson Chi-Square 83.379a 1 .000

Continuity Correctionb 81.587 1 .000

Likelihood Ratio 115.707 1 .000

Fisher's Exact Test .000 .000

Linear-by-Linear

Association

83.254 1 .000


a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 48.26.


26

5. Conclusion Numerous studies on MHM in India is a very encouraging practice which sheds light on the fact

that there is a growing interest on the subject matter amongst the academics, at least. It is to be

noted that majority of these studies found that girls are unaware of menstruation before

menarche and hence the feelings of stress, anxiety, depression, uneasiness, dirtiness and anger is

most commonly seen among them. While the importance of puberty and reproductive health

education is universally recognized, it becomes a topic of debate in our country when the

question arises “who should educate young girls in the country about it?”

Although menarche is celebrated in southern regions of the country, we found through our study

that in the state of MP this physiological change brings a substantial amount of physical and

psychological burden. This psychological burden is further compounded by societal beliefs in

restriction of activities such as not being allowed to go out of the house, not being allowed to

touch anything that’s considered holy and not being allowed to touch anything or sometimes

even enter the kitchen. While education about puberty and menarche may possibly dissipate the

taboos prevalent in the society, a holistic approach and an innovative strategy to counter the

negative attitudes towards menstruation is the need of the hour.

Government of India and Government of MP have taken initiatives to address the deeply

penetrated problem of menstrual hygiene management in the country and the state, but the

question remains “Is that enough?”, or “Is it making the desired impact?” and “Is distribution of

low-cost sanitary napkins just a band-aid to the wound?”. The study revealed that the most

crucial factor that needs to be addressed is the family support. While in approximately 90% of

the cases, the first confidant for the adolescent girl respondent was the mother, it is to be noted

that majority of the mothers were illiterate, hence, it can be inferred that mother’s education and

involvement in any scheme proposed and implemented by the government must be a sine qua

non.

According to the field experience report of the field investigators engaged in this study, the

most vital factor for not using the sanitary napkins was the affordability. FI from Bhind district

reported that the aanganwadis sold one packet of sanitary napkins at Rs. 6 earlier and now the

same packet is being sold at Rs. 25. The increase in the cost was found to be a discouraging

factor among both women and adolescent girls to continue using the sanitary napkins. About

60% of the girls responded that they didn’t use sanitary napkins because they were too

embarrassed to ask the shopkeeper about it. The same number among adult women was found

to be about 26.3%. Ease of access was the second common factor observed for non-usage of

sanitary napkins, about 28% of adolescent girls said that the shop was too far from their home

or that no one buys them the product. The same factor was reported as a hindrance by about

37% of adult women.


27

Another incidental yet interesting finding that the study came across is the flow of information

regarding better MHMP isn’t necessarily unidirectional (mother to daughter). In about 14 cases,

the study found out that daughters were the primary source of information for less educated

mothers, and the new information received by the mother from the daughter was more trusted

considering the source of the information and brought about changes in menstrual hygiene

management.

It has also been pointed out earlier that MHM should concern men and women alike. Following

is a graphical presentation of girls with educated fathers and their feeling embarrassed about

menstruation. If we take a look at the UDITA scheme proposed by the government of MP

which involves a provision of UIDTA CORNER in the local aanganwadi where adolescent girls

and women get together to learn about the physiology of menstruation and safe methods of

menstrual hygiene management, we recommend that fathers and brothers of adolescent girls be

also involved in such knowledge sharing and building thus empowering the female segment of

the society even more.

When asked about the disposal of the

used absorbent, 46.3% of the adult

female respondents said they threw it

in a trashcan, about 42% (combined)

said they threw it outside the house or

in drains and water bodies and only

10.3% said they burned it after use.

Majority of the respondents were not

35

17

32.83

13.16

2

0

5

10

15

20

25

30

35

40

Illiterate Primary Middle School High School Graduate andabove%

ofr

esp

on

de

nts

' mo

the

rs w

ith

ed

uca

tio

nal

st

atu

s

Education Status

% of Educated Mothers

46.33

21.16

20.66

10.33

Methods of Absorbent Disposal

Trashcan

Threw outside the house

Drains and water bodies

Burn it


28

aware of the environmental hazard posed by the unsafe disposal of the absorbent. In pure

numbers if we calculate the burden on the environment, of unsafe and unsanitary disposal of the

absorbent, it comes to about 3,600 pads disposed by each female at a rate of 10 pads/cycle for

30 years of menstruation. The magnitude of the burden is further intensified when it is seen

within the context of state and national population. To put things a little more into perspective,

for the state female population of menstruating age, the number becomes (2,18,43,686 x 3600)

78,637,269,600. The number is much bigger for the entire country. For such numbers it is

reasonable to think the amount of plastic that goes into the environment is considerably

significant.

When adolescent girls were asked if they

knew of the cause of menstruation,

majority of them knew (59.3%) that it was

a normal physiological process, 25.6%

answered that it is a pathological process

and 15.1% considered menstruation a

“curse from God”.

Also while analyzing the results of the study it was found out that educational status for

illiterate women and for women who only studied till primary school practiced poor menstrual

hygiene. 100% of the illiterate females used old rag as an absorbent during menstruation and

from those who studied till primary school, only about 8% used sanitary napkins; the remainder

used an old rag. Education as a socio-cultural determinant of poor MHM plays a significant

role, as is evident from the graph above, wherein 100% of the females with education of middle

school and higher used only sanitary napkins as the absorbent during menstruation.

07.87

100 100 100

0

20

40

60

80

100

120

Illiterate Primary Middle School High School Graduate and

above

% use of sanitary napkins vs education in adult

women

59.325.6

15.1

Cause of Menstruation

Physiological/Hormonal Disease Curse from God


29

While it was observed that about 60% of the respondents’ fathers were educated from middle

school and above, a remarkable proportion of the adolescent girls in the sample said they were

embarrassed to be around the male members of the family.

25.5

13.6

27.6 26.6

6.5

58.82

70

98.78 96.8792.85

0

20

40

60

80

100

120

Illiterate Primary Middle School High School Graduate andabove

Father's Education vs. Girl Feeling Embarrased

% of respondents' Fathers % of girls feeling embarrased


30

6. Recommendations

Based on the findings and conclusion mentioned in the previous sections of this report, it stands

to reason that education should be used as a tool for social and behavior change. One of the best

ways to derive this societal change is communication for development strategy. While in a

conservative society, like within our state, we should encourage dialogue on this subject and try

to dissipate the wide knowledge gap that exists which is otherwise filled by socio-cultural and

religious taboos, superstitious practices and many other myths and misconceptions around the

subject matter.

Secondly, when the government proposes initiatives like UDITA program, inclusivity of all the

family members, including male members, should be encouraged.

Thirdly, education on menstrual cycle as a biological and physiological process essential for the

well-being of a girl and woman’s health should be introduced in the schools, along with the

appropriate education on maintaining proper hygiene and not exacerbating the uro-genital and

reproductive health of the individual female.

Fourthly and lastly, through this report, we also want to emphasize on the work being done by

the state government and WASH for better environment. Appropriate education for disposal of

used absorbent should be employed as a tool and also use of environmentally safe menstrual

cups should be encouraged, which will eventually lower the amount of non-biodegradable plastic

being thrown into the environment. Schools should install incinerators in the bathroom facility

for females and ensure the adolescent girls know the correct usage of the installed machine.

Often while discussing menstrual cups, the cost-factor usually gets some “raised eyebrows”,

however, a study conducted by the National Institute of Health and Centre for Disease Control

and prevention (CDC)(7) looked into the cost-effectiveness of sanitary napkins, tampons and

menstrual cups and concluded that menstrual cups are a satisfactory alternative to sanitary

napkins and tampons, and that they have the potential to be a sustainable solution to menstrual

management with moderate cost savings and much reduced environmental effects with sanitary

napkins or tampons.

Speaking of the cost factor as a function of encouraging the usage of safe methods for

management of menstrual hygiene, a recent development has been the exemption of sanitary

napkins as a product on which Goods and Services Tax (GST) is liable. Earlier, sanitary napkins

were liable for 12% GST. This step seems to be in the right direction.

In the previous year, much of the silence on menstruation and menstrual hygiene has been

overcome by the state, a few illustrations would include, installations of low-cost sanitary napkin

dispersal machines at a few railway stations in the state. This wave of social change is also

significantly brought about by the movie “Padman” released this year, which soon became a

topic of conversation among all sections of the society. Also, the hashtag “socialchange”


31

(#socialchange) was introduced by Bollywood stars on social media outlet such as Facebook,

Twitter and Instagram, wherein they posed for the camera holding a sanitary napkin in their

hands or their pockets. Much of this was followed by college students and it soon became a trend

in the urban sections of the state.

It is a much required start for the state but based on the findings of this study, we have to say that

we have a long way to go before we can say the battle has been won.


32

7. References 1. Menstruation: A taboo subject in India. An article from Business Standard. Retrieved from

http://www.business-standard.com/article/current-affairs/madhya-pradesh-fares-worst-in-

unhygienic-menstrual-practices-across-india-117061900188_1.html

2. Secular trends in menarcheal age in India: Evidence from the Indian Human Development

Survey. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219698/

3. Mahon. T, Fernandes M. Menstrual Hygiene in South Asia: A neglected issue for WASH

programs. Gend Dev 2010

4. Goel. M, Mittal. K. Psycho-social behavior of urban Indian adolescent girls during

menstruation. PMC 2011.

5. Kumar. D et. al. Menstrual pattern among unmarried women in northern India. PMC 2013.

6. Chakravarty D. Development communication perspective of menstruation in rural India.

Journal of content, community and communication.Vol. 4, year 2, Dec. 2016.

7. Howard, C., Rose, C. L., Trouton, K., Stamm, H., Marentette, D., Kirkpatrick, N., … Paget,

J. (2011). FLOW (finding lasting options for women): Multicentre randomized controlled trial

comparing tampons with menstrual cups. Canadian Family Physician, 57(6), e208–e215.

project report assessing the menstrual hygiene management

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