A presentation by Dr Nicola Jones and Kiya Gezahegne from Addis Ababa University at the UNFPA Menstrual Health Symposium in May 2021

1. Adolescent experiences of menstrual health and wellbeing:
reviewing the evidence
Primary school students in Ebenat, Ethiopia © Nathalie Bertrams / GAGE 2020
Nicola Jones (ODI) and Kiya Gezahegne (Addis Ababa University)
May 2021

2. Access to MHM varies tremendously across sub-Saharan Africa
The most recent Multi-Indicator Cluster Surveys (MICS) have found
• HIGH: 98% in Zimbabwe and Lesotho LOW: 92% in Sierra Leone and Ghana
Most women use appropriate materials.
• HIGH: 97% Zimbabwe LOW: 93% in Sierra Leone
Most women have a private place at home to wash and clean.
• Of rural women, 88% in Sierra Leone and 12% in Lesotho use reusable materials.
• Of urban women, figures are 48% and 2.5% respectively.
Rural women are more likely than urban women to use reusable materials.
• HIGH: 20% in Gambia and Sierra Leone LOW: 13% in Lesotho
Despite access to materials and privacy, it is common for women to restrict their activities.
PMA surveys have found:
• The proportion of women who use pads only, ranges from 83% in Ghana to 9.7% in Niger
• The proportion of women who use cloth only, ranges from 4% in Lagos (Nigeria) to 58% in Burkina Faso

3. But there are important data gaps for girls
Questions are asked of all women 15-49 years
However, while the surveys collect data separately for adolescent girls 15-19, the
reports on the findings do not disaggregate which activities are restricted or ask
girls how they manage their periods at school.
Moreover, these surveys have been found to over-represent women who are
educated, urban and wealthier (Hennegan et al., 2018)
And questions are not asked in DHS for girls under 15 years so we are missing out
on data about the experiences of very young adolescents

4. GAGE: MHM and Ethiopia
• When did you get your
period?
• What do you use to
manage blood flow?
• What do you do with
used products at home?
At school?
• What activities are
affected by
menstruation?
• How did you learn about
puberty?
• What do you know
about menstruation?
How often? What causes
it? What does it signal?

5. In Ethiopia, girls often lack timely accurate information
Of rural girls who are menstruating:
• 93% know that menstruation happens monthly
• 82% know that menarche means pregnancy can
happen
‘I have not received information about it
from anybody.’ (married 15-year-old)
‘It is taboo to talk about menstruation.’
(16-year-old girl)
‘When my first menstruation came, I was screaming, holding my ears. My cousin said
“what happened to you?” I said “I don’t know when but they raped me”. She laughed.’
(12-year-old girl)
Of rural girls who are NOT menstruating:
• 51% know that menstruation happens monthly
• 71% know that menarche means pregnancy can
happen
‘It is when women are about to give
birth that they experience menstruation.’
(13-year-old girl)

6. In Ethiopia, girls’ MHM varies by location and now during the pandemic
Of the 15–17-year-old girls in GAGE:
• 87% have reached menarche
• Girls in urban areas get their periods earlier: 13.9 vs. 14.5 years
How do girls manage their periods?
Urban Rural
Reusable pads 46% 26%
Cloth 16% 41%
Disposable pads 40% 17%
Nothing 2% 16%
How do girls manage their periods at school?
Urban Rural
Disposal 85% 58%
Wash and reuse 2% 20%
Do not go to school 9%
Does not change at school 4% 11%
‘I had to wear many clothes over and over the pant to protect the leakage…after the inner cloth got
enough, we took it out and wash it.. I change and wash again and again.’ (18-year-old rural girl)
‘The pack that contains ten
packs is sold for twenty birr.’
(15-year-old urban girl)
‘I don’t have enough money to buy pads since corona, I’m making do with
one but it’s very uncomfortable and I feel embarrassed. Also I don’t have
soap to wash my clothes ’ (18-year-old migrant girl, urban town)

7. Gaps in MHM leave girls’ lives restricted
‘Girls in the past used to miss school for about
50 or 60 days per year due to fear of humiliation
related to menstrual cycle.’ (Father)
What limits do girls face during their
periods?
• Do not work: 59%
• Do not go to school: 17%
• Do not prepare food: 15%
Urban girls are more likely to experience
restrictions than rural girls:
34% vs 16%
• Because urban girls are more likely to
be in school
• Because urban girls are less likely to
rely on reusable—and inexpensive--
period products
Teacher showing the sanitary kit, Ethiopia © Nathalie Bertrams / GAGE 2020

8. Act with Her is supporting girls’ MHM by normalizing menstruation in families
and communities
‘When they are on their period, we shouldn’t make them feel embarrassed. The
company provide pads for them and there will be no problem if they use that. We also
have to let them know that it is a blessing.’ (12-year-old boy)
• AWH is an adolescent safe spaces programme aimed at transforming gender norms, including
around menstruation, reaching 50,000 adolescents over a five year period, funding by BMGF
and implemented by Pathfinder and evaluated by GAGE using a RCT methodology.
• Broad aims include puberty education and improved MHM.
• In Amhara and Oromia—girls saw a 30% increase
in knowledge about menstruation.
• Boys’ knowledge also improved.
I would be ashamed when I had my menstruation and become absent from school.
But after I joined Pathfinder, I understand that menstruation is nature’s gift and I
don’t get ashamed.’ (13-year-old girl)

9. Relevant publications
Transforming gender norms through life-skills programming
in rural Ethiopia: short-term impacts and emerging lessons
for adaptive programming (Oromia case study)
Transforming gender norms through life-skills programming
in rural Ethiopia: short-term impacts and emerging lessons
for adaptive programming (Amhara case study)
Transforming gender norms through life-skills programming in
rural Ethiopia: short-term impacts and emerging lessons for
adaptive programming (Afar case study)
Young adolescent girls' knowledge of menstruation
and puberty: a rapid evidence review
‘They did not take me to a clinic’: Ethiopian adolescents’
access to health and nutrition information and services
Gender and regional inequalities in
adolescent health and nutrition in
Ethiopia

10. Contact Us
Dr Nicola Jones, GAGE Director
n.jones@odi.org.uk
www.gage.odi.org
@GAGE_programme
GenderandAdolescence
About GAGE:
 Gender and Adolescence: Global Evidence
(GAGE) is a nine-year (2015-2024) mixed-
methods longitudinal research programme
focused on what works to support adolescent
girls’ and boys’ capabilities in the second
decade of life and beyond.
 We are following the lives of 20,000
adolescents in six focal countries in Africa,
Asia and the Middle East.