Literature Review to Assess Menstrual Hygiene Management Practices Among Adolescent Girls in India.

August 2017
This publication was produced for review by the United States Agency for International Development.
It was prepared by Vinita Satija, Alia Kauser, Rashmi Kukreja and May Post for the Health Finance and Governance Project.
LITERATURE REVIEW TO ASSESS
MENSTRUAL HYGIENE MANAGEMENT
PRACTICES AMONG ADOLESCENT GIRLS
IN INDIA

The Health Finance and Governance Project
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August 2017
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Recommended Citation: Satija, Vinita, Alia Kauser, Rashmi Kukreja, and May Post. August 2017. Literature
Review to Assess Menstrual Hygiene Management Practices Among Adolescent Girls in India. Bethesda, MD: Health
Finance & Governance project, Abt Associates Inc..
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LITERATURE REVIEW TO ASSESS
MENSTRUAL HYGIENE MANAGEMENT
PRACTICES AMONG ADOLESCENT
GIRLS IN INDIA
DISCLAIMER
The authors’ views expressed in this report do not necessarily reflect the views of the United States
Agency for International Development or the United States Government.

i
CONTENTS
Acronyms................................................................................................ iii
Executive Summary ............................................................................... iv
1. Introduction ......................................................................................1
1.1 Background............................................................................................................1
1.2 Problem Statement and Objectives of the Review .....................................1
2. Methodology......................................................................................3
2.1 Literature Review ................................................................................................3
2.2 Report Writing.....................................................................................................3
3. Key Findings ......................................................................................4
3.1 Knowledge, Cultural Beliefs, and Information Sources About
Menstruation.........................................................................................................4
3.2 Menstrual Hygiene Management Practices and Affecting Factors...........6
3.3 Type, Cost, Access, and Other Barriers to Absorbent Use ..................11
3.4 Environmental Implications of Disposal Practices.....................................13
4. Innovations And Good Practices In MHM ....................................16
4.1 Kenya ....................................................................................................................16
4.2 Rwanda.................................................................................................................18
4.3 India.......................................................................................................................18
5. Discussions and Implications..........................................................20
Annex A: Sources of Information About MHM ..................................23
Annex B: Types of Absorbents Used Globally ....................................24
Annex C: References.............................................................................26

ii
ii
List of Tables
Table E1. Menstrual Products Available in the Market............................................................. viii
Table E2. Disposal Mechanism of Menstrual Absorbents and Environmental Implications
........................................................................................................................................................ viii
Table 1. Pooled Proportions of Sources of Information About Menarche and
Menstruation, Overall and by Setting, in Indian Studies Published Between 2000
and 2015.........................................................................................................................................5
Table 2: Snapshot of Studies Analyzing MHM Practices and Other Normal Activities
Influencing MHM in India. ..........................................................................................................7
Table 3: Menstrual Products Available in the Market. ...............................................................12
Table 4: Disposal Mechanisms of Menstrual Absorbents and Environmental Implications
.........................................................................................................................................................14
Table A1. Sources of Information About MHM...........................................................................23
Table A2. Advantages and Disadvantages of Disposable vs. Non-disposable Pads,
Tampons and Menstrual Cups................................................................................................24
List of Figures
Figure E1. Different types of absorbents, and their advantages and disadvantages. .......... vii
Figure 1: Different types of absorbents, and their advantages and disadvantages..............11
Figure 2: FLO: An innovative product developed to wash and dry cloth pads...................19
Figure 3: A more hygienic way to dry reusable pads .................................................................19
Figure 4: The pouch can be concealed securely under clothes...............................................19

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ACRONYMS
LMIC Low- and Middle-Income Countries
MHM Menstrual Hygiene Management
MoHFW Ministry of Health and Family Welfare
SHE Sustainable Health Enterprises
USAID United States Agency for International Development

iv
EXECUTIVE SUMMARY
Introduction and Background
Menstrual hygiene management (MHM) is a problem for adolescent girls in low- and middle-income
countries. MHM refers to the practice of being well informed about menstruation and its cause,
maintainence of good hygiene during menstruation, and use of clean absorbents to absorb menstrual
blood that can be changed privately, safely, hygienically and as often as needed for the duration of the
menstrual cycle. It also involves their safe disposal. Management of menstrual hygiene is crucial for an
adolescent girl and woman to live healthy and productive lives with dignity. MHM is especially important
for adolescent girls because of the linkage between MHM and school attendance. However, limited
access to accurate information and products for sanitary hygiene makes menstruation a distressing
experience for adolescent girls and women, especially girls attending school. In most of the developing
countries including India, many adolescent girls and women do not have access to basic facilities such as
safe and hygienic absorbents, running water, and even toilets to maintain the menstrual hygiene (Shah et
al., 2013)
Problem Statement and Objectives of the Review
There is limited consolidated evidence on the use of various types of menstrual absorbents and disposal
practices followed by adolescent girls. Policy-makers require updated information about ground scenario
in different geographies and social settings for the development of a comprehensive package of MHM
intervention, efficient operational plan and to ensure successful uptake of the scheme by targeted sub
population.
The objective of the study is to conduct a secondary review of literature and present consolidated
evidence about menstrual hygiene management practices among adolescent girls in India, with special
emphasis on types of absorbents used and their disposal, and to understand the nature of environmental
hazards caused by unsafe disposal of sanitary napkins.
Methodology
The study was conducted over a four-month period and involved secondary data collection and review.
The scope, objectives, and research questions were formulated and finalized in consultation with the
Ministry of Health and Family Welfare and USAID. Review involved an internet search of major journals
on the subject. Studies with information about MHM on Pubmed, Google Scholar, and other such sites
were reviewed. Key words paired with ‘adolescent girls in India,’ ‘menstrual practices,’ and ‘MHM’
during the search were ‘knowledge, attitude, perceptions, practices, management, disposal practices, use
of absorbents, health issues linked with MHM, social taboos, cultural practices and MHM, and disposal
and environmental risks.’ Key findings from the secondary data collection and analysis were compiled
into a report.
Key Findings
The key findings have been derived from extensive analysis of over 60 papers that were shortlisted for
the final review. These included (1) a paper based on a systematic review and meta-analysis that

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examined all papers published between 2000 and September 2015 to assess the status of MHM among
adolescent girls in India (10-19 years) (Van Eijk et al., 2016) and (2) a study mapping the knowledge and
understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and
middle-income countries (Chandra-Mouli and Patel, 2017).
The secondary review has yielded important insights about the current status of knowledge and taboos
prevalent around the concept of menstruation, the types of absorbents used currently and MHM
practices. Barriers to use of different types of absorbents have also been identified, as have the
environmental implications of the current disposal methods. Good practices in MHM in India and Africa
have been discussed since they provide useful insights into sustainable solutions that can be tried and
encouraged to strike a balance between health safety of girls/ women as well as health of the
environment in mind, without compromising on either.
Key findings addressing all the research questions are summarized below.
Knowledge, Cultural Beliefs and Information Sources About
Menstruation
Knowledge and awareness
 About 48 percent of girls are aware about menstruation before menarche; awareness rates have
grown over the years, especially after 2010.
 There is a substantial knowledge gap among the girls regarding the origins of menstrual blood or
that it is linked with the ability to conceive. On an average, only about 23 percent of the girls
knew that the uterus is the source of bleeding, and approximately 55 percent consider
menstruation normal.
 Information about MHM practices is inadequate, even in the older girls who have already started
their menstruation. Only about 30 percent are well informed about hygiene practices. Social
taboos further hamper the knowledge levels.
 Regional variations are wide in knowledge levels and knowledge about menstruation increases
with age. Urban vs. rural setting, education of parents (especially mother), household
occupation, media exposure, and economic status have a significant influence on girls’ knowledge
and information about menstruation.
 School-based health education has led to significant improvements in MHM practices like
washing the absorbent cloth with soap, drying the cloth in the sun, and disposing of it safely, as
well as washing and bathing. The proportion of girls using soap to clean their genitalia
significantly increased from 30.0 to 94.3 percent due to health education in one study.
Sources of information
 For over 50 percent of the girls, mothers is the main source of knowledge.
 Mother is followed by friends (27%) and female relatives (18%).
 Teachers (12%), media like books, radio, and internet (15%), and health workers (18%) have less
influence though their potential to impart accurate information is high.
 Information provided to girls by mothers is very little and given too late, usually after menarche
rather than before. Often, the mothers also communicate their own misconceptions and beliefs
to their daughters, thereby continuing the cycle of misconceptions.
Prevalent Menstrual Hygiene Management Practices
Use of absorbents

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 In India, there is a bent in favor of external protection methods like cloth and sanitary pads as
compared with internal protection methods like tampons and menstrual cups.
 In rural community settings, as many as 68 percent of women still use cloth. This could be
because it is cheaper, easily available in every home, and reusable.
 In urban areas and among school-going girls, cloth is gradually being replaced by pads, with over
60 percent girls preferring to use pads and only about 37 percent using cloth. These girls, having
more exposure and education than non-school-going girls are likely to be more informed about
MHM practices and this could also account for the higher usage of sanitary pads by them.
 Other than sanitary pads and cloth, women in rural communities sometimes use material like
ashes, newspapers, dried leaves, and husk sand to aid absorption.
 Use of tissue and cotton has also been identified, but only on a very small scale.
 Use of tampons is restricted to a small proportion of girls (less than 3%) and women who are
living in urban areas, are well informed, have the affordability and/or are environmentally aware.
Menstrual cups usage is much less but there are no studies mentioning girls using them.
Personal hygiene:
 There are regional variations in bathing daily (response range: 63.6 % to 97.6%) and washing
practices during menstruation with girls in urban areas being more regular, perhaps due to
better availability of water and sanitation facilities.
Factors Affecting Menstrual Hygiene Management Practices
Socio-cultural and religious beliefs
 Most girls practice some restrictions during menstruation due to religious or socio-cultural
norms/beliefs. About 77 percent of girls and women avoid praying, visiting holy places and
touching religious texts. About 38 percent exercise restrictions in eating. As many as 24 percent
of girls choose to sit away from household members during menstruation. These restrictions
affect the girls’ mental state, hygiene practices, and health.
Environment available to adolescent girls for MHM at school and in the home/community
 Currently, about to 24 percent of girls refrain from physical exercise and attending school
during menstruation, due to lack of water, disposal facilities, clean toilets for girls in school and
fear of soiling their dresses and inability to change. Significant differences exist across rural and
urban regions with absenteeism being higher in rural areas.
 Key reasons for school abseenteism during menstruation were lack of proper disposal facility of
sanitary napkins (75%) and lack of continuous water supply for washing (67.5%) in school.
Missing school on a monthly basis is likely to hamper the girl’s education.
 Only about 51percent of adolescent girls have toilets in their homes. Urban areas have
significantly better facilities for girls than rural areas. Lack of a toilet at home takes away the
privacy that girls need to manage their menstral cycle in a safe and hygienic manner.
Gender issues and other factors
 Many households in rural India do not have private toilets as discussed above, and this is
reflective of lack of sensitivity towards womens health and privacy needs.
 The number and quality of public toilets for women are also far from adequate. Even in a city
like Delhi, there were an estimated 132 public toilets for women, as compared to 1534 for men
in 2014. This is indicative of the ignorance of a sensitive matter like women’s health and MHM.

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A girl’s and her mother’s education, ethnicity, household occupation, economic status, exposure
to mass media, and availability of private space and water are significant factors influencing
menstrual hygiene and autonomy in the management of menstruation.
Type, Cost, Access, and Other Barriers
 There are two types of absorbents that can be used during menstruation: external and internal.
External protection products (like sanitary pads, i.e. disposable pads and newer reusable pads)
are usually attached to the crotch of underpants to absorb menstrual flow after it leaves the
body, while internal protection products (like tampons, muenstrual cups, and menstrual sponge)
are inserted into the vagina to catch or absorb menstrual flow before it leaves the body.
Advantages and disadvantages of each type are summarized in Figure E1.
Figure E1. Different types of absorbents, and their advantages and disadvantages.
 External protection options, namely commercially or locally produced disposable sanitary pads
and cloth are the most used absorbents, with cloth being more used in rural areas and pads in
urban areas.
 Internal protection methods are not popular perhaps for family, cultural, and religious reasons.
Internal protection can cause the hymen to break, which is given a lot of importance to
determine the virginity of the girl.
 The percentage of girls who are currently using commercial disposable sanitary napkins as a
menstrual absorbent is nearly seven times higher in rich households (44%) than in poor ones
(8%). Cost is the deterring factor for about 79 percent. Access is the deterring factor for about
11 percent of the girls.
INTERNAL PROTECTION
→Tampons
→Sea Sponge Tampons (natural product)
→Disposable Menstrual Cups
→Reusable Menstrual Cups
ADVANTAGES:
-Much Easier to use once the correct way is
learned
-Menstrual cups can be re-usable and are
environmentally friendly
-Good absorbing capacity
DISADVANTAGES:
-Not easily available in India so far, though
popular in developed countries
-Need to be inserted into the vagina, which can
be a reason for lesser popularity
-Risk of Toxic Shock Syndrome with tampons if
not used correctly
-Hygiene and availability of water and soap are
particularly important
-More costly than external protection methods
EXTERNAL PROTECTION
→Commrecial Disposable Sanitary Pads
→Commercial Reusable Cloth Pads
→Reusable or Disposable Cloth
→Tissue/Cotton
→Reusable, absorbable period panties
ADVANTAGES:
-Commercial sanitary pads: hygienic, safe to
use
-Cloth pads : cost effective, reusable
-Cloth : Easily available, economical,
-All have good absorbing capacity
DISADVANTAGES:
-Tissues & cotton: Lose strength when wet,
can fall apart, difficult to hold in place.
-Commercial disposable pads: Expensive, not
-Old cloth: becomes unhygienic if unclean.
-For all, users need privacy to clean and
change; adequate water supply and soap
OTHER NATURAL
PRODUCTS
Mud, cow dung, ash, dry leaves
and other such products
(used in absence of other
protection)
ADVANTAGES:
-Free
-Locally available
DISADVANTAGES:
- Relatively unhygienic, high
risk of contamination and
infection
-Difficult and uncomfortable
to use
-Poor absorbents

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 As a whole, the various barriers identified in use of sanitary napkins include: (1) lack of
awareness, (2) poor health-seeking behavior, (3) limited availability of the product at economical
prices, (4) non-availability in the rural and interior areas, (5) financial constraints, (6) absence of
toilets for girls, (7) shyness to buy napkin in shops, (8) lack of disposal facilities, and (9) no space
for cleaning/changing.
 Biodegradable options available are currently very few and reusable cloth pads manufactured
commercially are very expensive (price range of INR 75-495 per pad). Moreover, awareness
about them as well as of environmental consequences of using disposable products is low, even
among the educated and financially well-off sections of society.
 Currently available non-biodegradable and biodegradable menstrual products in the Indian
market are shown in Table E1, with details about their approximate price range and number of
manufacturers.
Table E1. Menstrual Products Available in the Market.
Type of Product
Number of
Manufacturers
Brands Price Range
Non-biodegradable
disposable sanitary
pads
6 with multiple
product variants each
Whisper, Stayfree, Carefree, Sofy,
Wager Hygiene, Active Ultra (Saral
Designs)
INR 3.5 – 15 per pad
Biodegradable
disposable sanitary
pads
4 Saathi, Anandi, Sakhi, Wager Hygiene INR 2.5 – 20 per pad
Reusable cloth pads 7 Ecofemme, Uger, Shomoa, Saafkins,
My pad, SOCH,
INR 75 – 495 per pad
Menstrual Cups 7 She cup, Moon cup, Luna cup,
Stonesoup wings, Rustic Art, V Cup,
Alx cup
INR 650 - 2800 per
cup/kit
Tampons 1 OB ProComfort INR 12 per tampon
Environmental Implications of Disposal Practices
 Increase in use of safe menstrual hygiene products like disposable sanitary pads has an
environmental cost. Commercial disposable and non-biodegradable sanitary pads account for
close to 60 percent of product use by young girls and women, and this happens in the absence
of safe waste disposal mechanisms.
 More than one billion non-biodegradable sanitary pads are disposed into landfills, rural fields,
urban sewerage systems, and water bodies every month. This equates to 113,000 tons of
menstrual waste annually.
 Disposal of menstrual wastage does not have clear guidelines and law in India.
 Waste disposal mechanisms used range from burning (17%), burying (25%), throwing in open
spaces (23%), and flushing (9%) to proper disposal as municipal waste (45%). Throwing
absorbents with the routine municiple waste is more common in urban areas perhaps due to
better waste management systems. Environmental implications of each disposal process is
summarized in Table E2.
Table E2. Disposal Mechanism of Menstrual Absorbents and Environmental Implications

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Disposal of
menstrual
absorbent
Total
pooled
proportion
*
Rural
pooled
proportion
*
Urban
pooled
proportion
*
Slum
pooled
proportion
*
Environmental
implications
Throw with
routine
waste/dustbin
45 28 70 51 Menstrual waste enters the
solid waste stream, is placed in
landfills to disintegrate over
hundreds of years
Thrown in open
spaces like
water bodies,
roadside
23 28 15 30 Can contaminate water
sources and clog drains
Burning in open 17 15 23 - Burning of commercially
available pads at low
temperatures can create odors
and expose nearby population
to health risks related to air
pollution
Burying 25 33 12 - Without appropriate
composting, waste will take
hundreds of years to degrade
Flushing in toilet
or in pit latrines
9 10 7 - Absorbents mix with fecal
sludge, complicates disposal of
that sludge (in the case of
septic tanks) or interferes with
the production of usable
manure (in the case of leach
pits)
*Pooled proportion is a percentage that has been derived from data in studies included in the above systematic review.
 Even the municipal waste that is generated is largely filling up the landfills, causing further
environmental problems, in the absence of suitable high-powered incinerators.
 Incinerators are emerging as a preferred disposal and treatment option. However, it is still not
clear whether they can efficiently burn pads with high moisture content and super absorbent
polymer.
 In India, manufacturers require to disclose the environmental concerns (post-disposal and during
manufacturing) along with the method of use, indication of which side is absorbent, disposal
instruction, frequency of recommended change, date of manufacture and expiry date. However,
these guidelines are not being adhered to.
Discussion and Implications
Menstruation, which is a normal biological feature in women, continues to be masked in a culture of
silence and shame as it is taken to be something ‘dirty’ and ‘impure.’ Even today, girls and women, under
the garb of socio-cultural and religious practices imposed by society, continue to practice restrictions in
food intake, matters of hygiene such as bathing, and day-to-day physical activities during menstruation.
These restrictions are practiced by educated girls as well. In fact, school absenteeism during menstration
is not uncommon. This happens more in schools where facilities such as clean toilets for girls, disposal
facilities, and adequate water for washing are not adequate. While use of safe menstrual hygiene
products has grown over the years, this trend is not uniform across regions and socioeconomic levels.

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But use of menstrual products comes with costs to the environment in the absence of proper waste
segregation, management, and disposal. It is time to move towards options that are both women friendly
and environment friendly. Extensive literature review, secondary research, and analysis produce the
following policy and programmatic implications:
 There is a lack of information, guidance, and support on the changing bodily and MHM needs of
very young adolescents (10-14) and adolescents (15-19) in India. School teachers and health
workers whose capacities can be strengthened can play a more important role in informing and
guiding girls about menstruation and good MHM practices. Currently, their role as a source of
information is insignificant compared to the role of the mother, who may not always have the
most accurate information.
 Awareness programs for men and boys on MHM are equally important to de-stigmatize the
concept and create a more supportive environment for girls to facilitate good MHM practices.
 Girls and women need choices for menstrual products. Newer environmentally friendly
products such as reusable cloth pads are available but are expensive. Options to expand markets
for reusable cloth pads through social marketing and partnerships with manufacturers should be
considered to decrease cost, increase access, and expand choice of MHM products.
 Supply-side activities should be complemented by demand side activities such as social and
behavior change communication and other communication strategies including mass media and
new media (mobile and digital technology) for MHM advocacy and awareness.
 To improve MHM, mere awareness generation and provision of menstrual products is not
sufficient; the entire MHM value chain and infrastructure related to MHM is essential. These
include, but are not limited to (1) access to water; (2) safety, cleanliness, privacy and availability
of MHM facilities like toilets for girls and women; (3) engaging men and boys and integrating
gender approaches; and (4) exploring the role of the private sector in MHM. In short, it requires
a multi-sectoral approach and engagement and collaboration across ministries.
 Schools, both government and private, should be required to have adequate toilet facilities for
girls, with proper waste disposal systems and sufficient water at all times. Lack of such facilities
should not be a deterrent to good MHM practices, as it currently is.
 Lack of sensitivity of men and other family members about girls’ need for privacy, cleaning
facilities, water, and good hygiene at home is one major reason that many rural areas do not
have household toilets. This trend, whether it is due to ignorance or religious reasons, has to be
reversed.
 With the changing products landscape, the complex issue of disposal and the management of
menstrual waste needs attention at all levels: school, homes, community, and public places.
Proper waste management and safe disposal of menstrual products is important. There is limited
guidance for disposal. Waste needs to be segregated. The law defining within which category
menstrual waste falls and how it should be disposed needs to be clarified.
 It is important to shift attention on the environmental issues and make menstrual product
development more sustainable in the long run with lesser costs to consumers.
o Cloth is a viable product option, especially for those who cannot afford other products.
Unhygienic use and maintenance of cloth should be addressed through appropriate
information and availability of innovative low-cost products such as FLO that can help
maintain cloth in a hygienic manner.
o Awareness and availability of reusable and biodegradable products like cloth pads and
menstrual cups that have minimal impact on the environment should be increased.
Currently, their uptake is limited to consumers who have environmental awareness and
can afford them. A positive trend in recent years, however, is the growth of self-help

xi
groups and social enterprises that have started manufacturing and selling low-cost and
environmentally friendly products.
o Innovations in non-toxic and biodegradable sanitary pads can address the adverse impact
of MH products on waste management systems. Such innovations should be piloted,
tested, and scaled up. Innovations and good practices are discussed in Section 4 of this
report. There is a need to learn from innovations and build the evidence base on what
works in the Indian context.
 Awareness programs should not only work to dispell misconceptions related to menstruation,
they should also provide women with information about choices of menstrual products and
information about waste disposal.

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1. INTRODUCTION
1.1 Background
Menstrual hygiene management (MHM) is a problem for adolescent girls in low- and middle-income
countries (LMICs), particularly when attending school, and India is no exception (Dasgupta and Sarkar,
2008). Management of menstrual hygiene is crucial for adolescent girls and women to live healthy and
productive lives with dignity. MHM refers to the practice of being well informed about menstruation and
its cause, maintainence of good hygiene during menstruation, and use of clean absorbents to absorb
menstrual blood that can be changed privately, safely, hygienically and as often as needed for the
duration of the menstrual cycle. It also involves their safe disposal. Poor MHM practices may result in
health symptoms involving the urinary and genital tracts (MoHFW, 2011). Menstrual practices are
associated with numerous taboos and socio-cultural restrictions for adolescent girls and women, which
limit access to schooling and socializing, adding to existing gender discrimination.
Limited access to accurate information and products for sanitary hygiene makes menstruation a
distressing experience for adolescent girls and women. Girls require accurate and comprehensive
information about what menstruation is, why it occurs, menstruation hygiene management, regular
access to menstrual absorbents (such as cloth, napkins, or any material or product used to collect
menstrual flow), access to clean water, sanitation facilities, and privacy to change and dispose the
menstrual absorbents for healthy passage through the menstrual cycle. In most developing countries,
many adolescent girls and women do not have access to basic facilities such as safe and hygienic
absorbents, running water, and even toilets to maintain menstrual hygiene (Shah et al., 2013).
Recognizing the relevance of MHM to the health, wellbeing, and educational achievements of girls, the
Government of India has initiated an array of policies and programs to improve MHM practices through
multiple ministries and departments. In 2011, the Ministry of Health and Family Welfare (MoHFW)
launched a scheme for promotion of menstrual hygiene among adolescent girls under the National Rural
Health Mission. Since then the scheme has undergone various revisions to increase the geographical
coverage of the scheme, accessibility of sanitary napkins at low cost, awareness of menstrual hygiene
among adolescent girls, and safe disposal of sanitary napkins. However, the road ahead is long and there
is a need to explore opportunities and product options to improve MHM practices.
1.2 Problem Statement and Objectives of the Review
Girls and women in India (as in many other developing countries) use a variety of safe and unsafe
absorbent materials during menstruation, which may be disposable or non-disposable. The choice of
absorbents is guided by their knowledge, access, and the affordability of products and facilities to wash
or dispose them, as well as the socio-cultural acceptability of absorbent materials and facilities. The
choice of absorbents and practices related to disposal or reuse can have implications for the health of
girls and women as well as substantial impacts on the environment. There is limited consolidated
evidence on the use of various types of menstrual absorbents and disposal practices followed by
adolescent girls. Policy makers require updated information about the state of MHM in different
geographies and social settings for the development of a comprehensive package of MHM interventions,

2
efficient operational plans, and strategies to ensure successful uptake of schemes by targeted sub-
populations.
The MoHFW needs comprehensive information about prevalent MHM practices among adolescent girls,
knowledge and attitudes towards MHM, disposal practices, advantages and disadvantages of various
types of absorbents, and the environmental hazards linked with safe disposal of absorbents. This
information will help strengthen policies and programs related to MHM and adolescent well-being.
In accordance with the problem statement, the broad objective of this study is to conduct a secondary
review of literature and present consolidated evidence about MHM practices among adolescent girls in
India, with a special emphasis on current knowledge about menstruation that influences MHM practices,
types of absorbents available and those that are actually used, the environment available for MHM, and
disposal mechanisms. It also aims to understand the nature of environmental hazards caused by unsafe
disposal of sanitary napkins.
Specific research questions that have been addressed are:
1. What is the knowledge and attitude of adolescent girls on MHM practices and what are the
sources of information?
2. What are the social and cultural beliefs and taboos which influence the choice of absorbents,
hygiene practices, and disposal of absorbents?
3. What are the most prevalent MHM practices among Indian adolescent girls?
4. What are the different types of absorbents used by the adolescent girls including both non–
disposable (cloth, commercial reusable sanitary pads, menstrual cups etc.) and disposable
options (natural material like mud, cow dung, commercial sanitary pads, tampons etc.)? What
are the mechanisms of disposal?
5. What are the advantages and disadvantages of disposable vs non-disposable napkins and other
absorbents?
6. How do cost and access barriers influence mensuration hygiene practices?
7. What are the environmental hazards linked with unsafe disposal of disposable napkins?
This study was conducted by the USAID-funded Health Finance and Governance project from May to
August 2017. This report presents key findings and insights, which are expected to inform the way
forward for policies and programs related to menstrual hygiene management and adolescent well-being.

3
2. METHODOLOGY
The study was conducted over a four month period and involved secondary data collection and review.
The scope, objectives and research questions were formulated and finalized in consultation with the
MoHFW and USAID. Key findings from the secondary data collection and analysis were compiled into a
report.
2.1 Literature Review
To explore the research questions, an extensive literature review of the published peer-reviewed
papers, journal articles, project reports, state reports, and white papers was conducted. While we
reviewed the status of MHM in India and several other low and middle income countries, the focus in
this report was to describe the current levels of knowledge and practices relating to menstrual hygiene
in India only, given the aim of the study and research questions.
Methods of analysis and inclusion criteria were specified in advance. We searched for studies with
information on MHM on Pubmed, Google Scholar, and other such sites. Key words paired with
‘adolescent girls in India,’ ‘menstrual practices,’ and ‘MHM’ during the search were ‘knowledge,’
‘attitude,’ ‘perceptions,’ ‘practices,’ ‘management,’ ‘disposal practices,’ ‘use of absorbents,’ ‘health issues
linked with MHM,’ ‘social taboos,’ ‘cultural practices and MHM,’ and ‘disposal and environmental risks.’
Two particularly useful papers and sources of other references were (1) a paper which comprised a
systematic review and meta-analysis that examined all papers published between 2000 and September
2015, to assess the status of MHM among adolescent girls in India (10-19 years) (Van Eijk et al., 2016)
and (2) a study mapping the knowledge and understanding of menarche, menstrual hygiene, and
menstrual health among adolescent girls in low- and middle-income countries (Chandra-Mouli and Patel,
2017).
2.2 Report Writing
This report answers all the research questions that were identified as crucial in the Indian context. The
process of culling out the answers involved analyzing the findings from the multiple papers and articles
reviewed. Findings have been categorized into four sub-sections under the main section of key findings
(section 3). Sub-section 3.1 addresses research questions 1 and 2 related to the awareness and
knowledge pertaining to MHM practices among adolescent girls in India, main sources of information and
socio-cultural taboos, and their impact on MHM. Sub-section 3.2 addresses research question 3,
pertaining to current MHM practices. Sub-section 3.3 identifies the cost and access barriers linked to
use of different types of absorbents and thus addresses research questions 4, 5s and 6. Sub-section 3.4
answers the research questions 4 and 7, touching upon disposal and environmental concerns. The
report also highlights some best practices in MHM in India in section 4. Some examples have also been
drawn from other low- and middle-income countries oin Africa, as they can provide useful lessons.
Finally, section 5 discusses the implications of the report findings and emergent opportunities.

4
3. KEY FINDINGS
This section presents key findings from the study of MHM practices in India. Findings and insights
addressing the research questions have been grouped under four sub-heads in this section: (1)
Knowledge, cultural beliefs, and information sources about menstruation, (2) Prevalent MHM practices
and affecting factors, (3) Cost, access, and other factors determining absorbent use, and (4)
Environmental hazards linked with unsafe disposal of menstrual hygiene products.
3.1 Knowledge, Cultural Beliefs, and Information Sources
About Menstruation
Girls in India, as in many LMICs, enter puberty with knowledge gaps and misconceptions about
menstruation. This leaves them unprepared to cope as menstruation begins. Many are unsure of when
and where to seek help, in part because the adults around them, including parents and teachers, are
themselves ill-informed and uncomfortable discussing sexuality, reproduction, and menstruation. The
word menstruation has since earlier times been counted as something ‘dirty, polluting, and shameful.’ It
has also been associated with a number of social taboos and myths (Deo and Ghattargi, 2005; Singh,
2006). Such beliefs lead to inaccurate knowledge about menstruation and affect MHM practices.
Awareness about menstruation, its causes, and management vary from state to state and from rural to
urban areas, with better awareness in urban areas. Household occupation, media exposure, and
economic status are other determinants, as are parents (especially mothers) level of information and
education. Age is also a factor, with girls who have reached menarche being more informed than girls
who have not yet started menstruating.
Premenarche awareness about menstruation: The findings of a meta-analysis on premenarche
awareness about menstruation studies in India from 2000 to 2015 reveal that among 88 studies with
available information, the pooled prevalence of premenarche awareness was 48 percent (Van Eijk et al.,
2016). In a multivariate analysis, the prevalence was affected by setting, region, and year of study, with
significantly higher awareness over time and in the East and West of India as compared to in the North.
Awareness was also lower in rural and slum settings. Studies done in other countries have shown
parents’ education level to also have a significant influence on premenarche knowledge. For instance, in
Nigeria, pre-menarcheal girls whose parents had received tertiary education were the most likely to
have been trained on MHM (Aniebue, Aniebue, and Nwankwo, 2009). A recent Indian study (Kapoor
and Kumar, 2017) conducted in Jammu and Kashmir found that only 49 percent of the participants were
aware about menstruation before menarche (mean age of menarche in this study was 13.43 years).
Source of bleeding: There is a substantial knowledge gap among girls regarding the origins of
menstrual blood. In the meta-analysis, only about 23 percent of girls knew that the uterus is the source
of bleeding, and approximately half (55%) considered menstruation normal. Studies carried out in four
different states (Bobhate and Shrivastava, 2011; Thakre et al., 2011; Sudeshna and Aparajita, 2012;
Narayan et al., 2001; Arora et al., 2013) also indicated that no more than a third of girls correctly
identified the uterus as the source of menstrual blood. In one study (Bobhate and Shrivastava, 2011), age
had a significant influence on the Mumbai city slum dwellers’ knowledge, with older girls being more
knowledgeable about menstruation than their younger counterparts (p-value <0.05). Regional variations

5
are wide and knowledge levels among girls vary from as little as 2.5 percent (Dasgupta and Sarkar, 2008)
to as many as 63.3 percent of girls aware of the source of bleeding (Yasmin et al., 2013). Only a third of
rural-living high school girls surveyed in India associated the attainment of menarche with the capacity to
conceive (Shanbhag et al., 2012).
Knowledge about MHM practices: While awareness about what menstruation is is low in younger
girls who have not yet attained menarche, knowledge about menstrual hygiene and practices is similarly
inadequate, especially in the older girls who have already started menstruation. A recent descriptive
cross-sectional study conducted with 100 adolescent girls from grades 9 to 12 at a Government Girls
School in Shimla, Himachal Pradesh found that 71 percent of the older girls had inadequate knowledge
about menstrual hygiene (Mahajan and Kaushal, 2017). The same study found that mother’s education
had a significant positive association with the knowledge scores of the participants. Another study
undertaken in three districts in Uttar Pradesh found that although knowledge of menstrual hygiene was
low among the three sampled districts, significant differences were found in knowledge, practice, and
perception of menstrual hygiene across the districts (Malhotra et al., 2016). Household occupation,
media exposure, and economic status were found to significantly associated with girls’ knowledge and
information about menstruation in this study (Malhotra et al., 2016).
School-based health education can lead to significant improvements in MHM practices like washing
absorbent cloths with soap, drying them in the sun, and in disposing of them safely (Nemade, Anjenaya,
and Gujar, 2009). The same study also found that the proportion of girls using soap to clean their
genitalia significantly increased from 30.0 to 94.3 percent due to health education (Nemade, Anjenaya,
and Gujar, 2009).
Sources of information: Mothers were most commonly mentioned as the knowledge source in 43
studies of the meta-analysis, with 52 percent of girls reporting their as the main source (Van Eijk et al.,
2016). Mothers were followed by friends with 27 percent of girls reporting them as a source. Female
relatives (18%), teachers (12%), media like books, radio, and internet (15%), and health workers (18%)
were the other sources of information, though they were less commonly reported. Regional differences
were also found (Van Eijk et al., 2016). Detailed findings from the meta-analysis study are shown in Table
1.
Table 1. Pooled Proportions of Sources of Information About Menarche and Menstruation, Overall
and by Setting, in Indian Studies Published Between 2000 and 2015
Information
source on
menarche
Total studies
out of 88
pooled
%
Rural
(total 39
studies)
%
Urban
(total 37
studies)
%
Slum
(total 5
studies)
%
Mother 43 52 15 52 18 50 4 5
9
Friends 37 27 12 32 15 24 3 20
Relatives, including
sister
26 18 10 15 14 19 4 5
Teacher 25 12 8 11 12 13 2 15
Media (books,
movies, internet,
radio)
17 15 6 17 9 16 0 0
Health workers 4 18 1 0. 2 .4 1 .06

6
01 2
Source: Van Eijk AM, Sivakami M, Thakkar MB, et al. 2016. Menstrual hygiene management among adolescent girls in India: a systematic review and metaanalysis. BMJ Open 2016;6:
e010290. doi:10.1136/bmjopen-2015-010290.
Recent individual studies also found mothers as the main source of information across states. For
instance, Mahajan and Kaushal (2017) found that most girls receive gynecological information from their
mother, religious books, older sister, or a peer. In another study, one of the latest on the topic,
Chandra-Mouli and Patel (2017) compiled information about the most common source of information
about menstruation for rural and urban girls from various studies conducted in India and several other
LMICs. Findings for India are presented in Annex A, which shows that in one study (Kanotra, Bangal, and
Bhavthankar, 2013) as many as 94 percent of girls mentioned their mother as a source of information.
However, most of these studies indicate that the information provided was generally very little and given
too late, usually after menarche rather than before. Often, mothers communicate their own
misconceptions to their daughters, perpetuating social and religious taboos.
3.2 Menstrual Hygiene Management Practices and Affecting
Factors
Correct MHM practices are essential for health and well-being. Daily bathing, adequate washing of
genitalia, and use of sanitary pads or other sanitized/hygienic absorbents form an essential part of a girl’s
routine for hygienic management. Continuation of normal activities, including physical exercise and
maintaining a balanced diet including fruit and vegetables rich in iron and calcium are equally important
(UNICEF, 2008). Despite these recommendations, MHM practices remain poor in India and in many
LMICs (Dasgupta and Sarkar, 2008).
The cultural, social, and family environments in which girls grow up have immense influence on their
beliefs, attitudes, and practices during menstruation (UNICEF, 2012). Cultural taboos imposed by
society often prevent young girls from seeking help and impose restrictions on their diet and activities
when menstruating (Garg, Sharma, and Sahay, 2001; Narayan et al., 2001; Thakur et al., 2014). In India,
poor access to water, sanitation, and hygiene facilities in schools, inadequate puberty education, and lack
of hygienic MHM items (absorbents) cause girls to experience menstruation as shameful and
uncomfortable, hampering healthy MHM practices. The situation is no better for girls living in slums and
rural areas, where toilet facilities are not adequate and MHM items like absorbents are not easily
available or affordable.
Section 3.2.1 discusses finding related to a few key MHM practices, namely the use of absorbents and
personal hygiene during menstruation. Section 3.2.2 highlights some of the crucial factors which
influence these pactices, including socio-cultural beliefs, religious beliefs, and gender issues.
3.2.1 Current Menstrual Hygiene Management Practices
Use of absorbents: Findings from the meta-anlaysis (Van Eijk et al., 2016) reveal that cloth, which has
been traditionally used to absorb menstrual flow, is still used in many parts of the country. In community
settings, as many as 68 percent of women were found to be using cloth. However, cloth is gradually

7
being replaced by pads, particularly in urban areas and among school-going girls, with only about 37
percent of school-going girls using cloth. While cloth has its own advantages of being easily accessible,
affordable, and environmentally friendly, its use can be a concern where shortage of water leads to
improper washing and lack of private space to dry in the sun leads to cloth storage/hiding in unhygienic
places, which increases probability of urinary tract infections and health risks (Shanbhag et al., 2012;
Arunmozhi and Antharam, 2013; Muralidharan, Patil, and Patnaik, 2015). Drying in the sun is
recommended for its microbiocidal effect, but girls in some studies preferred hiding wet cloths in
cupboards or under clothes because of shame (Khanna, Goyal, and Bwahsar, 2005). Some of the
previous studies have revealed that despite having knowledge, due to cultural restrictions and a lack of
infrastructure (including a toilet at home, separate bathing spaces, and space to discard or burn the
absorbent), girls and women often experienced embarrassment and were unable to observe proper
hygiene practices during menstruation (Narayan et al., 2001; Bharadwaj and Patkar, 2004; Fernandes,
2010; Thakre et al., 2011).
One study found a large number of women in India sometimes resort to using ashes, newspapers, dried
leaves, and husk sand to aid absorption due to lack of other materials (SOS Children’s Village, 2014).
There are very few studies in the Indian context mentioning the use of internal protection by girls. In
the meta-analysis (Van Eijk et al., 2016), one study in urban Tamil Nadu asked about materials inserted
into the vagina (reported by 26.9%), but it was unclear if these were tampons (Arunmozhi and
Antharam, 2013). Another study in urban Karnataka mentioned tampons, with five girls reportedly using
them (Pokhrel et al., 2014). Yet another very recent study conducted in 2017 with 486 school-going
girls in Bengaluru City of Karnataka found only 2.7 percent of the adolescent girls to be using tampons
(Srinivasa and Manasa, 2017). No studies reported use of menstrual cups.
Table 2 compiles the findings of several studies conducted in different states of India pertaining to the
use of absorbents. One of the major sources of this compilation is a recent paper by Chandra-Mouli and
Patel (2017). As in the cases of sources of information about menstruation and menstrual practices (in
Annex A), they compiled information about personal hygiene practices during menstruation like daily
bathing and the impact of menstruation and beliefs related to it on the normal activities of rural and
urban girls (like playing or going to school) for various LMICs from studies conducted over the last 15
years.
Table 2: Snapshot of Studies Analyzing MHM Practices and Other Normal Activities Influencing
MHM in India.
First
author,
Year
Setting
School
status
#
Use
sanitary
pads
(%)
Use
sanitary
pads+
cloth (%)
Use old
or new
cloth
(%)
Other
material
like
tissue,
cotton,
etc. (%)
Bathe
daily
(%)
Avoid
social
and
physical
activity
Abstinen
-ce from
religious
activity
Missing
school
Narayan
2001
Rural School-
going 327 1.7% 48.0% 82.5% NR NR - - -
Narayan
2001
Urban School-
going
292 8.3% 17.1% 72.2% NR NR - - -
Khanna
2005
Mix Out-of-
school
304 2.0% NR 90.9%
0.3%
NR - - -
Khanna
2005
Mix School-
going
307 6.2% NR 68.4% 0.7% NR - - -

8
Khanna
2005
Rural Mix
281 3.2% NR 92.2% 0.7% NR - - -
Khanna
2005
Urban Mix
330 4.8% NR 69.0% 0.3% NR - - -
Dasgupt
a 2008
Rural School-
going
160 11.3% 40.0% 48.8% NR NR 36.3% 60.0% 13.8%
Mudey
2010
Rural School-
going 300 15.7% NR 46.7% NR NR NR 87.0% NR
Omidva
r 2010
Urban School-
going
350 68.9% NR 19.1% 11.1% 81.7% - - -
Thakre
2011
Rural School-
going
146 30.8% NR 69.2% NR NR
NR 44.7% 5.2%Thakre
2011
Urban School-
going 241 60.6% NR 39.4% NR NR
Goel
2011
Urban School-
going
478 NR NR NR NR 92.9% 42.7% 76.2% 14.0%
Shanbha
g 2012
Rural School-
going
329 44.1% 21.2% 34.7% NR 88.8% NR 94.2% NR
Sudeshn
a 2012
Rural School-
going 190 13.2% 24.2% 62.6% NR NR NR 75.8% 37.9%
Nair
2012
Urban School-
going
3,443 45.5% 38.2% 16.3% NR 97.6% - - -
Juyal
2013
Mix School-
going
453 38.4% 26.7% 34.9% NR 63.6% 8.6% 87.4% NR
Bodat
2013
Rural School-
going 622 48.1% NR 51.9% NR NR NR NR 43.2%
Kanotra
2013
Rural School-
going 323 89.5% NR 10.5% NR NR 76.6% NR NR
Yasmin
2013
Urban School-
going 147 82.3% 1.4% 16.3% NR 85.7% 18.4% 90.5% NR
Wasnik
2015
Rural School-
going 435 33.6% 9.2% 57.2% NR NR - - -
Rana
2015
Rural Mix
400 39.0% NR 61.0% NR NR 28.0% 53.2% 26.4%
Bhattac
haryya,
2015
Urban School-
going - 81.7% 18.3% - - - - - -
Kapoor
2017
Rural School-
going
132 59.1% 26.5% 14.4% - 93.2% 10.0% 51.5% 28.5%
Note: NR=No response.
Studies have been arranged in ascending order of their year of publication. It is interesting to note that
use of sanitary pads has grown over the years, especially after 2010 in both rural and urban areas.
Another interesting trend which substantiates the meta-analysis findings is that use of cloth continues to
be much higher in rural areas as compared to urban areas, even in recent years (Wasnik, Dhumale, and
Jawarkar, 2015; Rana et al., 2015). Most of the studies have been conducted with school-going girls.
These girls, having more exposure and education as compared to non-school going girls, are likely to be
more informed about MHM practices, and this may account for their higher usage of sanitary pads.

9
Personal hygiene during menstruation: Knowledge, urbanization, and the presence of sanitation
facilities and water influence the personal hygiene of girls. One study of rural school-going girls in North
India found that 90.91 percent of participants regularly washed their hands, and 86.36 percent of those
participants used soap and water for hand washing (Kapoor and Kumar, 2017). Regular cleaning of the
external genitalia was reported by 65.91 percent of participants, of which 66.67 percent used soap and
water and 33.33 percent used only water.
Reported bathing practices in India ranged from all 200 rural-living tribal girls in one state abstaining
during menstruation (Dhingra, Kumar, and Kour 2009) to nearly all 3,443 girls in urban areas of another
state bathing daily (Nair et al., 2012). One study found that the practice of daily bathing was significantly
more common (p < 0.05) among urban-living girls than rural-living girls in Dehradun, Uttarakhand (Juyal,
Kandpal, and Semwal, 2013), and another found that both a regular source of water and a private
bathroom exclusive to a family had significant (p < 0.001) relationships with taking a daily bath (Yasmin
et al., 2013). In communities in Gujarat, 91 percent of girls reported staying away from flowing water
when they did not have a bathroom in their house; some feared soiling the public toilets (Mahon and
Fernandes, 2010).
3.2.2 Factors Affecting MHM Including Daily Activities During Menstruation
Socio-cultural taboos: Socio-cultural taboos and beliefs about menstruation can adversely impact
girls’ and women's emotional states, behaviors, and health. Shame and stigma associated with
menstruation prevents open discussion, including seeking help. Fear of others seeing their reusable cloth
absorbents prevents some girls and women from properly washing their cloths with soap and drying
them in the sun.
Most girls impose behavioral restrictions on themselves during menstruation due to cultural
norms/beliefs. About 77 percent of girls and women avoid visiting holy places and touching religious
texts across the country (Van Eijk et al., 2016). This is largely due to the belief that menstruation is
impure and dirty. About 38 percent impose restrictions on eating. As many as 24 percent of girls will sit
away from household members during menstruation. In one study, as many as 98.48 percent of the
respondents followed some restriction or taboo during menstruation, despite being school-going and
thus educated (Kapoor and Kumar, 2017). Main restrictions followed by the participants were in:
attending religious functions (51.54%), routine household work (34.62%), attending school (28.46%),
refraining from eating certain types of food (23.85 %), and playing (10%).
Environment available to adolescent girls for MHM at school and in the home/community:
The safety, cleanliness, accessibility, and privacy of MHM facilities at school, home, or other
environments is essential to promoting good MHM practices.
Van Eijk et al. (2016) found 64 studies that discussed school absenteeism during menstruation. About 24
percent of percent of girls refrained from physical exercise and attending school during menstruation,
with significant differences across regions. Reasons for absenteeism were physical discomfort or pain,
lack of water, hygiene, and disposal facilities in school toilets, fear of staining their clothes, and
restrictions imposed by relatives or teachers. Only about 37 percent of girls reported changing their
absorbent in school. This is largely because many schools do not have safe, clean, accessible, or private
toilets with disposal facilities where girls can hygienically clean themselves. For instance, one study
conducted on school-going girls in rural West Bengal found that the main reasons for girls’ absence from

10
school during menstruation were lack of proper disposal facility of sanitary napkins (75%) and lack of
continuous water supply for washing (67.5%) in their school (Sudeshna and Aparajita, 2012).
Most girls prefer to change absorbent materials at home rather than in school or other public places
(Thakre et al., 2011). Cloth use was also associated with increased absenteeism. This could be because
cloth does not have the same absorbing capacity as sanitary napkins and so risk of staining and
discomfort is higher. Missing school on a monthly basis jeopardizes girl’s education. If girls had easy
access to affordable and long lasting sanitary pads, and better MHM environments in schools, reduce
fears and discomforts that lead to shcool absenteeism could be reduced.
In the meta-analysis, about 51 percent of girls reported having toilets at home (range of responses
varying from 36% to 67%), and there was a significant difference between urban and rural settings, with
more girls in urban areas having toilets at home (Van Eijk et al., 2016). Lack of a toilet at home impedes
the privacy that girls need to manage their menstral cycle in a safe and hygienic manner, such as changing
their disposable/re-usable absorbents or cleaning their reusable absorbents in. A recent study by Kapoor
and Kumar (2017) in the state of Jammu and Kashmir found that among school-going girls, among the 40
percent of the girls who used cloth during menstruation, 83 percent had problems while washing and
drying of the cloth. The problems consisted of shortage of water (40%), lack of privacy (40%), and lack
of space for washing and drying (20%). In the same study, toilets were present in the homes of only 76
percent of girls. Other recent studies also highlight the scarcity of toilets and privacy as difficult trends.
In Uttar Pradesh, a study of school-going and non-school-going girls (73% were school-going) in 3
districts found that 36 percent of girls lack private spaces and 9 percent lack water for washing their
absorbent cloths (Malhotra et al., 2016). Further, only 61 percent had a private bathing space and 85
percent lacked toilet facilities within the house.
Another study on examined secondary school girls in rural areas of West Bengal found that about 71.6
percent of girls did not have toilets and water facilities in their house (Sudeshna and Aparajita, 2012). A
majority (62.6%) of the girls used cloth as their only menstrual absorbent and 52.1 percent washed the
reusable cloths in pond water with soap due to the absence of facilities in their own house. To dispose
of their absorbents, most of the girls threw them indiscriminately in a pond (53%) or in the nearby
bamboo garden (45%). The same pond was used daily chores like washing utensils, clothes, and for
bathing.
Gender issues affecting MHM: Ignorance of men in households and lack of community sensitivity
towards girl’s and women’s health needs may help explain why many rural households do not have a
toilet. Even the number and quality of public toilets for women are far from adequate. A study by SOS
Children’s Village (2014) found that in Delhi there were an estimated 132 public toilets for women
compared1,534 for men. This is clearly indicative of the lack of attention given to MHM and women’s
health. To address this issue, the provision of sanitary napkins and adequate facilities for good MHM
practices must be explicitly considered in municipal planning and public policy. A positive step in this
direction has been taken recently by the South Delhi Municipal Corporation. It has issued directions to
all 4,618 licensed eating outlets, including hotels, to make their washrooms accessible to the public at a
fee of INR 5. This is a positive development for the urban women of South Delhi, as prior to the
instructions, only 40 toilets out of 580 public urinals and 480 public toiliets could be used by women
(Hindustan Times Newspaper, 2017). Similar initiatives are needed in other parts of Delhi and across
India.
Other factors: Socioeconomic characteristics such as place of residence (state/district, rural/urban), a
girl’s and her mother’s education, ethnicity, household occupation, economic status, exposure to mass
media, and availability of private space have been found significant factors in influencing menstrual

11
hygiene and autonomy in MHM practices (Malhotra et al., 2016). Improving the education and social
status of girls and women are some of the crucial ways to positively influence community health status
at large and to overcome cultural taboos. Education for male family members is also pertinent in
combating deep rooted social beliefs and cultural taboos (Garg and Anand, 2015).
3.3 Type, Cost, Access, and Other Barriers to Absorbent
Use
Types of absorbents: There are two basic types of absorbents that can be used during menstruation:
external and internal. External protection products are usually attached to the crotch of underpants to
absorb menstrual flow after it leaves the body, while internal protection products are inserted into the
vagina to absorb menstrual flow before it leaves the body. Figure 1 showcases different menstrual
products and their advantages and disadvantages; Annex B further classifies them as disposable and non-
disposable and discusses their advantages and disadvantages in greater detail. Some absorbents
mentioned such as sea sponge tampons and period panties are not yet used in India.
Figure 1: Different types of absorbents, and their advantages and disadvantages.
External protection options are more popular in India, particularly in rural areas. This is perhaps because
of family, cultural, and religious reasons. Internal protection can cause the hymen to break, which is
sometimes considered important to determine the virginity of girls. However, it is an established fact
that the hymen may not even be present in all girls, and moreover it can break for several reasons
including vigorous sport activities (Hegazy and Al-Rukban, 2012).
INTERNAL PROTECTION
→Tampons
→Sea Sponge Tampons (natural product)
→Disposable Menstrual Cups
→Reusable Menstrual Cups
ADVANTAGES:
-Much Easier to use once the correct way is learnt
-Menstrual cups can be re-usable and are
-Good absorbing capacity
DISADVANTAGES:
-Not easily available in India so far, though popular in
develoed countries
-Need to be inserted into the vagina, which can be a
reason for lesser popularity
-Risk of Toxic Shock Syndrome with tampons if not
used correctly
-Hygiene and availability of water and soap are
particularly important
-More costly than external protection methods
EXTERNAL PROTECTION
→Commrecial Disposable Sanitary Pads
→Commercial Reusable Cloth Pads
→Reusable or disposable Cloth
→Tissue/Cotton
→Reusable, absorbable period panties
ADVANTAGES:
-Commercial sanitary pads: hygienic, safe to use
-Cloth pads : cost effective, reusable
-Cloth : Easily available, economical, environmentally
friendly
-All have good absorbing capacity
DISADVANTAGES:
-Tissues & cotton: Lose strength when wet, can fall
apart, difficult to hold in place.
-Commercial disposable pads: Expensive, not
-Old cloth: becomes unhygienic if unclean.
-For all, users need privacy to clean and change;
adequate water supply and soap
OTHER NATURAL
PRODUCTS
Mud, cow dung, ash, dry leaves and
other such products
(used in absense of other
protection)
ADVANTAGES:
-Free
-Locally available
DISADVANTAGES:
- Relatively unhygienic, high
risk of contamination and
infection
-Difficult and
uncomfortable to use
-Poor absorbants

12
Sanitary pads and cloth are the most widely used absorbents across states. Commercially available
disposable sanitary pads are growing increasingly popular over time, especially in urban areas and among
school-going girls. Among rural school-going girls, usage varied from about 16 percent (Mudey et al.,
2010) to as high as 89 percent (Kanotra, Bangal, and Bhavthankar, 2013). Among urban school-going
girls, usage ranged from about 46 percent (Nair et al., 2012) to 82 percent (Yasmin et al., 2013). Pad
usage was uncommon between 2000 and 2010, but has increased in the years since.
Old and new cloth is also used extensively, despite difficulties in cleaning and drying. Use is generally due
to lack of other options. Only studies by Khanna, Goyal, and Bwahsar (2005) and Omidvar and Begum
(2010) mentioned the use of tissue and cotton, though on a very small scale. Finally, only one study (SOS
Children’s Village, 2014) identified the use natural products like ash, dried leaves, and husk sand by
women to aid absorption.
Cost, access, and other barriers: Sanitary napkins, if manufactured in a hygienic manner, are
universally accepted as a safe method of practicing menstrual hygiene. They also have better absorbing
capacity and are culturally more acceptable in India as compared to tampons and menstrual cups. Thus,
they can be a good option for adolescent girls to use as compared to cloth and other materials like
tissue, cotton, or natual materials. A study in rural India reported that girls using sanitary pads reported
less cases of poor fit and rashes compared to girls using cloth (Rana et al. 2015). However, cost
remained a concern for pad users.
Today, several brands of commercial sanitary pads, both biodegradable and non-biodegradable, are
available in the market (Table 3). These are easily accessible in cities and bigger towns. Biodegradable
options are currently very expensive and awareness about them as well as of the environmental
consequences of using disposable products is low, even among the educated and financially well-off
sections of society. Consequently, non-biodegradeable disposable products are more commonly used.
However, even these are costly for the lower- and middle-income sections of society (Malhotra et al.,
2016). The percentage of girls who were currently using commercial disposable sanitary napkins as a
menstrual absorbent was nearly seven times higher in rich households (44%) than in poor households
(8%), and cost was the deciding factor for 79 percent of girls in one study (Kapoor and Kumar, 2017).
Other factors were non-availability and disposal problems.
Table 3: Menstrual Products Available in the Market.
Type of Product
Number of
manufacturers
Brands Price Range
Non-biodegradable
disposable sanitary pads
6 with multiple product
variants each
Whisper, Stayfree,
Carefree, Sofy, Wager
Hygiene, Active Ultra
(Saral Designs)
Biodegradable disposable
sanitary pads
4 Saathi, Anandi, Sakhi,
Wager Hygiene
Reusable cloth pads 7 Ecofemme, Uger, Shomoa,
Saafkins, My pad, SOCH,
INR 75 – 495 per pad
Menstrual Cups 7 She cup, Moon cup, Luna
cup, Stonesoup wings,
Rustic Art, V Cup, Alx cup
INR 650-2800 per cup/kit
Tampons 1 OB ProComfort INR 12 per tampon

13
Table 3 shows that even reusable cloth pads are quite expensive at the time of purchase, though they
may be more cost-effective in the long run. Biodegradable disposable napkins are not as expensive and
are similar in pricing as commercial pads, but their production is on a limited scale by smaller and lesser
known brands. There is only one manufacturer for tampons in India. Menstrual cups have seven
manufacturers and are reusable, biodegradable, and cost-effective in the long run, but again awareness
about menstrual cups is low, while other factors such as difficulty of proper use and cultural barriers
also limit use. Some believe menstrual cup use can increase the size of the vagina, though this is not true.
Other barriers identified in use of sanitary napkins include: (1) lack of awareness, (2) poor health-seeking
behavior, (3) limited availability of the product at economical prices, (4) unavailability in rural and
interior areas, (5) financial constraints (regardless of price), (6) absence of toilets for girls, (7) shyness
about buying napkins in shops, (8) lack of disposal facilities, and (9) lack of space for cleaning/changing.
(Mahajan and Kaushal, 2017).
To address the problems of cost and access, especially in rural areas, the National Rural Health Mission
initiated a scheme for the promotion of menstrual hygiene among adolescent girls in rural areas of the
country in 2010. The main focuses of the scheme were to increase awareness among adolescent girls
about menstrual hygiene and increase access to and use of high quality sanitary napkins by adolescent
girls in rural areas. At the community level, Accredited Social Health Activists were made responsible
for ensuring an adequate supply of sanitary napkins for adolescent girls who require them (NRHM
Newsletter, 2011). The napkins branded as “Freedays” were to be supplied to adolescent girls at a
nominal and subsidized price of INR 6 per pack of six napkins. The price remains unchanged and the
program is now run by the National Health Mission, into which the National Rural and Urban Health
Missions have been merged. While this is a very well regarded and much needed initiative, there are still
some problems with the scheme. Foremost, it has yet to cover all the districts of India. Additionaly,
there are indications that there could be a problem with the quality of pads supplied and regularity of
supplies. Once such instance was noted by Sharda Mahila Vikas Society, which is a voluntary
development organization promoting women’s awareness and empowerment in the rural and tribal area
of the Jhagadia block of South Gujarat. While implementing an adolescent health and awareness program
locally, Sharda Mahila Vikas Society observed problems related to the use of the subsidized sanitary pads
due to irregular supply, lack of awareness on how to use them, the sub-optimal quality of the pads, and
unavailability of appropriate means of disposal, which resulted in low acceptability (Shah et al., 2013).
Further studies across other states where the scheme is being implemented are needed to determine
the scale of these problems.
There is a need for a wider variety of external and internal protection products to be made available for
adolescent girls to choose from, especially in a populous country like India. The entry of more
manufacturers into the market will not only widen choices but also lower costs through competition.
3.4 Environmental Implications of Disposal Practices
As reported in the fourth National Family Health Survey, 57.6 percent of girls and young women aged
15- 24 years reported the current use of safe hygiene products, generally sanitary pads (IIPS, 2017). This
figure is similar to our findings from the secondary data (section 3.3), where approximately 55 percent
of girls reported using locally or commercial available sanitary pads. Due to continuous efforts of the
government and multiple schemes to improve the MHM practices, especially in rural areas, more and

14
more girls and women of reproductive age are using disposable sanitary pads than ever before.
However, increased use of disposable sanitary pads without increased availability of of appropriate
disposal and treatment options will lead to new and worsening MHM-related environmental hazards. Per
one estimate, more than one billion non-biodegradable sanitary pads are disposed into landfills, rural
fields, urban sewerage systems, and bodies of water every month, equating to 113,000 tons of menstrual
waste annually (Wateraid India, 2017).
Soiled sanitary napkins discarded with general household waste every day burden human and
environmental health. More than 90 percent of a sanitary napkin is made of crude oil plastic, while the
rest is made of chlorine‑ bleached wood or cotton pulp. Most tampons and sanitary napkins also contain
dioxins and furan, highly toxic environmental pollutants. Reusable menstrual cups, on the other hand,
are an environmentally-friendly option because they are reusuable and, when the time for disposal
comes, are biodegradable, being made of silicon.
Menstrual waste is considered sanitary waste, and the Government of India has issued guidelines for
community disposal of “sanitary waste” under the Solid Waste Management Rules 2015 and in the
Municipal Solid Waste (Management and Handling) Rules 2000 (Ministry of Environment, Forest and
Climate Change, 2015). Under these guidelines, soiled sanitary napkins need to be wrapped securely in a
newspaper or suitable biodegradable wrapping material and placed in the domestic bin meant for non-
biodegradable waste or dry waste. The waste must then be transported to the appropriate processing
facility/ material recovery facilities/ secondary storage facility or sanitary landfill facility along with other
non-biodegradable (dry) waste. According to Van Eijk et al. (2016), the total pooled proportion of
disposal of menstrual absorbents thrown out with routine waste is only 41 percent (Table 4). The
remaining waste is often flushed down toilets, burned, buried, or thrown loosely in open fields or near
bodies of water, to the detriment of health and the environment. In one study where girls resorted to
burning absorbents, most agreed that burning is not a good option, but opined that they did not have
any other choice (Malhotra et al., 2016).
Table 4: Disposal Mechanisms of Menstrual Absorbents and Environmental Implications
Disposal of
menstrual
absorbent
Total
pooled
proportion
*
Rural
pooled
proportion
*
Urban
pooled
proportion
*
Slum
pooled
proportion
*
Environmental
implications
Thrown with
routine waste
45% 28% 70% 51% Menstrual waste enters the
solid waste stream, is placed in
landfills to disintegrate over
hundreds of years.
Thrown in open
spaces like
water bodies,
roadsides
23% 28% 15% 30% Can contaminate water
sources and clog drains.
Burning in open 17% 15% 23% - Burning of commercially
available pads at low
temperatures can create odors
and expose nearby populations
to health risks related to air
pollution.
Burying 25% 33% 12% - Without appropriate
composting, waste will take

15
hundreds of years to degrade.
Flushing in toilet
or in pit latrines
9% 10% 7% - Absorbents mix with fecal
sludge, complicating disposal of
that sludge (in the case of
septic tanks) or interfering
with the production of usable
manure (in the case of leach
pits).
*Pooled proportion is a percentage that has been derived from data in studies included in the above systematic review.
A very small proportion of the sanitary products disposed with routine waste is burned in large scale
incinerators designed to deal with biomedical waste. When menstrual waste enters the solid waste
stream, it is usually subject to the same treatment as other solid waste – placed in landfills to
disintegrate. The disintegration of sanitary product takes approximately 500 to 800 years. Only cities
like Bangalore and Pune are reported to be implementing solid waste interventions to effectively
segregate and identify menstrual waste during routine garbage collection. As much as 30 percent of
waste is thrown away in open spaces like rivers, lakes, wells, and roadsides, which contaminate water
sources and block drains as the super absorbent polymer gel in sanitary pads continues to absorb
external sewage fluid and expands until it balloons out and blocks the sewage pipes. Burning, which
accounts for 17 percent of waste disposal, leads to air pollution and creates odors which expose nearby
populations to air pollution and associated health risks.
Recently, incinerators have emerged as a preferred disposal and treatment option, particularly in
schools. The Swachh Bharat Mission, the MHM Guidelines for Schools, and the Ministry of Drinking
Water and Sanitation gender guidelines all promote the use of incinerators. In Tamil Nadu, incinerators
have even been installed in some schools (Jayasurya et al., 2017). Low cost incinerators and electric
incinerators are best suited for pads with high cellulose content. However, it is still not clear whether
they can efficiently burn pads with high moisture content and super absorbent polymer. Moreover, they
are available in many designs which do not adhere to Central Pollution Control Board standards for
emissions.
In India, as per the Indian Standard Specification for Sanitary Napkins, revised in 1993, and related
studies by Department of Consumer Affairs (Consumer Voice, 2013), sanitary napkin manufacturers are
required to disclose the environmental concerns (post-disposal and during manufacturing), methods of
use, indications of which napkin side is absorbent, disposal instructions, recommended frequency of
changing napkins, date of manufacture, and date of expiration. Despite this, most products in the market
do not disclose the chemicals that are contained in the absorbent gels, fillers, or covering of their
products, nor other environmental concerns. Common sanitary napkin chemicals are known to have
serious health impacts from long term exposure and pose grave environmental concerns in the absence
of proper disposal. Lack of data or studies exploring these issues makes it a challenge to educate
stakeholders on the environmental consequences of improper dispoal (Jayasurya et al., 2017).

16
4. INNOVATIONS AND
GOOD PRACTICES IN
MHM
This literature review has found answers to the list of research questions it sought to explore. It has
shown that there has been a slow but steady increase in knowledge related to menstruation, its causes,
menstrual hygiene, and waste disposal practices, especially in urban areas and among school-going girls.
Use of cloth and other natural materials is decreasing and use of disposable commercial and locally
available sanitary pads is increasing. However, social and cultural taboos continue to hinder MHM for
girls. Education and awareness generation efforts can help in changing cultural nroms and reducing
stigma related to menstruation. Sensitization about the environmental consequences of different MHM
options, particularly the use of disposable absorbents, is also needed as India’s MHM strategy evolves.
In this section, we share examples of good MHM practices seen in Kenya, Rwanda, and India. Kenya and
Rwanda are LMICs with similar MHM concerns as India. These examples are evidence that it is possible
to develop menstrual products that are low cost, non-toxic, biodegradable, reusable, and
environmentally friendly. Some innovative low cost products that can help make the MHM experience
easier and more hygienic for adolescent girls are also discussed.
4.1 Kenya
Approximately 65 percent of women and girls in Kenya cannot afford sanitary pads. One package of
sanitary pads costs the equivalent of the daily wage of an unskilled worker, and most women need two
packages per cycle. Some girls use cloth or other makeshift solutions, but find that they have an
increased risk of leakage - a major embarrassment when attending school. Evidence shows that
menstruation-related challenges increases absence from school, causing Kenyan girls to miss
approximately 3.5 million learning days per month (Secor-Turner, Schmitz, and Benson, 2016).
I –Care Cloth Pads: Afri-Can Trust, a Kenyan nonprofit organization working with marginalized youth
and women to create economic opportunities, began manufacturing low cost, reusable cloth sanitary
pads called “I-Care Pads.” The HANSHEP Health Enterprise Fund, implemented by the USAID-funded
SHOPS project, supported improvement and distribution of the I-Care Pads through schools in order to
promote reproductive health and reduce school absenteeism among low-income girls in Kenya (SHOPS
Project, 2015). One I-Care Pads kit has four pads that can be used for up to one year. The pads are 45
percent less expensive than the least expensive disposable napkins available in the market, making them
more accessible for girls and women living below the poverty line. Moreover, they are high quality and
reusable hygienic products. Afri-Can Trust partners with schools to reach their primary target market of
girls, ages 10-18. It trains teachers as both sales agents and health resources for young girls. Through
teachers, Afri-Can Trust provides essential training in menstrual hygiene, dispelling myths and raising
awareness about the importance of proactively managing one’s reproductive health in order to stay in
school and improve future opportunities.

17
By 2018, Afri-Can Trust plans to reach 180,000 women and girls in East Africa, ensuring they are
confident and in charge of their own lives through the I-Care program and use of I-Care Pads (SHOPS
Project, 2015).
Affordable pads made from local resources: ZanaAfrica is another Kenyan social enterprise that
has developed affordable sanitary pad products made from local resources. HANSHEP Health Enterprise
Fund supported its development and testing of health comic inserts that seek to change health behaviors
of women and girls who buy its sanitary pads in Kenya (SHOPS Project, 2015).
Pilot on Menstrual Cups: The African Population and Health Research Center conducted a pilot
study (2013) to assess the cultural, practical, and health-related appropriateness and feasibility of the
menstrual cup as a method for managing menstrual flow for adolescent girls and women in Kenya.
Menstrual cups have been used in developed countries since the 1930s. The research identified the
following potential benefits in the endline survey, after menstrual cups were introduced:
Benefits on school attendance and participation:
 Improved concentration: At baseline, 47 percent of girls said their concentration dropped in
school due to periods, but only 29 percent felt that way during the end line assessment.
 Girls had less fear of soiling clothes.
 There was improved participation in school activities.
 Absenteeism related to embarrassment decreased.
Economic benefits:
 Reduced productivity loss in working women: At baseline, 28 percent of women reported
that periods stopped them from doing their everyday activities, but by endline only 17
percent reported the same.
 Menstrual cups are reusable and do not need to be purchased on a monthly basis like
sanitary pads.
 Less water needed to clean the menstrual cup compared to water that would be consumed
for cleaning cloth.
Health benefits:
 No occurrence of skin irritations (as sometimes caused by sanitary pads).
 Health issues that required medication after menstruation such as bruises or lesions from
skin irritation were not experienced with menstrual cups.
 No odor from menstrual cups as no blood comes into contact with air.
Social benefits:
 Less stress about leakage, and less embarrassment.
 Less fear of being noticed, gossiped about, or bullied.
 Owning a menstrual cup reduced the temptation to solicit money through transactional sex
(in order to purchase pads or other methods to manage menstrual flow).
Through this pilot, useful information was gathered about the potential benefits and challenges of
menstrual cup use. Challenges included needing access to toilets, privacy, security, and water for proper
use. Further research is needed on these potential benefits and challenges of menstrual cup use, and
their appropriateness and acceptability among adolescent girls and women in India.

18
4.2 Rwanda
Sustainable Health Enterprises (SHE) in Rwanda follows a social entrepreneurship approach to
MHM. SHE’s first advocacy campaign, ‘”Breaking the Silence,” called attention to taboos surrounding
menstruation and prompted the Rwandan government to budget US$35,000 to procure sanitary pads
for schools in 2010 (UNESCO, 2014). The Ministry of Education also added MHM to the national school
health and nutrition plan. SHE also supports women entrepreneurs who use local materials to produce
affordable, eco-friendly menstrual pads. Affordability is a critical aspect, as SHE estimates that over one-
third of school absenteeism among girls is due to pads being too expensive (UNESCO 2014). Girls
instead use rags, despite lacking the proper conditions to adequately clean them. In response to these
challenges, SHE introduced the ‘SHE LaunchPad,’ a feminine care product intended to reduce negative
environmental impacts associated with pad products and create local jobs, all while being half the price
of other regionally-produced brands (UNESCO, 2014).
4.3 India
Making Periods Normal program: The “Making Periods Normal” program is a Dutch initiative
implemented by a partnership of Simavi, Rutgers, and Women on Wings (Simavi, 2016). In 2015 they
launched “1WEEKEXTRA,” an awareness campaign named for the one week every month that many
Indian girls and women are often unable to participate in daily life during their period due to inadequate
MHM or associated beliefs (Simavi, 2016). Intervention areas were located in Munger and Bhagalpur,
two districts in the state of Bihar, India. The aim of the program was to increase knowledge about
menstrual hygiene and make sanitary pads more widely available to make daily lives of the girls and
women easier.
Through training and information sessions conducted in schools and communities, the program helped
in increasing the menstrual hygiene knowledge of 278,000 men and women in the two districts.
Participants are now aware of the importance of menstrual hygiene, the risks of poor menstrual hygiene,
and how to achieve better menstrual hygiene. Additionally, through a local network female
entrepreneurs, access to high-quality and affordable sanitary napkins was expanded for 35,000 girls and
women. In the coming years, the joint program aims is to educate 660,000 girls and women in Bihar on
better menstrual hygiene, expand affordable sanitary pads access to 165,000 girls and women via the
local distribution network of female entrepreneurs, give 815 women jobs in the distribution network,
and raise awareness among 200,000 boys and men about the importance of menstruation and menstrual
hygiene (Simavi, 2016).
Not just a Piece of Cloth (NJPC): In 2005, ‘Goonj’ (Hindi word for ‘echo’), an award-winning social
enterprise, started the NJPC initiative, which is focused on opening dialogue on the generally ignored
subject of menstrual hygiene and exploring new affordable cloth napkin options (Goonj, 2017). The
NJPC program seeks to provide a physical product but also stresses behavior change and education and
to achieve long term progress. ‘MY Pad,’ Goonj's clean cloth pad, is developed out of old cloth collected
from urban masses. The organization collects donated clothes, then sorts for only cotton items which
can be turned into sanitary cloth pads. Other materials are used for new product development. The
cotton clothes are soaked, washed, and dried before being and examination with a metal detector to
identify hooks or buttons for removal. Clothes are ironed to remove moisture and are cut into standard
sizes. Cloth pads are then manufactured by women from the community, who are simultaneously
educated on how to make it on their own pads in the future (Goonj, 2017). In 2014, the price per pad
was about INR 2 (Daily News and Analysis, 2014).

19
Figure 2: FLO: An innovative
product developed to wash
and dry cloth pads
Figure 3: A more hygienic
way to dry reusable pads
Figure 4: The pouch can be
concealed securely under
clothes
Proactiveness of other non-governmental organizations and community-based
organizations: Activism on safe and sustainable menstruation over the years has culminated in quite a
few awareness programs, social enterprises, and self-help groups which undertake pad-making.
 Uger pads, Ecofemme, and Goonj are Indian organizations active in addressing rural and urban
consumers through the production of cloth pads and initiation of dialogues about MHM
(Jayasurya et al., 2017). Their products, along with pads by Shomota, another Indian brand, are
reusable pads, biodegradable, and relatively affordable (Table 3).
 Another innovative awareness generation approach is Menstrupedia, a comic developed by Aditi
Gupta to educate girls about menstruation in a fun and child-friendly way (Menstrupedia, 2017).
Other Innovative Initiatives
FLO: Use of cloth and cloth pads developed locally is a necessity for girls and women in India and other
LMICs who cannot afford to buy the more expensive sanitary pads. To overcome the challenge of
washing and drying cloth pads hygienically, the innovative product ‘FLO’ was developed in 2015 by
Mariko Iwai, a student at the Art Center College of Design in California (Iwai, 2017). It is a menstrual kit
that allows girls to wash, dry, store, and carry reusable sanitary pads in a more affordable and hygienic
manner. The design consists of a portable basket made from high strength plastic, which the user can fill
with their pads, detergent, and water and then spin using attached strings (Figure 2). It needs half the
usual amount of detergent and water used in regular washing. The string and basket can then be taken
apart and used for hanging and drying the wet cloths (Figure 3). Its creators recommend covering the
contraption in a burlap cloth, to keep the drying pads hidden from view. The kit also includes a zip-top
pouch that can be worn under clothes for carrying the cleaned and dry pads (Figure 4). The carrying
case also has an odor-resistant space to store used pads, giving girls a discreet way to carry pads to
school. The full kit costs about US$ 3.

20
5. DISCUSSIONS AND
IMPLICATIONS
Menstruation, a normal biological process in women, continues to be masked in a culture of silence and
shame. Even today, girls and women, under the guise of socio-cultural and religious rules imposed by
society, continue to practice restrictions in food intake, matters of hygiene such as bathing, and other
day-to-day activities during menstruation. For school-going girls, school attendance suffers during
menstruation, particularly for those who go to schools that lack basic toilets, waste disposal, and water
supply facilities. Men and boys are inadequately sensitized on the topic, making MHM environment and
experiences more difficult for girls and women to handle smoothly. This review identified several factors
that contribute to these issues, the implications of which are discussed below.
Education of mothers: Strangely enough, women who themselves experience menstruation go on to
instill in their daughters the belief that menstruation is unclean and that there are restrictions to be
followed. This happens more when the mother is uneducated or ill-informed about MHM. With
mothers being the main source of information for their daughters in 55 percent of the cases identified,
improving their education, awareness, and empowerment is a key approach to breaking the
perpetuation of the myths and taboos surrounding menstruation.
Education of girls and the role of schools, teachers, and health workers: India is a large and
highly populous country. Within a population of about 1.3 billion, there are 125 million adolescent girls
and 400 million women who menstruate (Menstrual Health Day Consultation Workshop, 2017). It is
crucial to address their health needs and concerns. Findings of this study show that currently, there is a
lack of information, guidance, and support on the changing body and MHM needs among very young
adolescents (10-14) and adolescents (15-19) in India. School teachers, if properly sensitized on the
subject, can help in addressing this gap. Their potential as change instruments has not yet been realized
and there is a very low percentage of girls who approach them to gain information or share their
concerns about menstruation. Evidence indicates that school-based health education programs can lead
to significant improvements in MHM practices and data substantiating this has been discussed in the
report (Nemade, Anjenaya, and Gujar, 2009). Thus, school-based interventions need to be strengthened
and scaled-up.
Strengthening the MHM environment in school to reduce school absenteeism: It is ironic
that while girls education is stressed upon in India now more than ever before, lack of adequate toilets
for girls, poor water supply, and lack of waste disposal facilities are major reasons of school absenteeism
among girls during menstruation. Even school-based interventions discussed above cannot help if girls do
not have the privacy practice MHM at school. Therefore, it should be made mandatory in schools-
government or private, and rural or urban, to create a good MHM environment by providing access to
menstrual hygiene materials, toilets, clean, safe, and private places to change, adequate water and
sanitation facilities. Without proper facilities for girls, the school environment is unsafe, unhealthy,
gender-discriminatory, and overall inadequate.

21
Gender concerns: This report has discussed the gender perspective behind the current MHM
environment and practices, both in school and at home. Lack of sensitivity of men and other family
members about girls’ need for privacy, cleaning facilities, water, and good hygiene materials at home is a
major reason that many rural areas do not have household toilets. This trend, whether it is due to
ignorance or religious reasons, has to be reversed through awareness and behavior change
communication strategies. Awareness programs for men and boys on the matter are particularly
important to destigmatize the topic of menstruation and create a more comfortable environment for
girls, thereby facilitating good MHM practices.
Offering more choices to girls and women: Traditionally, the girls and women of India have been
using external protection in the form of cloth as an absorbent, especially in areas where sanitary napkins
were not available in the markets. A major drawback of cloth use is the risk of infection if the cloth is
not cleaned and dried properly. There is also shame associated with soiling cloths and hanging them in
the open where it could be seen by others. Offering more non-cloth options is one way of addressing
these issues. The last decade has seen growth in the use of sanitary napkins, especially those offered by
foreign organizations who entered the market and promoted disposable sanitary napkins in India. As a
consequence, today about 57 percent of girls and women choose disposable napkins over cloth.
However, sanitary napkins are much more expensive than cloth and their monthly purchase is an
expensive proposition for many girls and women, especially those living in rural and tribal communities,
those who are illiterate, and those coming from the lower and middle socio-economic strata of society.
To overcome the problems of cost and access, the government has initiated programs for girls and
women whereby they can buy locally developed subsidized sanitary pads. Social enterprises and self-help
groups have also started to make low-cost, clean, and environmentally-friendly absorbents available for
girls and women. Such enterprises need more encouragement and support from the government.
Additionally, the Government can work with private sector commercial manufacturers to incentivize
production of low-cost and environmentally-friendly products, including thus far underutilized options
options like menstrual cups, which are reusable and biodegradable.
Concerns about currently available absorbent choices: The government, private sector, and
social enterprises are undoubtedly working to overcome the supply-related concerns of cost and access
of absorbents. The questions that now arise are (1) are these efforts enough to address the problems,
and (2) are disposable sanitary pads necessarily the best option?
Our findings suggest that until now, all the efforts made by the government as well as by the community-
based organizations and non-governmental organizations have not been able to address the needs of
India’s large population of girls and women. Clearly, persistent efforts are needed and more low-cost
hygienic pads need to be manufactured and made more widely available.
The second concern is whether disposable sanitary pads are the best option. Section 3.4 on
environmental implications sheds ample light on the risks associated with using disposable sanitary pads
made out of non-biodegradable and toxic materials. Moreover, with 113,000 tons of menstrual waste
generated annually due to improper waste management practices, the environmental dangers associated
with using disposable sanitary napkins cannot be understated. Thus, there is a need to continue
exploring products other than disposable sanitary pads.

Literature Review to Assess Menstrual Hygiene Management Practices Among Adolescent Girls in India.

Literature Review to Assess Menstrual Hygiene Management Practices Among Adolescent Girls in India.

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