Research & Reflections on Menstrual Hygiene Management & Education (India & Nepal)


Research & Written by INES IM


In India, Rayka Zehtacbhi’s 2018 Oscar-winning documentary film Period. End of Sentence and Amit Virmani’s 2013 documentary film Menstrual Ma, both detailing the efforts of Indian entrepreneurs supplying and manufacturing low-cost sanitary pads for their respective communities, have generated buzz. Nepal’s menstruation problems, on the other hand, have recently come under worldwide scrutiny following the media-covered deaths of girls practicing Chaupadi.[1] Chaupadi is a practice in Nepal that forces women to spend 4-5 days in a shed extraneous to their homes while menstruating— deriving from the belief that menstruating women are untouchable.[2]

In between the release of the two films, in 2015, the Ministry of Drinking Water and Sanitation (now the Ministry of Jal Shakti)[3] of India released the Menstrual Hygiene Management India: National Guidelines. The Guide detailed efforts for reform in India, focusing on how to improve the education, resources, and stigma in India on/around menstruation as a part of Swachh Barat, or the ‘Clean India’ initiative.[4] The Nepali government banned Chaupadi in 2015 and criminalized it in 2017 with fines and jail time.[5] This legislation and media suggests that people’s attitudes towards and the stigma around menstruation have been changing for the better. However, it is difficult to determine the actual effects of what the media and government have done. There could be a disparity between the world’s view of India and Nepal’s management of menstruation and the actual situations of the countries.

This paper aims to link Indian and Nepali government legislation to the individual experience and fill in the gaps of information that exist between the two. This paper also aims to cover more recent data, as most articles detailing menstrual taboos are from the late 90’s or early 2000’s.[6] And finally, this paper aims to hear personal narratives and views of women living in Nepal and India from their own words.

Literature Review

Menstrual management is clearly deemed as important for many reasons, but most broadly and basically in that, as said in the 2016 Menstrual Hygiene Matter resolution, “many [menstruation related] myths and social norms restrict women and girls’ levels of participation in society.”[7]

Almost all literature on poor menstrual management seems to recognize that in many underdeveloped countries, such as India and Nepal, tackling bias/stigma around menstruation is the main goal. The Maverick Collective 2017 stated Hindu beliefs and scriptures have influenced practices to deem “[menstruating] women “untouchable,” and prohibiting … [them] from inhabiting public space, socializing with others, and sharing food and water sources.”[8] According to the 2012 WaterAid Menstrual Hygiene Management resolution, Hinduism (practiced by approximately 80% of the population in India[9] and Nepal[10]) holds beliefs that bodily excrements, including menstrual blood, are pollution.[11] Thus, women in India and Nepal often suffer through cultural practices and beliefs such as Chaupadi (Nepal-specific), abstaining from religious activities, not being allowed to prepare food[12], not being allowed to touch running water[13], and a large number of other practices. A 2009 WATERAID report quoted a participant living in Dhading: “a woman is ritually impure during menstruation and anyone or anything she touches becomes impure as well.”[14]

Including the practices mentioned before, author Kothari, in a study in Japiur, India, described the negative practices to be divided into either the psychogenic category (i.e, the fear of menstrual blood), and sociogenic (“patriarchal social systems perceiving woman as impure or dirty”)[15]. This finding was supported in a 2001 Delhi study, where authors Garg, Sharma, and Sahay described the area’s understanding of menstruation to be the removal of dirty blood, or ganda khan— a belief that further supports the taboo of menstruation being a dirty, impure thing.[16] In general, menstruation seems to have a prevailing stigma of shame, and many areas seem to have negative perceptions of menstruation.[17]

Literature on the subject of menstruation has looked to tackle both the purveyors and implications of these cultural stigmas. One factor that seems to be present on both ends of the problem is education, or the lack thereof.

In both India and Nepal, there seems to be a severe lack in quality menstrual education in schools. According to the Maverick Collective study, “adolescent girls lack consistent access to education on sexual and reproductive health [in Nepal]”.[18] WaterAid cited that mothers and sisters seem to be the main source of education when it comes to menstruation in both India and Nepal[19] In many cases, as proven by studies in India, many girls seem to have their first education on menstruation after their menarche.[20] In addition, according to a 2012 WaterAid study, many girls are unaware about the biological function of menstruation.[21]

Lack of education is a huge problem for physical, health reasons, especially in rural or tribal contexts. According to a study in Gujarat, India, “lack of menstrual hygiene was found to result in adverse outcomes like reproductive tract infections. Better knowledge about menstrual hygiene reduced this risk.”[22] The current literature reflects that girls need adequate menstrual hygiene education so that they can manage their own menstruation in a clean, safe way.

Written works often gloss over the individual stories, needs, and cultural idiosyncrasies of specific groups of people in an effort to be all-encompassing. Specifics are reserved for the more urban areas of India and Nepal where the problems are less severe. Thus, the data from rural areas, where issues like Chaupadi (Nepal-specific) are more prevalent, is not in abundance.

Rather than detailing individual experiences, current literature seems to mainly be static and data-based. Because the implications of menstrual taboos are so personal, there is value in the personal narrative that isn’t being reflected in these studies.

It was extremely difficult to find relevant, recent literature on menstruation and menstrual health in India and Nepal. Studies on taboos in India were decades old, and general guidelines were also years behind. With the fast-paced and recent government legislation in India and Nepal correlating with Menstrual Hygiene Management, more recent literature is important for an accurate depiction of the narrative around menstruation.

Safe menstrual hygiene management is no small problem— almost all women menstruate every month. Nepal is a country with an estimated population of 29 million people— daily, 290,000 women in Nepal are menstruating.[23] India, on the other hand, has a population of around 1,296,834,042 as of July 2018,[24] with 649,574,719 members of that population being women as of 2018.[25] It is imperative that accurate, relevant information on such a large number of the global population is accessible.

Data and Methodology:

This paper primarily relies on document analysis based on secondary data research accompanied by personal interviews. Sources of documents include academic journals, public policy papers, government policy documents and literature on menstrual hygiene management as well as data from published documents of international organizations. Informal personal communication with professionals working in the sphere of young women’s education accompanied the secondary data for individual-level perspectives. While the sample size for personal communication is few, the conversation served as a means to understand the current status and practices of MHM from various levels. Limitations in the paper arose from inconsistent and scare data for specific figures in India and Nepal pertaining to recent and accurate data findings[HS1] .


Findings:

The 2017 Maverick Collective report in Nepal published that 83% of women in Nepal use cloth, and 15% actually use sanitary pads.[26] An interviewed international development professional providing education services to rural women of Nepal shared similar observations, stating that, as of 2019, most girls, even those living in urban areas, use cloths. However, she also stated that the Nepali government has recently been providing sanitary napkins for girls.

An article by the Guardian published that 88% of Indian women use ash, newspapers, and leaves during menstruation[27], and a corresponding journal by Shah et al published that 12% of Indian women use sanitary pads.[28] Overall, the main barrier for women when it came to using sanitary pads was that they were too expensive.[29] However, in the town of Mahabubnagar in the outskirts of Telangana State, one educator interviewed shared that, as of 2019, only very few women still use cloths (and those women are mostly isolated in rural areas). She also asserted that free sanitary pads (2 pads per girl) are being distributed in government schools.

A large factor contributing to poor menstrual hygiene management seems to be a lack of access to public, gender separated bathrooms. India’s Ministry of Jal Shakti boasts, at the time of writing this paper, that 99.83 percent of India to has access to public toilets, though whether those toilets are gender-separated is unclear.[30] The educator from Mahabubnagar asserted that separate bathrooms do not seem to be a priority for the government, though they were mandated in the 2015 Menstrual Hygiene Management guidelines. She stated that she had not seen changes in terms of gender separated toilets.

The education professional in Nepal stated that the Nepali government is taking efforts to construct toilets for girls. According to the Maverick collective report, in 2017, only 46% of Nepal had access to high quality sanitation facilities, and only 28% of schools had gender separated toilets.[31] The professional’s statement may represent some change.

Both interviewees supported data founding other papers on the state of menstrual education in their respective countries. The studies in Haryana and Jaipur reported that 68% and 92% of girls in the study weren’t aware of what menstruation was before their menarche, respectively.[32][33] The Indian educator asserted that, at least in her community, girls were seldom ever given education before their menarche— most of their came from their mothers after their first period. However, she asserted that she had seen Menstrual Hygiene Management education being implemented in districts— that education consisted of instruction on how to use pads, how to be hygienic, and just formal education on menstruation in general. Specifically, she had seen the topic of biological menstruation being taught to students, though the girls were separated from the boys.

As for reproduction, specifically, the Nepal contact asserted that in the hill and mountain areas of Nepal, the marriage and motherhood age was roughly 18-22, and in the plains areas, the age was 13-16 (illegal, young planned marriage is still being practice). The contact from India also asserted that women are being married early, illegally, in India.

The Nepali professional relayed that girls are usually taught about menstruation by their mothers. She asserted that schools in Nepal currently don’t have formal programs on menstruation. As an official of an NGO that supplies menstrual education for girls in Nepal, our contact works to educate girls and their mothers in non-formal, non government-affiliated classes on menstruation and reproductive health. However, she stated that there is discussion on endorsement and revision of school curriculums to include menstrual education.

Both contacts in Nepal and India somewhat corroborated assertions of negative cultural stigma around menstruation. Ms. Tahniyath disagreed that there are taboos around menstruation in India, but also noted that girls often feel uncomfortable speaking about menstruation due to a negative stigma. Ms. Joshi asserted that the cultural taboos in Nepal stemmed from Hindu beliefs in untouchability. She said that the negative stigma is most clearly seen in the practice of Chaupadi.

The contact in India mentioned that many girls and women stay at home from school or work to deal with their menstrual cycles. She even said that they cite ‘stomach pain’ as their reason for leaving, as the taboos are so prevalent that it would be embarrassing to mention menstruation. The contact in Nepal said that many girls do not go to school as a result of heavy bleeding during menstruation. Due to the poor facilities of school and lack of access to management materials, a lot of girls in Nepal find it more manageable to stay at home.

The Indian government has been making legislative strides to combat the problems with menstruation in India over the past couple of years with their Menstrual Hygiene Management India: National Guidelines.[34] In Prime Minister Narendra Modi’s independence day speech in 2014, he said, quoted, that “[is the] dignity of women is not our collective responsibility?” and that “all schools in the country should have toilets with separate toilets for girls. Only then our daughters will not be compelled to leave school midway.”[35] The guideline details efforts to reform menstruation education, dissolve taboos, improve facilities, distribute sanitary napkins, provide disposal, and in general foster an atmosphere of support.[36] Smaller efforts have also been made— for instance, Maharashtra state implemented a plan to make menstrual hygiene education mandatory in schools, as well as educating parents on dissolving menstruation taboos in 2017.[37] The educational professional in India stated that she had not only heard of the government’s efforts, but had also seen results. Over the past years, she had seen the government sending doctors to schools, implementing education, raising awareness, and giving out pads. She also stated that the Indian government had begun publishing advertisements, articles, and films that involve menstruation, a step that she believes indicates a change in attitude— for the better.

Nepal’s main legislation efforts have been specifically against Chaupadi. As part of their 2017 criminalization of the practice, the government has torn down Chaupadi sheds and implemented fines— however, an article published by NPR detailed how government policy isn’t effective against long-held cultural beliefs.[38] The Nepal educator corroborated these findings: she asserted that the practice still continues, even after the ban as Chaupadi is a social practice. Because people believe it averts bad luck, many people are afraid of stopping so as to avoid ill towards their families. She added that the criminalization[HS2] has not been effective.

Notably, both contacts in India and Nepal said that there are serious health risks resulting from poor menstrual hygiene management in their respective countries. The Indian professional emphasized how women in India have recently been vocally expressing discomfort over irritations, infections, itching, and excess discharge. She stressed that suppression of discussion on menstruation issues have led to complications such as miscarriages. The Nepal educator said that Chaupadi practice has led to death for many women. She also noted that the criminalization of the practice has led to other, unsafe alternatives.

DISCUSSION

One surprising result of the data collection was to see how much positive change is occurring in Nepal and India. The lack of coverage on the effects of the Nepali and Indian government’s menstruation reform efforts projected the image that change was not occurring. However, both contacts in India and Nepal emphasized that they were seeing significant differences; however, long-lasting, systematic change would take time. For example, the educator in Nepal emphasized how, even with it outlawed, women in Nepal believing in the benefits of Chaupadi were inflicting the practice on themselves. The professional in India mentioned how she could not really think of any negative cultural practices against menstruation, an assertion that could be due to the practices being so deep rooted that they are unnoticeable as unusual to an Indian woman. It also points to regional, economic and spatial inequalities that exist in such a large country with varying population groups. In addition, the fact that menstrual education, if it is even being taught, is only being taught to women, further indicates how much farther reform has to go. Without education, people in Nepal and India will not know better against the taboos and Hindu beliefs of impurity associated with menstrual blood. The taboos bring a vicious cycle to menstrual education— affected adult figures don’t feel comfortable discussing the issue with minors, and thus generations of people remain scared and uneducated when it comes to menstruation.

Along those lines, it is interesting to see how non-government organizations are stepping up to educate women in Nepal where the government is not. The Nepal educator’s organization, World Education, offers courses on menstruation and reproductive health to mothers and daughters. It is programs like these that seem to be influencing conversation to change the Nepali government’s education system to include a reproductive health aspect.

One question that naturally arises is whether or not menstrual hygiene reform, when compared with other issues, is a priority for developing countries like India and Nepal. However, one has to realize that menstruation is an issue that affects the life of almost every woman. Education, work, and overall participation in every-day life are hindered by complications due to menstruation— without dealing with menstruation issues, women are systematically at another disadvantage against the men around them. And menstruation issues don’t only affect women; women being forced to stay home from work or school are thus hindered from contributing to the economy and their country.

In both countries, there doesn’t really seem to be menstrual education, formal or not, for younger girls (i.e. younger than menarche age). With menstrual and reproductive education (if any) and the average marriage and childbirth ages for girls happening in their late teens in India and Nepal, girls are being educated too late on reproduction. There seems to be a disparity with the importance of menstruation/reproductive education and the age at which it’s being taught.

On a positive note, menstruation reform is directly giving some women jobs. In Jharkhand, India, over 55,000 women have been trained as rani mistri (or female masons) to construct toilets under Swachh Barat. Their resulting financial freedom is an interesting plus to the already positive effects of the Swachh Barat initiative in general, and indicates a shift in power for women in some parts of India and a possible turning of the gender narrative.[39]

Finally, it is interesting to see, compared to the data from the studies referenced in this paper, how rapidly change is occurring. Swachh Barat’s progress is a perfect example of recent change in India; the interviewed professional contacts’ assertions of attitude and small policy changes happening in their respective countries are others. Menstruation is an incredibly personal, hard to encapsulate issue— but the attitudes, policies, and knowledge around it is constantly changing and evolving. It is clear to see from the data in this paper that things are improving, and only seem to be going up.

The Way Forward:

As in accordance with the purpose of this paper, the world has the right to know if the reforms in India and Nepal are working. It is important to make sure that the Indian and Nepali government continue their work to improve menstrual hygiene management in their respective countries and follow their proposed legislations and guides. Hopefully, the educational work being done by NGOs, especially in Nepal, will influence the government to change for the better.

More women in the government could significantly improve menstrual hygiene management in Nepal and India. Women officials could provide more empathy and understanding towards fellow menstruating women, especially because of the taboos and fear around menstruation (especially from men).

The governments in India and Nepal must increase access to sanitary napkins: namely, pads. Relatedly, more efforts should be made to have gender separated bathrooms and disposal facilities. These steps are outlined in global Menstrual Hygiene Management guides, and in the Indian National Guide, but true implementation of these reforms is paramount for the safety and hygiene of women in both countries.

The deep cultural stigma in Nepal and India is not only a main cause of poor attitude and practices towards menstrual hygiene, but also a main reason why reform, such as the banning and criminalization of Chaupadi in Nepal, is not effective. There is no room for true change to happen without the removal of cultural stigma. Although, of course, this will be difficult, the task really falls on educators (both governmental and independent) to teach the next generation against the menstrual taboo. Hopefully, in the long run, future generations of Nepali and Indian people, especially young women and men, will feel that the discussion of menstruation is a comfortable, safe, and healthy one to have.



[1] Danielle Preiss, "Banished To A 'Menstrual Shed,' A Teen In Nepal Is Bitten By A Snake And Dies," Goats and Soda, July 10, 2017, Women & Girls, accessed August 24, 2019, https://www.npr.org/sections/goatsandsoda/2017/07/10/536483652/banished-to-a-menstrual-shed-a-teen-in-nepal-is-bitten-by-a-snake-and-dies. [2] Khagendra Dahal, "Nepalese Woman Dies after Banishment from House during Menstrual Period," British Medical Journal 337, no. 7680 (November 22, 2008): 1194, https://www.jstor.org/stable/20511378. [3] Press Trust of India, "Govt forms 'Jal Shakti' Ministry by merging Water Resources and Drinking Water Ministries," Business Standard (India), May 31, 2019, accessed August 24, 2019, https://www.business-standard.com/article/pti-stories/govt-forms-jal-shakti-ministry-by-merging-water-resources-and-drinking-water-ministries-119053100711_1.html. [4] Ministry of Drinking Water and Sanitation Government of India, Menstrual Hygiene Management National Guidelines, by Ministry of Drinking Water and Sanitation, December 2015, accessed August 24, 2019, http://www.ungei.org/resources/files/pub_doc107.pdf. [5] Danielle Preiss, "Law In Nepal Sets Penalties For Forcing A Woman Into A Menstrual Shed," Goats and Soda, August 10, 2017, [Page #], accessed August 24, 2019, https://www.npr.org/sections/goatsandsoda/2017/08/10/542585664/law-in-nepal-sets-penalties-for-forcing-a-woman-into-a-menstrual-shed. [6] Suneela Garg, Nandini Sharma, and Ragini Sahay, "Socio-Cultural Aspects of Menstruation in an Urban Slum in Delhi, India," Reproductive Health Matters 9, no. 17 (May 2001): https://www.jstor.org/stable/3776394. [7] Sarah House, Thérèse Mahon, and Sue Cavill, Menstrual Hygiene Matters (WaterAid, 2012), 25, last modified 2012, accessed August 24, 2019, https://menstrualhygieneday.org/wp-content/uploads/2016/12/Menstrual-hygiene-matters-low-resolution.pdf. [8] Maverick Collective, "Menstrual Health and Hygeine Management in Nepal Scoping Review," review, Maverick Collective, last modified June 20, 2017, accessed August 26, 2019, http://maverickcollective.org/menstrual-health-and-hygeine-management-in-nepal-scoping-review/. [9] The World Factbook, "South Asia:: India," in The World Factbook, by Central Intelligence Agency, last modified October 2, 2019, accessed October 14, 2019, https://www.cia.gov/library/publications/the-world-factbook/geos/in.html. [10] The World Factbook, "South Asia:: Nepal," in The World Factbook, by Central Intelligence Agency, last modified October 2, 2019, accessed October 14, 2019, https://www.cia.gov/library/publications/the-world-factbook/geos/np.html#field-anchor-people-and-society-religions. [11] House, Mahon, and Cavill, Menstrual Hygiene, 26. [12] WaterAid, Is Menstrual Hygiene and Management an Issue for Adolescent School Girls?, 1, March 2009, accessed October 14, 2019, https://sswm.info/sites/default/files/reference_attachments/WATERAID%202009%20Menstrual%20hygiene%20school%20adolesencegirls-nepal.pdf. [13] Shruti Chopra and Krishnan Sharma, "The Development of Menstrual-related Beliefs and Behaviors During Adolescence in Semi Rural Haryana (India): A Conceptual and Empirical Formulation," Anthropologie (1962-) 49, no. 2 (2011): 101, accessed August 24, 2019, https://www.jstor.org/stable/26272368. [14] WaterAid, Is Menstrual, 10. [15] Bela Kothari, "Perception about Menstruation: A Study of Rural Jaipur, Rajasthan," Indian Anthropologist 40, no. 1 (Jan/June 2010): 45, accessed August 25, 2019, https://www.jstor.org/stable/41920109. [16] Garg, Sharma, and Sahay, "Socio-Cultural Aspects,". [17] UNESCO, Puberty Education & Menstrual Hygiene Management (Paris, France: UNESCO, 2014), 10. [18]Maverick Collective, "Menstrual Health," review, Maverick Collective. [19] WaterAid, Is Menstrual, 17. [20] Kothari, "Perception about," 47. [21] House, Mahon, and Cavill, Menstrual Hygiene, 22. [22] Sobha P. Shah et al., "Improving Quality of Life with New Menstrual Hygiene Practices Among Adolescent Tribal Girls in Rural Gujarat, India," Reproductive Health Matters 21, no. 41 (May 2013): 205, https://www.jstor.org/stable/43288976. [23] Maverick Collective, "Menstrual Health," review, Maverick Collective. [24] The World Factbook, "South Asia:”. [25] The World Bank, "Population, female - India," chart, The World Bank, 2019, accessed October 14, 2019, https://data.worldbank.org/indicator/SP.POP.TOTL.FE.IN?locations=IN&view=chart. [26] Maverick Collective, "Menstrual Health," review, Maverick Collective. [27] Lakshmi Sandhana, "India's Women Given Low-cost Route to Sanitary Protection," The Guardian, January 21, 2012, Women, accessed October 14, 2019, https://www.theguardian.com/lifeandstyle/2012/jan/22/sanitary-towels-india-cheap-manufacture. [28] Shah et al., "Improving Quality," 205. [29] Shah et al., "Improving Quality," 213. [30] https://sbm.gov.in/sbmdashboard/IHHL.aspx [31] Maverick Collective, "Menstrual Health," review, Maverick Collective. [32] Kothari, "Perception about," 47. [33] Chopra and Sharma, "The Development," 95. [34] Ministry of Drinking Water and Sanitation Government of India, Menstrual Hygiene. [35] Ann Schraufnagel, "India's Need for School Toilets," Pulitzer Center (Washington, DC), February 16, 2016, accessed August 26, 2019, https://pulitzercenter.org/reporting/indias-need-school-toilets. [36] Ministry of Drinking Water and Sanitation Government of India, Menstrual Hygiene. [37] Pallavi Smart, "Maharashtra Government Makes Menstrual Hygiene Mandatory in Schools," Mid-Day (Maharashtra, India), November 1, 2017, accessed August 29, 2019, https://www.mid-day.com/articles/maharashtra-government-makes-menstrual-hygiene-mandatory-in-schools/18700182. [38] Preiss, "Banished To A 'Menstrual," Women & Girls. [39] Pratibha Singh, "How female toilet builders are taking on menstrual hygiene management in India," Unicef: for every child (blog), entry posted May 28, 2019, accessed August 26, 2019, https://www.unicef.org/stories/how-female-toilet-builders-are-taking-menstrual-hygiene-management-india.

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