Ernestina Coast, Joe Strong and Samantha Lattof explain how weak evidence is prolonging the economic burden, shame, and gendered experience of menstruation in low- and middle-income countries by using India as an example.

“America has Superman, Batman, Spiderman… but India has Padman.”  So goes Pad Man, Bollywood’s internationally acclaimed (Netflix available) movie based on the life of Arunachalam Muruganantham, an activist who fought to make sanitary pads affordable and available to women in India. The film spotlights the realities that women in India face: the economic burden, shame and gendered experience of menstruation.

One quarter of the world’s population is female and of reproductive age, and most will menstruate monthly. The experience of puberty and first period (menarche) can define a girl’s life, including being expected to take on adult roles, change her dress, change her behaviour or reduce her mobility. It is estimated that of the 100 million girls of high school age currently not in school around the world, menstruation and puberty are significant underlying factors. Despite Pad Man’s epic musical number Sayaani, in which the older women in the town celebrate a young girl’s first menstruation with opulence, they end by banishing her to sleep outside the family home for five days, a daily reality for many women and girls in India and elsewhere.

How do girls currently experience puberty and menstruation?

Young girls, aged 10-14, can have extremely negative experiences during the early stages of puberty and menstruation. Across low- and middle-income countries, the evidence indicates that girls are frequently unprepared for when they first start menstruating and the changes that occur during the onset of puberty. In India, 60.3% of girls did not know about menstruation. In Bangladesh, 64% of girls reported “reaching menarche in fear”.

During menstruation, girls find themselves constrained by norms that impact their everyday lives. 70% of girls in Nepal reported that they could not go to school during menstruation and 100% reported that they were not allowed to cook. Across contexts, girls felt unable to discuss menstruation, either because of their own secrecy and shame, or due to fear of judgement. For girls who experienced their first menstruation later in life, these feelings were far less significant than for girls who experienced their first menstruation between 10 and 14 years old, potentially due to a longer timeframe in which to prepare for menarche.

The use of sanitary pads is generally low amongst young adolescent girls in low- and middle-income countries, according to the studies evaluated. Alternative absorbents are used, such as cloths, though girls find that cleaning these make it difficult to keep menstruation secret and, therefore, can lead to experiencing shame. During a study in India in which girls were offered pads and high-quality absorbent cloths, all preferred using them to the ordinary cloth that was previously the main absorbent. Beyond interventions, however, the price of these hygiene products meant that they were unobtainable. For example, in Siaya, Kenya, where the mean annual household income is 600-700 USD, a package of pads costs 1 USD. It is nearly impossible for young girls to afford up to two package of pads needed per menses.

How good is the evidence?

An incredibly low number of studies, 44, focus on gathering evidence on the experience of puberty and menstruation amongst young adolescent girls in low- and middle-income countries. This contrasts the growing need for evidence, as it is increasingly understood that these experiences can have a lasting impact on the lives of women and girls.

Studies that aimed to gather evidence on the experience of menstruation and puberty among young adolescent girls underwent quality assessment. Only two studies (Mason et al. 2013; Valizadeh et al. 2017) had strong evidence; the remaining 42 studies had moderate to weak evidence. Evidence rarely focused specifically on young adolescent girls, and when it did so it largely looked at girls within school. This sampling approach does not reflect the reality that girls aged 10-14 might no longer be attending school or might be absent due to menstruation-related reasons.

Though some studies included evidence from people other than adolescent girls, adolescent boys were rarely included. The potential roles that men and boys can play remain under-researched. Even those studies that did include adolescent boys did not ask them questions about menstruation. It means that where puberty and menstruation are social issues, the evidence is unable to capture the knowledge, attitudes and behaviours of other individuals during the onset of puberty and menstruation in young girls.

What needs to change?

Given the significance of puberty and menstruation for young adolescent girls, the current volume and quality of the evidence is inadequate. There remains a need for socio-culturally relevant evidence, broadened beyond just school-going girls to include men and boys, as well as girls who are not in school. Beyond this, more evidence must be gathered that considers specific issues faced by girls in different communities and states across the world. This evidence should also examine the roles that other individuals can play in the lives of girls during menstruation and puberty.

In addition to more evidence, grounded in the lived experience of girls, we need more consistent standards of what constitutes “good” hygiene practices and “adequate” knowledge of puberty and menstruation can be created. Developing global standards and measures can better inform future policies to improve the lives of young adolescent girls.

Girls’ views and voices are rare in the current evidence base. Future research must facilitate their meaningful participation in setting agendas and shaping interventions in order to capture the complexity of girls’ experiences. Or, as Arunachalam Muruganantham, AKA, Padman has said: “Why wait till they are women? Why not empower girls?”

This blog post has been adapted from Puberty and menstruation knowledge among young adolescents in low- and middle-income countries: a scoping review, published in International Journal of Public Health on 10 February 2019. This research was supported by the Gender and Adolescence: Global Evidence (GAGE) programme which is funded by UK Aid from the UK Department for International Development (DFID).

Ernestina Coast is Professor of Health and International Development in the Deptartment of International Development.  Her research is multidisciplinary and positioned at an intersection of social science approaches including health, gender and development. Joe Strong is a PhD candidate in the Department of Social Policy and is a demographer, researching the relationships between men, masculinities and women’s abortion-related care in Ghana. Dr. Samantha R. Lattof is a global health consultant with over ten years of experience conducting research and driving health programs and projects. 

This article was first published on the LSE South Asia Blog.

The views expressed in this post are those of the author and in no way reflect those of the International Development LSE blog or the London School of Economics and Political Science.