Peer ethnographic study on menstrual health & hygiene management.

Research Report.

SUMMARY: Menstruation signals a girl's entry into womanhood, sexual activity, and reproduction and as such, is a crucial time for adolescent girls to learn about their bodies and their health. Yet effective solutions to improve menstrual health are lacking, as evidenced by girls' lack of knowledge and unhealthy practices. In Nepal, less than half of adolescent girls have adequate knowledge about menstruation, and only one in ten practices good menstrual hygiene. Adolescent girls' inability to effectively manage menstrual hygiene affects their education, physical health, psychological and emotional well-being, and general quality of life. Adolescent girls in Nepal face many sexual and reproductive health problems and challenges, amidst gender disparity and other discriminatory social norms in Nepali society. Child marriage is legally prohibited, yet 17% of women aged 15-19 begin childbearing (DHS 2016). The median age at first marriage is 17 years. The adolescent fertility rate is 71 per 1,000 women aged 15-19 years with wider differences in urban and rural settings (33% in urban and 80% in rural). During menstruation, a majority of girls (89%) also experienced some form of restrictions or exclusion. One extreme form of menstrual seclusion practice is called chhaupadi, a common social tradition in the far and mid-western hills and mountains that requires menstruating women to leave home and live in a chhau goth (cowshed or hut). Menstrual restrictions and traditional beliefs vary by ethnicity; for example, Hindu ethnic groups such as Brahmin, Chhetri, and Newar, have more restrictions than Janajatis (ethnic Nepalese). There exists limited research on menstrual health and hygiene in Nepal, even though studies confirm that adolescent girls lack consistent access to education on sexual and reproductive health and menstrual health. With inadequate education, they lack even a basic understanding of the biological process of menstruation, such as knowing that the menstrual blood flows from the vagina. Poor sanitation facilities and unavailability of water supply has exacerbated poor menstrual hygiene among adolescent girls. Only 28% of public schools in Nepal have separate facilities with toilets for girls. In 2011, 38% of households did not have a toilet. In 2015, only 46% of the population in Nepal had access to improved sanitation facilities. Safe and effective Menstrual Health Management (MHM) is a critical component of, and premise for, adolescent girls' sexual and reproductive health. When girls are more knowledgeable about their bodies and fertility, and able to effectively manage their menstrual hygiene, they may be more empowered and better equipped with the information, tools, and confidence necessary to manage their long term sexual and reproductive health, including family planning. Many girls experience fear, confusion, and concern at the time of menarche. In Nepal, 83% of the menstruating girls use cloth while only 15% use pads. Mothers are the immediate source for information, and they provide support during menstruation, followed by sisters and female friends. To learn more about girls' experience of menarche and menstruation we employed a peer ethnography to examine and evaluate adolescent girls' experience of menstruation, their attitudes about the experience, and the potential for making positive change in MHM. Peer ethnography enabled our research team to take an in-depth look not only at girls' lives but also at the role that family, friends, and institutions played in shaping their feelings and experience about menstruation. The narratives that we collected from 12 districts across the country made it apparent that insufficient education and accurate information about menstruation for girls before their menarche is crucial to preventing later emotional and psychological difficulties in managing menstruation as an adult, and these emotions and psychological challenges are not limited to MHM-related issues. We found that restrictive attitudes and misinformation about menstruation carried over into other areas of girls' lives: school, family relations, and selfperceptions about their role and potential in society. Irrespective of the study site, most adolescents said they obtained information and knowledge on MHM primarily through their mothers, sisters and other female relatives. The secondary chain of informants consisted of grandmothers, aunts, sisters-in-law, and female friends. Comparative analysis of the narratives indicated that, stricter cultural norms around menstruation correlated with settlements that were predominantly Hindu, whereas these norms and practices tended to be less restrictive and more flexible in communities populated by diverse groups, or primarily Janajati (ethnic people). Across study sites, however, nearly all girls had been taught to think of menstrual blood as "impure" or "dirty." While some girls reported that their menarche had been treated as an opportunity for celebration, future menstrual periods were characterized by restrictions about where girls could go, what they could touch, what they could eat, and where they could sleep. As a result, the experience of menstruation for many girls was dichotomized into a confused understanding of themselves as both pure and impure. Barriers to improved MHM in the study sites centered around improved education and awareness, the availability of pads, and access to facilities where girls could employ menstrual health practices safely and securely. Apart from the significant misinformation about menstruation, and menstrual blood, many girls expressed a desire to use pads but said they were either unavailable in their communities or too expensive to use habitually. Furthermore, cultural restrictions at home and a lack of separate toilet facilities in many schools forced many girls to bathe and change pads away from both places (occasionally in the forest or at isolated spots near rivers where their physical safety would not be assured). Despite these many challenges, most of the girls we talked to expressed a desire to see MHM improve, not just in terms of the materials available, but also in terms of the cultural beliefs and attitudes that serve to circumscribe females in a pre-ordained and inferior social position. They were able to express this desire for change as the need for more education and better facilities for girls, as well as the necessity to transform the institutions (e.g. schools, the state) that govern their lives.