Keywords

1 Introduction

When considering sanitation, gender should be an important aspect as men and women share about half the world population and they have different needs for sanitation. The importance of gender issues in sanitation promotion was already recognized in the International Year of Sanitation (IYS) in 2008. One of the five key messages of the IYS, “sanitation contributes to social development,” was further elaborated as follows: “Where sanitation facilities and hygienic behavior are present, rates of illness drop, malnutrition in children is reduced, more children, especially girls, attend school and learn better, and women’s safety and dignity are improved” (UN Water 2008: 8). Although the privacy, safety, and dignity of girls and women were mentioned, menstruation―a prime factor of privacy, safety, and dignity―was not discussed in detail.

Menstruation is a universal physiological phenomenon experienced by the female body. It refers to the regular monthly bleeding from the endometrium that occurs throughout a female’s reproductive lifecycle, apart from the gestational period and the puerperal period. Menstruation plays an important role as a female reproductive function and is closely linked to female health. At the same time, there are various issues for a woman to cope with menstruation.

It was mainly through the discussion process of setting the Sustainable Development Goals (SDGs) that the importance of menstrual hygiene management (MHM) became commonly recognized in international development. It became clear that menstruation-related issues need to be addressed as a development agenda from various aspects, such as achieving gender equality, promoting girls’ education, improving women’s reproductive health, and improving access to safe water and sanitation. UNICEF and NGOs initiated promotion and interventions of MHM.

On the other hand, menstruation is a domain that is often kept hidden in many societies. Talking about menstruation and disclosing that a woman is menstruating are often considered taboo (Akiho 2019; Mason et al. 2013). In some societies, it may not be a cultural taboo, but their social context makes them uncomfortable or shy to mention menstruation. Since menstruation is a phenomenon unique to women, it is hidden especially from men, and this has led to men not having enough knowledge about menstruation (Ishikawa and Sugiura 2011; Rajak 2015). Some argue that these were the reasons menstrual issues were set aside from the mainstream of international development (Tilley et al. 2013).

It is not just hidden, but there are many taboos surrounding menstruation, and it has various connotations depending on the culture. This makes it even more pertinent to understand local contexts of menstruation when large-scale international development assistance is considered.

In this chapter, the first objective is to review the development of MHM as an international agenda. The second objective is to highlight the cultural aspects of menstruation. A case study will focus on MHM in Uganda and the local reality of female students in a rural high school. I hope these will provide a concrete understanding of why gender, especially menstrual issues, and culture are important in both MHM and sanitation promotion. I will extract recommendations for interventions at the end.

2 Menstrual Hygiene Management as a Development Issue

2.1 Definitions of MHM

I will start by presenting the definition of “menstrual hygiene management (MHM),” which has now become a common jargon in international development. Later in this section, I will also touch on the newer phrase “menstrual health and hygiene (MHH)” that some organizations have started to use.

The first appearance of the phrase MHM with the acronym in an international meeting was in 2005 at a roundtable meeting hosted by the International Water and Sanitation Centre (IRC) and UNICEF (UNICEF and IRC 2005). However, it took some time for the concept to be recognized and widely understood. The definition of MHM varies depending on the organization and on the documents even within the same organization. One of the earliest and frequently cited definitions would be the following by the WHO and UNICEF Joint Monitoring Programme for Drinking Water, Sanitation and Hygiene (in short, JMP):

Women and adolescent girls are using a clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary for the duration of a menstrual period, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials. (WHO and UNICEF 2012: 16)

WHO and UNICEF (2012) in the same document further identified five preconditions for the above. The first point was about knowledge, suggesting “access to accurate and pragmatic information (for females and males) about menstruation and menstrual hygiene” (ibid). The other four points were materials and physical environment necessary to realize the above. Included were menstrual hygiene materials (such as sanitary pads), facilities that provide privacy for changing menstrual materials and for washing the body, water and soap for washing clothes and drying, and disposal facilities (ibid).

UNESCO (2014) proposed to include broader and systemic issues surrounding girls and women for MHM. They were summarized in the eight points below:

  1. 1.

    Accurate and timely knowledge

  2. 2.

    Available, safe, and affordable materials

  3. 3.

    Sanitation and washing facilities

  4. 4.

    Safe and hygienic disposal

  5. 5.

    Informed and comfortable profession

  6. 6.

    Referral and access to health services

  7. 7.

    Positive social norms

  8. 8.

    Advocacy and policy (UNESCO 2014: 31)

A new concept encompassing both the original definition of MHM by WHO and UNICEF (2012) and the broader systemic factors suggested by UNESCO (2014) is termed “menstrual health and hygiene (MHH).” As the title of the recently issued Guidance on Menstrual Health and Hygiene (UNICEF 2019) indicates, UNICEF nowadays uses the term MHH rather than MHM. Menstrual health and hygiene, according to UNICEF (2019), is a broader concept linking menstruation with health, well-being, gender equality, education, equity, empowerment, and rights. Some NGOs, such as Save the Children, also started using the label MHH, while some organizations use the term “menstrual health.” Although the concept is expanding, in this chapter, I will use the word MHM, since this was the term that drew international attention and the majority of the organizations still uses it.

2.2 Formation of MHM as a Development Agenda and Its Relation with SDGs

Menstruation was a topic rarely discussed openly as an international agenda. It should be noted, however, that there were development projects and volunteer activities aimed at supporting women and girls with menstrual management. For example, NGOs have developed educational materials, disseminated reusable sanitary pads, or supported constructing incinerators for discarded pads (House et al. 2012). I once visited a Japanese Overseas Cooperation Volunteer in Bangladesh to observe her activities; she was providing local women with technical guidance on how to sew reusable cloth pads.

One of the early large-scale interventions was in 2009 when UNICEF conducted a pilot project producing and disseminating a supplement book titled “Growth and changes” (Sommer 2009) for adolescent schoolgirls in Tanzania. The booklet provided practical information on menstruation, and it was approved by the Ministry of Education in 2010 to be used in the primary school curriculum. This project expanded to other countries as well.

The most significant trigger of the new trend of menstruation becoming a major agenda in international development was when discussions started about post-Millennium Development Goals (MDGs), which later was named Sustainable Development Goals. In 2011, the water, sanitation, and hygiene (WASH) sector held an international conference to discuss the new goals. Here, menstruation was taken up as one of the issues in sanitation and hygiene (WHO and UNICEF 2012). Based on a review of MDGs, the principles of SDGs became disparity reduction and inclusive development. It was agreed that sanitation facilities need to be accessible for girls and women during their menstruation as well. Also, in the examination of the concept of hygiene, menstrual hygiene was identified as a part of improved hygiene (Tilley et al. 2013). The notion that the difficulty of coping with menstruation was a cause for girls’ school absenteeism made menstrual management an agenda for the education sector as well (Sommer et al. 2014).

In 2012, the London-based research consortium Sanitation and Hygiene Applied Research for Equity (SHARE) and WaterAid, a major international NGO, published a detailed manual for practitioners to promote menstrual hygiene (House et al. 2012). WASH United, a nonprofit organization headquartered in Germany, also played an important role in advocacy; it proposed to designate 28 May as Menstrual Hygiene Day to raise awareness of MHM, and the first Day was commenced in 2014 (WASH United 2020). The date (28th day of the fifth month) was chosen, because the average menstrual cycle is 28 days and blood flow will continue for about 5 days. It was also in 2014 when the above-mentioned guideline on MHM was published by UNESCO (2014). With the slogan “Break the Silence,” active discussions and initiatives on menstruation were held internationally (WASHplus Blog 2015). It was around this time that the acronym MHM came to be widely used and became jargon in international development.

The goals of the SDGs were adopted at the general assembly of the United Nations in 2015. The term menstrual management itself was not included in the goals or targets, but MHM is said to be closely related to the following goals (Tiwari 2018; WASH United 2019a, b).

  • Goal 3: Ensure healthy lives and promote well-being for all at all ages.

  • Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all.

  • Goal 5: Achieve gender equality and empower all women and girls.

  • Goal 6: Ensure availability and sustainable management of water and sanitation for all.

  • Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.

  • Goal 12: Ensure sustainable consumption and production patterns.

In particular, target 6.2. in Goal 6 explicitly requires sanitation and hygiene to be gender-sensitive (see Table 5.1). The concept of hygiene in target 6.2 further explained by JMP includes menstrual hygiene management (WHO and UNICEF 2017: 2). JMP requires improved sanitation at a health-care facility to have at least one sex-separated toilet with menstrual hygiene facilities. Target 4.a in Goal 4 also implied a school sanitation facility that is gender-sensitive. The SDGs monitoring program guideline on school sanitation and hygiene included menstrual hygiene in their checklist (UNICEF and WHO 2016).

Table 5.1 SDG goals and targets related to gender-sensitive sanitation (United Nations 2015: 18; underlined by the author)
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2.3 Why MHM Is Important: Research Background

A major reason why menstrual management caught the attention of international development organizations was studies showing that menstruation was causing school absenteeism among female students (Sahin 2015; Sommer and Sahin 2013). For example, research conducted in Malawi showed that one-third of the female students said they were absent from school at least 1 day during their last menstruation (Grant et al. 2013). Another study in northern Ethiopia found that more than half of the girls claimed they had been absent from school due to menstruation, with 39% of the girls saying their academic ability had declined since their menarche (Tegegne and Sisay 2014). About 20% of Ugandan girls in a survey experienced menstrual blood leaking into their uniforms, and this was the major cause for missing school during menstruation due to fear and embarrassment that they may be teased again (Miiro et al. 2018).

For girls at school, sanitation facilities are crucial spaces for changing their absorbents. When girls are able to freely access gender-separated latrines at school, girls were less likely to miss school during their menstruation (Alam et al. 2017). A study on school sanitation (toilets) found that students use of the facility was associated with conditions such as pupil to toilet ratio, toilet type, how new the toilet was, and possibly its cleanliness, especially among girls (Garn et al. 2014). There is also a study reporting that a quarter of the studied girls accidentally dropped their menstrual items at school latrines, and 24% of them brushed/washed the item and reused it (Oduor 2015).

In addition, a lack of knowledge about menstruation especially among adolescent girls was identified by numerous studies. Many girls do not know about menstruation until the first menstruation; for example, 60.3% of the girls surveyed in India said they came to know about menstruation for the first time only at menarche (Shah et al. 2013). They also did not fully understand where menstrual blood came from. Adolescent girls generally lack knowledge of menstruation was the conclusion of a systematic review of 44 studies on menstrual knowledge of girls, aged 10–14 years old, in low- and middle-income countries (Coast et al. 2019).

These results seem to reveal the needs for MHM; with improvements in sanitation facilities in schools leading to an increase in attendance rates among girls (WaterAid and Tearfund 2002). When a teacher or a nurse held classes about MHM, not only did the knowledge about menstruation increase but also the proportion of the students who perceive menstruation as annoying decreased (Hennegan and Montgomery 2016; Su and Lindell 2016). It has also been suggested that the presence or absence of premenstrual education may affect adolescent dysmenorrhea (Chhabra et al. 2017).

However, statistical correlation and causal relationship between school absenteeism and access to menstrual pads or sanitation facilities are up for debate. The impact of MHM interventions is also yielding mixed results. For example, a study found that the distribution of sanitary products in intervention projects did not significantly affect school attendance among female students (Hennegan and Montgomery 2016). The mixed results could be mainly due to research methodology and measurement issues (Phillips-Howard et al. 2016), while they could be due to the design of the intervention including adaptation to cultural context.

It is important to note that it was not just the recognition of the research on local situations that pushed MHM to an international agenda. Private companies that manufacture female sanitary products also played a role (Sommer et al. 2015). Media also highlighted social entrepreneurs for developing menstrual products with “appropriate technology.”

Another aspect that requires further consideration is how the concept of MHM is treating local culture. When UNICEF supported the production of the menstrual education handbook for schoolgirls in 2009, it avoided referring to local cultures and taboos, which led to the approval and dissemination by the Tanzanian government. In 2014, when the broader concept of MHM was proposed, “positive social norms” was one of the eight aspects of MHM (UNESCO 2014). The document explains that taboo, shame, myths, and misconceptions continuing to flourish are obstacles for policy formation as well as health and educational professionals. Those norms and beliefs have their roots in a socio-cultural context, so simply negating them may induce some side effects. The next section further discusses this issue.

3 Cultural Issues: Menstruation Embedded in Socio-Cultural Context

Menstruation is not just a bodily but also a socio-cultural occurrence. In other words, a woman experiences menstruation in accordance with the social and cultural values attributed to it locally (Matsuo 2007; Namihira 2009). Each society has its customs and taboos related to menstruation, and the perception and management of menstruation can vary from one culture to another.

For example, a girl’s menarche in some societies is perceived not only as a sign that she has joined adulthood but also entering a new stage eligible for marriage. A rite of passage to celebrate the menarche would be conducted in a community (Buckley and Gottlieb 1988). Menstruation is a symbol of fertility and the ability to reproduce.

Contrariwise, menstruation, menstrual blood, or menstruating women are often perceived as dirty, polluted, and dangerous. These seemingly opposite perceptions can coexist in the same culture, which makes menstruation an ambiguous phenomenon. Many cultures, which associate menstruation with pollution, restrict some daily activities of menstruating women as taboo from the fear that those activities may spread the pollution and cause undesirable effects (Briffault 1927; Buckley and Gottlieb 1988; Douglas 1966). Actually, it is said that the word “taboo” originally came from the Polynesian word “tapu,” which was associated with “menstruation” (Briffault 1927). This shows that menstruation and taboo are closely connected to each other. For example, women in India are forbidden from worshipping at Hindu temples or performing any rituals while menstruating (Matsuo 2007). In Japan, menstruation, along with childbirth, has been perceived as unclean, and there are reports that the custom of isolating menstruating women in menstrual huts and restricting their daily activities continued in many regions of Japan even after the second world war (Namihira 2009).

Taboos related to menstrual blood influence the handling of used sanitary pads or other absorbents. For example, most female students in Indonesia use manufactured disposable sanitary pads with polymer, yet they do not discard used ones without washing off the blood. Menstrual blood is considered impure and should be washed off (Oguni 2019). The students do not change the pads at school toilets, because the facilities do not allow them to wash and discard the stained pads in an “appropriate” manner. Another research with adolescent girls in Gambia depicts that they are restricted from burning used sanitary pads saying that this can lead to their infertility (Shah et al. 2019).

Local material culture for menstrual blood absorbents also varies. In addition to the rather recent products such as manufactured disposable pads, reusable pads, and menstrual cups, there are different materials utilized for managing the flow. Some are traditional and some are improvised from whatever materials available. Included are used clothes, cottonseed, felt, banana stem fibers, papyrus fibers, plant leaves or ears, the dung of domestic animals, tissue paper, newspaper, notebook scraps, or sponge from bed mattresses. How those materials are used or discarded are shaped by the perceptions on menstruation and menstrual blood, in addition to the economic affordability.

Cultural taboos, materials, and perceptions are not intrinsic to or static in a society, as in the case of Japan (Namihira 2009; Tanaka 2013). Tanaka (2013) argues the development of new menstrual pads and strategic advertisement of the products had changed the perception of menstruation in Japan. In rural Papua New Guinea, the discontinuation of the custom of isolating women in menstrual huts in the early 2000s coincided with the spread of using disposable sanitary pads (Shinmoto 2013, 2019). Until then, everyone in the community knew which woman was menstruating due to the practice of secluding them in menstrual huts, but the use of disposable sanitary pads transformed menstruation into a hidden domain. These cases suggest that culture can change; a shift in material culture may have brought a change in cultural customs and perceptions on menstruation in the society.

Culture can change, yet in dealing with the current condition of women’s menstrual management, it is important to understand the local socio-cultural context in which menstruation is embedded (Sato 2019). Taboos surrounding menstruating women and menstrual blood still remain strong in many cultures. There are even cases reported where modern technology and medicalization are used to accommodate cultural taboos and result in reinforcing them. For example, contraceptive pills are used for delaying menstruation so that women can go to a ceremony in a Hindu temple (Matsuo 2007). Cultural taboos, as well as cultural knowledge, shape how women experience menstruation and how they manage it.

4 A Case Study from Uganda

4.1 Purpose of the Case Study

The purpose of this case study is to understand one of the local realities in a certain area, in this case, rural Uganda. Uganda was one of the earliest countries where political leaders made commitments on MHM for schoolgirls. Nonetheless, the delivery of such a decision takes time to reach the grassroots level, not just in Uganda but in any country or region. Since my focus is to understand how cultural issues shape the behavior related to menstruation, I will present here the situation in 2014 before any intervention reached the research site in Manafwa district, eastern Uganda. I will describe a detailed account of the conditions of menstruation among female students in the target area: how they perceive it, what is considered taboo, how do female students learn about menstruation, and what is their experience of menstruation.

4.2 Research Area

The fieldwork of the case study described in this chapter was conducted in Uganda. Uganda is located in eastern Africa and its GNI per capita as of 2019 was USD 789 (World Bank 2021). Its population is 41.6 million with 75.6% residing in rural areas (Uganda Bureau of Statistics 2020), and it consists of about 50 ethnic groups. In terms of basic sanitation coverage, it was 18.49% in 2017 according to the newest available data (WHO and UNICEF 2021).

Uganda was one of the earliest countries where politicians and government officials at the ministerial level recognized the importance of MHM in response to the advocacy of NGOs and international organizations. In August 2014, an international conference on MHM was held where the Minister of Education & Sports (who happened to be a woman) emphasized the importance of tackling menstruation-related problems among girls (NETWAS Uganda 2014). In 2015, “the Menstrual Hygiene Management Charter” was endorsed by the ministries and civil organizations and launched by the speaker of parliament (Ministry of Education, Science, Technology and Sports, Government of Uganda 2015). The ministries that signed the charter included the Ministry of Education, Science, Technology and Sports, Ministry of Gender, Labour and Social Development, Ministry of Water and Environment, Ministry of Health, and Ministry of Local Government. Though there was criticism that these policies lack financial backing and that it will take time for measures to reach schools throughout the country, they are considered to be examples of a national policy (Snel 2015).

The research site is in a rural area of Manafwa District located in eastern Uganda, and it was not affected by such MHM policy by early 2015. No real intervention had reached the school, which was the target of my study. The study site is located in a hilly area at an altitude of 1450–1600 m near the border with Kenya (see Fig. 5.1). The area is at the foot of Mt. Elgon, which has the fourth highest altitude in Africa (more than 4300-m high). The main occupation of the villagers is farmers, with matoke and maize being their staple foods. The area had no piped water at the time of research and had only boreholes with hand pumps that were shared by the community. The ubiquitous type of sanitation was pit latrines (a basic sanitation facility consisting of a hole in the ground to collect human waste with walls for privacy).

Fig. 5.1
figure 1

Map of the research site in Uganda

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More than 90% of the village population belongs to the Gisu ethnic group (also known as Bamasaba) of the Bantu people. Mt. Elgon is considered to be a holy mountain and the birthplace of the earliest ancestors of their ethnic group. Masaba is the name of their mythical founder, and Mt. Elgon is called Mt. Masaba in the native language.

The secondary school that was the target of this study is the only government school in its subcounty. The school system in Uganda comprises 7 years of primary school, 4 years of secondary school-Ordinary level (O-level), and 2 years of secondary school-Advanced level (A-level). The target school imparts both Ordinary and Advanced level education, with a total of about 1700 students in those 6 years. The school has a rainwater tank that dries up in the dry season. The students also use the community borehole located behind the school.

4.3 Research Methods

Data was collected by combining several research methods, namely (1) questionnaire survey (n = 90) targeting third- and fourth-year female students in O-level, (2) focus group discussions (three groups) by selecting students (n = 26 in total) from among the participants of the questionnaire survey, (3) interviews with female teachers, (4) interviews with local female residents, (5) an interview with the owner of the only store selling sanitary pads in the area (apart from local weekly markets). Information was collected from local residents in order to understand the differences in customs between generations and the traditional way of managing menstruation.

4.4 Code Language

In order to understand the perception of menstruation in Gisu culture, I started by asking how menstruation is referred to. In the Gisu language, the phrase generally used for going through the menstrual period is “going to Mt. Masaba” (khutsa iMasaba). When asked why they use this expression, the female students could not give an explanation, but only said, “That is what has been said for a long time.” Many of the older village women also did not know the reason, but some mentioned that the phrase had its origin in thoughts such as “Menstruation is as difficult as climbing Mt. Masaba” and “Mt. Masaba appears red in color on a moon-lit night.” The expression of going to the sacred mountain where the ancestors of the Gisu people were born can be interpreted as indicating awe associated with the sacred mountain and its connection with procreation.

There is another expression commonly used to express menstruation: “monthly illness” (khuluwara mumwesi). As the phrase suggests, it literally means an illness that comes every month. It is interesting to note that a negative expression, illness, coexists with the contrasting expression “going to the sacred mountain” for referring to menstruation.

There also exists some code words that can only be understood by the female students; they use these words when in the company of male students and villagers. For example, the abbreviation for a Member of Parliament (MP) is used as a pun to refer to the Menstrual Period (MP). The female students further use the pun to play on words by saying, “I’m in an election campaign right now” when talking about their menstrual period. In another example, a sanitary pad is sometimes called “bread,” and going to a kiosk (general store) to buy sanitary pads is called “going to buy bread.”

The fact that such code words exist implies the society to which the female students belong is making the students uncomfortable about others knowing that they are in their period. As I will describe later, the reason why they do not want others to know is not only because of embarrassment but also because they fear it will lead to sorcery on them.

4.5 Taboos Surrounding Menstruation

In Gisu culture, there are a number of actions that are considered taboo for menstruating women. In the focus group discussions, high school girls mentioned many such actions, although some taboos did not necessarily have a high consensus. For example, after some students mentioned a certain taboo, some other students reacted, “I heard that this is actually okay” or “Really? Is that a taboo?” In other words, there seem to be variations among individuals regarding what is considered taboo.

Table 5.2 lists the main taboos mentioned by the students. The list contains items that either all or a majority of the participants agreed to as being taboo. From the list of taboos, several broad categories emerge, which can be divided into the following:

Table 5.2 Acts considered taboo during menstruation
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One category of taboos is related to agricultural production. Forbidden were menstruating women going into groundnut, sweet potato, or pumpkin fields, and doing agricultural work, for example, seed planting, weeding, and harvesting in those fields. Some said just passing those fields should be avoided. It is believed that if a menstruating woman went to the field, the crops will dry or it will lead to a poor harvest. Similarly, climbing mango, avocado, and jackfruit trees will either spoil the fruit or lead to a low harvest. Though these crops are not staples in eastern Uganda, they are still commonly grown in this region.

There are also taboos related to drinking and eating. It is believed that drinking liquids other than water, such as milk, tea, or soda (carbonated drinks such as cola), will cause heavy blood flow and such drinks should be avoided during menstruation. Some said that if soda is offered to them (which is a luxury beverage for a high school student), they take it home on the pretext that, “I want to drink it slowly later,” and keep it at home until their period ends. Eating sugarcane is also forbidden during menstruation but that could be because of its high water content, which replenishes body fluids. Some said eating fried beans is also taboo during their period, though they could not give a reason for it. But in most cases, students seem to have their own physiological interpretation of the drinking and eating taboos.

The majority of the population in this area is Christian, and taboos related to the church also exist. It is believed that going to church and participating in activities such as the church choir or touching the Bible during menstruation would desecrate Jesus. Some students said that the church minister taught them that menstruating women should not come to church. However, some students argued that it was not taboo to touch the Bible during menstruation, and a heated debate ensued among the students during the focus group discussions. One counterargument was if you have a pad, you can go to the church. There was also an account that it is not possible to participate in the choir, which entails dancing in Ugandan churches, because of their severe back pain during their period.

Fairly strong taboos were noted regarding objects that had once absorbed menstrual blood. It is said that underwear or cloth used as a menstrual blood absorbent cannot be dried outside even after washing them with soap. Moreover, everyone agreed that discarding used sanitary pads or cloth used as an absorbent within the reach of people (and dogs) is “absolutely unacceptable.” In either case, it is believed that the objects that have (or had) menstrual blood can be taken to a person with malicious intent (mainly witch doctors) and be used to cast an evil spell. According to the students, the worst case is that a woman can become infertile as a result of the spell. It is not just the young students who had this fear, but also older women in the village. During my interview with a housewife with two children, she said:

One day I happened to leave my underwear on the outdoor drying line and it went missing. This made me very anxious. So, when I became pregnant, I heaved a sigh of relief that my missing underwear had not been used to bewitch me.

This fear of being bewitched is why careful attention is paid to the methods of washing and drying underwear with menstrual blood and cloth used as menstrual blood absorbent, as well as the disposal of used sanitary pads or any other absorbents.

Other taboos that came up during the discussions but with lower consensus were cooking, heavy work such as splitting firewood, playing in rivers, and riding a bicycle. During the focus group discussions, I found that it is difficult to differentiate taboos, which academics would label as a restriction due to the fear of some supernatural power (Sasaki 1994), from inhibited behaviors due to a physiological reason. For the girls themselves, these were all behaviors that they were told not to do and if they violate, a bad consequence would be brought to themselves or their family.

4.6 Imparting Knowledge About Menstruation

Who imparts knowledge about menstruation to girls and when do they do it? The survey data shows 82% of the girls learn about it from their mothers, while 8% from their paternal aunt (senge, in local language), 5% from their elder sisters, followed by 4% from teachers. In Gisu society, the paternal aunt is often responsible for sex education, but as for the knowledge on menstruation, the paternal aunt or older sister would teach about it only if the mother was deceased or had left the home after divorce.

The mother, aunt, or sister teaches the girl who had her first menstruation that starting menstruation means she became mature and she has to be careful with men. How to take care of the menstrual flow and how to keep themselves clean during the period are also among the lessons taught. Taboos related to menstruation are taught mainly by female family members, although some knowledge on taboo was taught by female schoolteachers and church members.

What was surprising was that about half of the female students did not know about menstruation, because they had not learned about menstruation either from their family or at school until their menarche. Out of the 90 high school girls (average age = 17 years), only 47% were told about menstruation before menarche; the average age of menarche among the students was 14.6 years. A student, looking back to her menarche, said “I was shocked and cried when I saw blood on my underwear. I did not know what went wrong with me.” This feeling was shared with many other girls who did not have the knowledge of menstruation on the day of menarche. This can be the result of the norm of not talking about menstruation openly even among family members. In Gisu culture, people do not have a rite of passage celebrating menarche, which may be an opportunity for knowing about menstruation before your own.

Menstruation is taught in science/biology during Year Six of primary school and Year Four of high school in Uganda. However, very often it happens that not everything in the textbook can be covered during the actual class periods. Moreover, in rural areas of Uganda, there are variations in the age at which children start primary education. Some students must repeat the same year even at a primary-school level if their academic performance is not satisfactory. Therefore, it is not uncommon for students in the upper grades of a primary school to be in their mid to late teens.

Not only when they study but also what they study through textbooks was questionable from a practical viewpoint for managing menstruation. In biology textbooks, the contents related to menstruation are covered under the subject of reproduction. It shows male and female organs and explains ovulation, which is important scientific knowledge but not necessarily linked to practical life skills. Female students in the focus group discussions said that they would like to learn more at school about topics such as irregular menstruation, coping with headaches and menstrual cramps, as well as about menstrual hygiene products (such as sanitary pads).

4.7 Absorbents for Menstrual Flow

The quality of blood absorbents is a factor that shapes the monthly experience of menstruation. Traditionally in Gisu culture, an absorbent called Ifungo as shown in the picture (Fig. 5.2) was used. This is made of fibers obtained from a dried-up stem of a matoke (banana) plant (Fig. 5.3). Since matoke is the staple food in this area, matoke plants are grown throughout the area. When in need, a woman would pull off a handful of the dried stem and crumple it up. Then, it is inserted into the vagina, like a tampon. Older women told me that they used to use it, but the majority of the high school students did not even know about it.

Fig. 5.2
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Traditional menstrual absorbents. (Photo by Sugita)

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Fig. 5.3
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Stem of a matoke plant. (Photo by Sugita)

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So what kind of absorbents do the high school students use for managing their menstrual flow? Table 5.3 shows the results of a questionnaire on the type of absorbents the students have used. In these multiple-choice questions, 96% of the female students answered that they have used manufactured disposable sanitary pads. It is followed by old cloth, underwear only, and reusable cloth pads. There are discrepancies between the experience of using them and the students’ claim of frequent use.

Table 5.3 Absorbents used for menstruation hygiene management (n = 90, multiple choice)
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The high percentage of manufactured sanitary pad use has to be noted with caution. Since the questionnaire allowed for multiple answers, those who answered that they use sanitary pads do not necessarily use them throughout the duration of their menstrual period. It appears that most girls use them only on days of heavy flow, and while they are at school. The reason, I think this, is because when I interviewed the owner of the only general store that sold sanitary pads in the area about his sales, it was not possible for his store alone to supply menstrual pads to most of the female students. There is a weekly market on Wednesdays in the area, but only a few merchants sold sanitary pads. Even in monetary terms, a pack containing seven to ten pads costs between 2000 and 3000 Uganda shillings (approximately USD 0.77–1.15 at the time of research), which is expensive considering that students rarely drank soda, which costs 1000 Uganda shillings. Over 91% of the students (n = 90) answered disposable sanitary pads are “very expensive” or “somehow expensive” in the questionnaire. The students also expressed, “sanitary pads are more modern and cooler.” The figure for manufactured sanitary pads may be inflated beyond the actual number being used.

“Old cloth” used as absorbents during their period was obtained from old T-shirts, other clothing, or old bedsheets, according to the students. They cut the cloth into squares and fold them before using them to line their underwear. On the other hand, reusable cloth pads have been sewn in advance and are sold in a package (or distributed by NGOs).

Surprisingly, there were students who responded that they only use underwear or toilet paper. The speculation is that they practice this around the fourth and fifth day when menstrual flow is comparatively light. Nonetheless, it is surprising that 49% of the girls have experience taking care of their period with underwear only. In addition, some students use cottonseed that they picked from cotton plants cultivated in fields on the way to the school. There were a few students who said, “I have no choice,” but to quietly pick the cottonseed from other people’s fields on their way to and from school.

4.8 Changing and Disposing of Menstrual Absorbents

How do the students change and dispose of their menstrual absorbents when they are at school? According to the survey, the most frequent answer for the location of changing was inside the school latrine booth (63%) (see Fig. 5.4). Some also used what they called a sakati (literal translation would be bathing shelter, but in this case, a space also used for urinating). Boarding students more likely went back to their dormitory room, which is located behind the school for changing. Some students said they would go back home during the break time to change, and 10% of the 90 girls said they don’t change while at school. In the focus group discussion, some students said the sakati at home is not an appropriate place for changing menstrual items, because their father may see the blood on the floor (locally small rocks are spread at the base to allow bathing water to drain into the soil).

Fig. 5.4
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Where students change the menstrual items while at school (n = 90, multiple choice)

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Almost everyone responded that they dispose of used sanitary pads, old cloth, cotton, and toilet paper into the pit latrine. The pit is deep and once things are dropped inside, they are out of reach. They throw them into a pit latrine, because otherwise, they fear that the absorbent with menstrual blood can be used for sorcery. A typical explanation given was:

“Even if a trash bin was kept in the cubicle of the latrine, I would never throw sanitary pads in it. My stepmother, who might be watching from behind, could pick it up after I leave and take it to the witch doctor.” Relations with the stepmother can be particularly strained in the polygamous Gisu society, and female students feared that their stepmother (or someone who has a grudge on her) might cast a spell on them.

When reusing old cloth, reusable cloth pads, and underwear, everyone said that they wash them with soap and hang them to dry in a place that is not visible to others. Many girls hang them indoors (hang them over the edge of a portable laundry basin and hide it under the bed). When they have to hang them outdoors, they hang them on the wall of a bathing shelter, which is generally located outside their house, and cover them with a thin cloth. This keeps the laundry hidden from the eyes of others, preventing the embarrassment of being seen by the father and from being picked up by someone for bewitching. The girls explain that it is “not good” for underwear or your menstrual blood to be seen by their father or male family members, but this is due to embarrassment and not fear of the spells.

5 Discussion and Recommendations

The research results show that seemingly simple behaviors associated with menstrual management pass through the filter of cultural norms and girls` perceptions. (1) Changing menstrual absorbents (2) using a latrine, (3) discarding used sanitary pads or other sanitary items, (4) washing menstrual items or underwear, and (5) drying them; all these behaviors were not conducted in a cultural vacuum. In this study site, talking about menstruation itself was often refrained from, and strong taboos were connected with the fear of their menstrual blood or items, which once had blood being exposed and used for bewitching. This in turn influenced the above “daily” behaviors.

When an intervention for MHM is to be introduced at schools, cultural context and the voices of female students regarding menstruation must be taken into account. I will discuss four points that emerged from the case study. These points also include my recommendations for implementing international MHM support.

The first is about the disposable sanitary pads and the methods of disposal. Female students said disposable sanitary pads are “modern and cool,” and claimed that they often use those pads. After usage, the pads are disposed of by throwing them into pit latrines due to the fear of the pads being used for sorcery. Provision of dustbins in the school latrine booth would not be a solution for this area, as the girls strongly suggested against it for that very reason. These manufactured menstrual pads (at least, currently most of them) do not decompose naturally. If women continue to discard the pads into the earth, it may lead to environmental issues as well as shorten the number of years for a pit latrine to fill up. There are some efforts to produce biodegradable and affordable pads in Uganda, such as EcoSmart pads or MakaPads (College of Engineering, Design, Art and Technology 2020). The appropriateness of installing an incinerator would need further examination reflecting the cultural belief or practice of an area, such as the taboo of burning menstrual blood. It is said that the disposal issue of sanitary products should be further addressed including its impact on the environment and health (Elledge et al. 2018).

Second, in disseminating reusable cloth pads, socio-cultural context and women’s practice also should be considered. The instructions of reusable cloth pads, in general, indicate washing them with clean water and soap, then dry them under direct sunlight. In the case of the above research area, clean water and soap were available. Female students were experienced at using old cloth as an absorbent and washed it well and dried it. However, reusable cloth pads, which have the structure to avoid leakage, are much thicker and do not dry easily. Considering the girls’ actual practice of drying menstrual absorbents, the thick, slow-drying cloth can become a breeding ground for bacteria. Fast-drying, antibacterial fabric may reduce the problem, but the cost may increase.

Here, I want to make it explicit that I am not supporting one product over the other. Disposable sanitary pads are easy and convenient to handle, while reusable pads are more sustainable. Other products such as menstrual cups have their own benefits. The point is the importance of understanding local context and cultural practices associated with these materials in introducing an intervention and considering the possible negative impact. That may lead to further development of an absorbent or sanitation facility that is appropriate for its culture, environment, and health.

The third issue is about education on menstruation. At the point of research, only 48% of the female students knew about menstruation before reaching menarche. Considering the rate of primary school students having to repeat grades in Uganda (and in many other countries), introducing menstrual education in Year Six might be too late. It is necessary to provide menstrual education for girls at an earlier stage in primary schools. Moreover, the content should focus on providing practical knowledge about how to handle menstrual bleeding, menstrual cramps, irregular menstruation, and other topics closely related to the problems faced by female students, rather than just teaching about ovulation and menstruation as a reproductive function described in current science textbooks.

My last point is about the treatment of cultural beliefs, taboos, and traditional methods of menstrual management. UNESCO (2014) identifies “positive social norms” as one of the essences of MHM. Some MHM educational materials and reports refer to cultural taboos or traditional methods with negative connotations. Although whether each belief or practice is actually harmful or not is up for debate, it is important to notice the hidden curriculum with the interventions. The students from the above case study called disposable sanitary pads “modern and cool” and other traditional methods “backward.” Some said it is not taboo to go to the church if you are using those sanitary pads. These notions can marginalize girls who also believe manufactured sanitary pads are cool, yet difficult to afford. During my visit to the same area, I heard some girls have young men with earnings buy pads for them in exchange for sex. These cases suggest that girls who cannot afford new products can get further sidelined with the dissemination of the discourse perceiving negatively of traditional absorbents and the spreading market of menstrual products.

Assistance for MHM is expected to grow in international development. MHM, I believe, is important for girls and women, and it will benefit them with proper consideration. I hope that MHM/MHH interventions and sanitation promotion will reflect the socio-cultural context and the voices of female students.

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