Introduction

For the last few years, a steady stream of news stories has emerged from Nepal, detailing the segregation of menstruating women. This traditional practice of living in menstrual huts (chaupadi)—remains most widespread in Western rural areas but is also practiced in other parts of the country, despite the Nepali Supreme Court ban in 2005 and numerous physical, emotional, and mental dangers associated with chaupadi. Our research team of Nepali and American scholars collected the life histories of 84 women in Nepal over a period of 16 months starting in June of 2016. These women ranged in age from 17 to 61 years old. The study area included the middle or hill areas of Nepal and the ethnic groups who reside primarily in the hill area, including high caste women and Dalit (so-called untouchable) women. We contend that women’s life histories are a meaningful location for studying menstrual health and hygiene. We ground our analysis in the specific sociocultural context of Nepali women themselves and their particular lived experiences.

How might micro-level examples such as individual women in Nepal and their life stories illuminate social structures and macro-level social change? We assert that researching gender and reproductive health at the micro-level reveals important dynamics about gender formation, the perpetuation of power, and the resistance to gendered constructions, which then better equips us to understand and develop more effective ways to support women and adolescent girls to empower themselves and enhance their menstrual health and hygiene. These findings can be placed in conversation with similar studies from other locations to find where the ideas converge and separate, and provide a more holistic view of menstrual practices and politics.

Setting the Context: Nepal

Nepal is a multiethnic, multilingual, and multicultural country with a population of about 30 million. A majority of people are Hindu (81.3% of the total population), followed by Buddhist (9%), Islam (4.4%), and other religions (5.2%) (Central Bureau of Statistics 2011). Nepal has one of the lowest-ranked levels of human development by UNDP (United Nations Development Program) standards: the UNDP ranked Nepal 144th in their Human Development Index and 115th in their Gender Inequality Index out of 188 countries (UNDP Human Development Report 2016). Families and communities reflect strict and consistent gender inequality in Nepal as these institutions are founded upon cultural and religious beliefs that create and reinforce Nepal’s gendered social order. Amidst gender disparity and other discriminatory social norms, Nepali women and girls face a complex set of challenges related to puberty and sexuality. Early marriage, early sexual activity, and early childbearing are common, culturally entrenched practices. Child marriage (bride below 18 years of age) is still prevalent in some parts of Nepal, although it is legally prohibited. The Central Bureau of Statistics (2015) estimated the adolescent fertility rate as 71 per 1000 women aged 15–19 years with wide differences in urban and rural settings (33 in urban and 80 in rural), and 16% of women aged 20–24 years have had a live birth before the age of 18.

In the context of Nepal, where the average age of menarche is 13.5 years old, adolescent women lack consistent access to education on sexual, reproductive, and menstrual health. Many Nepali women lack access to hygienic menstrual materials and disposal options, access to a private place to change menstrual cloths or pads, and clean water to wash their hands, bodies, and (if used) reusable products. Women are left to manage their periods in ineffective, uncomfortable, and unhygienic ways, including using bark, leaves, and dirty rags (WaterAid 2009, 2015). The dearth of affordable hygienic products and facilities is often compounded by cultural attitudes that view menstruation as shameful or dirty. As a result, many women and adolescent girls are excluded from fully participating in social and cultural life, including religious activities. Despite the great need, there have been very few studies on menstrual health and hygiene in Nepal.

Listening to Women’s Voices

Our goal in this chapter is to illuminate previously overlooked dynamics within the social constructions of gender as they play out around menstruation among the understudied population of women living in Nepal. The focus on these understudied women themselves and their individual experiences is an important way of expanding our epistemology and consideration of so-called legitimate knowledge vis-á-vis Dorothy Smith’s (1987) ‘everyday world’ and Patricia Hill Collins’ (1990) ‘everyday knowledge.’ We, therefore, ground our analysis in the everyday practices of ‘knowers’ (Smith 1987, 183–92). Each woman’s story in this research project is significant in its own right. Drawing from these life history narratives, we argue that looking closely at the micro-level illuminates what is possible at the macro-level.

Bleeding in Nepal: Reinforcing Tradition but Pushing for Change

Women’s identities are constructed and intricately connected to the social construction of motherhood and reproductive viability. Specifically, who a woman is (and who she identifies as and how she is identified by others) is a complex web of the socially constructed concepts of womanhood, reproduction, and motherhood. An adolescent girl’s menarche (first menstruation) is a social marker of a girl’s entry into womanhood. The subjective experience of menarche is not only important for understanding adolescents’ first-hand viewpoint, but also important from a societal standpoint for understanding how menarche is treated as an opportunity to reinforce gender expectations and roles.

Experiencing Menarche (First Menstruation)

The average age of menarche varied by age of the participants in this study. On average, women above the age of 40 first menstruated when they were 15 years old or older, whereas women between the ages of 26 and 40 had their first period after the age of 14. Younger participants first menstruated, on average, around 13 years old. Thus, younger women reported getting their periods sooner than their older counterparts (see Fig. 66.1). We found that most women were not well informed about mensturation at the time of their first period, leaving them scared, confused, and ashamed when they first saw blood.

Fig. 66.1
figure 1

(Credit: Jennifer Rothchild and Priti Shrestha Piya)

Menarche by age group

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For example, Sumangala Khadka (40, Sindhupalchowk) who had her period at 14, shared, “I had thought that it was a leech but the blood was a lot more . . . After seeing the blood and checking my body properly for leeches and not finding them, I was then sure that I had my period.” And Rekha Sunuwar (20, Kathmandu) told us, “I cried during my first time . . . I remember when I was nearing that age my mom started to control me, saying don’t go out and far . . . I was out and playing . . . during my first time . . . I didn’t know how to use [a] pad . . . .”

For the women in our study, their shared experiences of menarche can best be characterized by a lack of preparation that exacerbated feelings of fear, shame, and discomfort. Rather than harness their initial curiosity about menstruation that might be cultivated into a healthy approach for this natural process, their experiences were often surprise, confusion, and isolation.

Menstruation Education

Most of the women in the study said they had not received any education on menstruation. This finding is reflected in a 2012 study by the Ministry of Health [Nepal], New Era, and ICF International Inc. that found almost a quarter of teenage girls had ‘no idea’ what their menarche was prior to its onset. Siru Shrestha (50, Gorkha), who dropped out of school after fifth grade and had her first period at 16, said, “I thought some insect bit me when I saw blood going down my legs . . . Mother was away . . . I told a woman living in (renting) our house, (and) my sister scolded me . . . I cried terribly. I didn’t eat anything.” Likewise, Gita Silwal (44, Kathmandu) shared,

I didn’t know what menstruation was. My relatives used to tease . . . that I will experience something new when I reach the age of 13 or 14. I used to feel scared and think how does it feel to have these kinds of experiences? I had it at 12 years . . . I cried a lot . . . because I could not understand what is happening in my body . . . we feel shame.

Women also complained about the lack of information from their mothers. Nayana (46, Kathmandu) stated,

She (her mother) didn’t give any information. She just said that when you reach to certain age, you’d have menstrual bleeding. But I didn’t know that it happens every month and almost for lifetime. But I knew during menstruation we are prohibited to touch certain things and should also be clean . . . I only knew behavioral term, but had no idea about biological aspect.

Prior to the day of her first menstruation, Rekha Sunuwar’s (20, Kathmandu) mother made no mention of it, and instead, talked about how one day she would “grow up . . . and will get married and so on.” Rekha recalled that during her first period, “I used the pad in a wrong way . . . the sticky part was placed upside . . . (It) makes me laugh a lot (now) . . . (after periods) I feel I have become mature . . . (I realized) I should not go here and there (roam around) . . . .”

Some women narrators had greater access to information. They cited sources like friends, teachers, or health workers, who explained menstruation to them and told them not to feel anxious about it. Tripti Shrestha (45, Gorkha) remembered,

It would have been awkward at home but since I was in the hostel with girls of same age, going through similar things as me, it wasn’t as uncomfortable . . . Sometimes I felt bad but friends used to tell me that it was just the rule of nature.

Similarly, Saloni Rajbhandari (25, Nuwakot) shared, “our hostel in-charge made me understand that it was (a) normal and natural process.” It would seem that adolescent girls with access to education and accurate information about menstruation were not only more likely to feel more confident about their changing bodies but also more likely to maintain menstrual health and hygiene.

Managing Menstrual Health and Hygiene in This Context

Conversely, for many women in our study, not having open and informative conversations about menstruation at an early age and not having emotional support from others directly affected how these women managed their menstruation. As we will discuss later in this chapter, the importance placed on segregation and isolation of menstruating women far outweighed the importance of healthy and proper menstrual health management (MHM). As a result, MHM was rarely discussed and remained largely unpracticed.

Managing Menstrual Bleeding

Many older women (40+) in our study confessed that there was no practice of wearing underwear or undergarments in their youth. In fact, most of these women above 40 years shared that there was no orientation on wearing anything. Tripti Shrestha (45, Gorkha) said, “There was no system of wearing a pad. They would just let it (the blood) flow.” And Kripa Achami (59, Gorkha) recalled,

No, it (pad) was not there. There was even no practice of (wearing a) petticoat. I used to wrap up only Fariya (saree) . . . we used to wrap up Fariya and roll it inside like that . . . and after that got wet . . . I washed it . . . it would dry up and another day I used.

These women, as well as other older women in our study, said they eventually learned from others to use taalo, a piece of cloth such as old sarees or bed sheets to manage bleeding. Older women expressed a preference for using taalo. Further, because disposable pads were often too expensive and/or were not readily available in the markets, most of the women in our study used taalo. Younger women, especially from urban areas, with more income and more education, were more likely to use menstrual pads than older and rural women.

Managing Menstruation at School

Poor sanitation facilities and a lack of adequate water supply further exacerbate poor menstrual hygiene among women. Only 28% of public schools in Nepal have separate facilities with toilets for girls (UNICEF 2015). Likewise, a lack of adequate water supply or locks on toilet doors to maintain privacy negatively affect adolescent girls’ attendance and focus on studies. Additionally, there is a dearth of menstrual products available and little to no disposal pits for soiled pads in school facilities. Thus, during menstruation, many adolescent girls do not attend school (WaterAid 2009, 2015). In some districts, parents do not allow their daughters to go to school during menstruation; instead, parents insist daughters take rest at home. All of these factors contribute to high rates of absenteeism for adolescent girls. Samjhana Sharma (45, Gorkha) shared, “We could not go to school when we were having our periods. The first time, it was 22 days that I was hidden (secluded). I didn’t go to school. Second time, it was for 11 days. Third time for seven. When this continued, I didn’t go to school altogether.” And Sabina Thapa Magar (25, Dolakha) recalled, “It was after the five days of my menstruation. So, I didn’t use the cloth at that time. When the sir (teacher) entered in the class it started bleeding . . . So I ran from the class to house . . . The boys in the class were shameless and they used to tease the girls knowingly in such days.”

Other women also reported facing embarrassing situations in school. These issues regarding managing menstruation at home and at school underscore the role of harmful norms in shaping MHM. While adolescent women might prefer pads, and many women of all ages understand the value for improved MHM, all women in our study were caught in a complex web of attitudes and beliefs that place women’s menstruation in a negative light. Rather than understanding menstruation as a meaningful and positive step toward adulthood, most women in our study remembered battling shame and embarrassment during this adolescent phase of life.

Beliefs, Taboos, and Rituals Associated with Menstruation

The sociocultural beliefs about and perceptions of menstruation have been constructed by multiple factors having to do with cultural beliefs about women’s fertility and lack of purity. We found that strong beliefs about menstruating women as impure were present across all castes and ethnic groups in the lives of the women in our study, yet each caste and ethnic group maintained its own customs about recognizing and influencing MHM for women and girls.

Most women and adolescent girls experience restricted mobility and participation in normal activities during menstruation and were forced to observe traditional norms and practices of isolation and segregation, despite physical discomfort and/or lack of resources. Family members and communities perpetuated these sociocultural beliefs and taboos (Fig. 66.2).

Fig. 66.2
figure 2

(Credit: Jennifer Rothchild and Priti Shretstha Piya)

Common taboos reported in Nepal

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Women reported that during menstruation they were forbidden from touching plants, manual grain grinding machines (dhiki/jaato), water sources, or places where food was stored. Touching anything while menstruating, left it polluted—too dirty for anyone else to use. A menstruating woman should be careful to not let even a drop of water fall from her mouth while drinking, as that drop could then pollute the ground. Women interviewees talked about how at the end of their menstruation, they were instructed to bathe, as well as wash the items (utensils, clothes, bed sheets, towels, et cetera) that they used separately from everyone else during the fourth day of their period.

Women also shared how community members seemed intent on restricting the mobility of adolescent girls after menarche; the belief was that an adolescent girl should no longer roam around freely as she now could become pregnant. Barsha Khatri (55, Dolakha) said, “People used to tell that we must not go to others’ (place) after menstruation . . . If she goes, she may get pregnant and so on . . . (After menstruating) I used to think like that, now I must do marriage and search a good man to marry.” Women also reported that as adolescents, they were discouraged from maintaining friendships with boys. Concerns like these reflect fears that a premarital pregnancy would negatively affect a family’s reputation and a young woman’s standing in the community. As a mechanism of social control, family members instilled their daughters with shame and fear.

Menstruation Beliefs and Rituals Among High Caste Hindus

While menstruation is a normal physiological process, Hindus consider women impure, untouchable, and undesirable during menstruation (Ueda 2012). Dominant Hindu practices are based on the belief that when women menstruate, impure blood leaves the body, and the body becomes impure. The woman’s impurity forbids her from practicing religious and other sacred activities. Societal pressures to maintain menstrual restrictions become even more potent when menstruating women internalize these beliefs and begin to practice self-exclusion. Believing the mythical interpretations of menstruation and internalizing the concept of having an ‘impure body,’ menstruating girls and women become fearful that the gods might bring misfortunes onto them or their families. Menstrual problems such as abdominal pain and cramping are interpreted as punishment for not abiding by the restrictions. And because the menstruating woman is removed from religious rites, it becomes easier for larger society to disregard menstruation as a natural process, and instead, blame the menstruating woman for any unfortunate events that might occur, for example, a family member becoming ill or a landslide that destroys a home.

Almost all the high caste Hindu women in the study shared that the first reaction of the person (mostly sisters, mothers, or female relatives) who they told after seeing blood was to hide them from the male members of their immediate family. As Ramita Dahal (33, Dolakha) explained, “(I) told my mother . . . Then, my mother scolded me for looking at my brother’s face and (she) said, ‘Do you want to eat (kill) your one and only brother looking at his face while having period? . . . In our Chhetri caste, a girl should not look the face of her brother while having her first period so I was taken to another place to hide.”

This practice of hiding often left the women feeling afraid, ashamed, guilty, and confused about the possibility of something terrible happening to their male family members if they did not comply with this practice. As illustrated by Sarita Neupane (32, Nuwakot), “Mother used to explain about these things . . . if this (period) happens then you shouldn’t look at father or brothers . . . I felt like crying . . .”

What is notable in these shared stories was how menstruation was framed as a concern for men or boys. This framing (or reframing) implies that menstruation becomes an area deserving of interest and focus only when it has a negative impact for males.

To protect their male family members, menstruating women are hidden, that is, put into seclusion. This practice of seclusion is often more strictly observed among high caste Hindu women and typically means living away from their own home and keeping a distance from kitchens, prayer rooms, and temples. One of the most extreme forms of menstrual seclusion practice in Nepal is chaupadi, which despite being first outlawed in 2005, forces menstruating girls and women to live outside their homes in a chaupadi shed (or animal shed) for four to seven days. Chaupadi comes from the belief Hindu scriptures dictate secretions associated with menstruation and childbirth to be religiously impure, deeming women untouchable, and prohibiting menstruating women and girls from inhabiting public space, socializing with others, and sharing food and water sources (Ranabhat et al. 2015). Although beliefs and practices are gradually changing, even today, in many parts of the country, women and girls either are forced to spend three to four days outside of their homes, often in sheds, or in a separate room or area while they are menstruating. The practice is more deeply rooted in and widely practiced among certain Hindu communities living in Far and Mid-Western regions of Nepal. However, the practice persists throughout the country (Central Bureau of Statistics 2015). For example, from our study, Archana Rana, now 35, was hidden in a cowshed in a suburb of Kathmandu during her first menstruation. She recalled, “There was a cow shed on the ground floor of the house . . . so I was there in the house but inside an in-built cow shed . . . I used to go out early in the morning and bathe and come back, and my food and all necessities would be brought to the cowshed.”

This practice can increase risks of infections, including reproductive tract and genital infections, due to poor hygiene linked to lack of access to clean water (Singh et al. 2001). Women are also forbidden from consuming dairy products, meat, and other nutritious foods, for fear they will spoil them, and must survive on a diet of dry foods, such as rice. As a result, anemia and emaciation among women are two times higher in chaupadi-practicing areas (Ministry of Health [Nepal], New Era, and ICF International Inc. 2012). Despite these health hazards, women in our study frequently talked about living in cowsheds during menarche and in subsequent menstruations. Sumangala Khadka (40, Sindhupalchowk) shared, “During periods we either slept in the shed with cattle or in the veranda outside the house.”

Beyond the physical, the effects of chaupadi are extremely dehumanizing and stressful. Psychological problems linked to stigmatization and isolation, including substance abuse (for example, smoking and alcohol consumption), are often a consequence of the practice, while isolation leaves women vulnerable to rape and animal attacks (Ranabhat et al. 2015; Robinson 2015). Rubina Mishra (43, Nuwakot) recalled, “I felt bad . . . I had to sit on the same place and couldn’t go out even in the afternoon.”

Despite the psychological and physical tolls on girls and women, the Nepali government has not made chaupadi a priority: The Nepali Supreme Court outlawed the practice in 2005, but it took more than a decade for the Nepali government to enact a law to criminalize the custom.1 To date, the law has yet to come into effect. Government officials argue that prosecuting violators will be difficult.

Instead, the patriarchal system reinforces prescribed gender roles. The seclusion practices remind women that they must police themselves once they start menstruating, that young women become ‘polluted’ and ‘impure,’ and that they must conduct themselves accordingly, including secluding themselves from men and boys. Many women interviewees shared that they were told repeatedly that the time had come when they could no longer wander about as they once had as children.

Menstruation Among Newars

The Newars of Kathmandu and Bhaktapur have a culture of baarha or gufa rakhne (with ‘gufa’ literally meaning ‘cave’) ritual that is similar to the hiding or seclusion practices of other high caste Hindus, but this ritual differs in the sense that it is more of a celebration of adolescent girls coming of age and a traditional way to prepare girls for adulthood and menstruation. Siru Shrestha (50, Gorkha) shared, “In the Newar community, when a girl reaches (about) ten years old, she is taken to gufa room. She has to remain in this gufa room for twelve days.”

During those twelve days, the girl is visited by female relatives who teach her how to dress and apply makeup. Although Newars are more accepting of menstruation as a rite of passage in comparison to other high caste Hindus, the gufa ritual also serves to reinforce gender norms and gendered expectations as girls learn how to present themselves like adult women.

Tripti Shrestha (45, Gorkha) explained that, “In Newar households, (After that Gufa ritual we) . . . avoid going to the Puja (worship) room and avoid touching holy materials (during subsequent menstruations).” The gufa room is intended to hide the menstruating girl from all men and the sun and is typically a designated room in the girl’s own home. Thus, despite a greater social acceptance of the onset of menarche, Newars still consider menstruation a pollution of adolescent girls’ bodies that needs to be hidden.

Prevalence of Rituals Among Non-Hindus and Low Castes

Among non-Hindus, Janajati groups, and low castes and Dalits, the restrictions and seclusion regarding menstruation are typically not practiced, moderately practiced, or rapidly changing. These groups tend to be more socially lenient about menstruation compared to their Hindu counterparts and often regard it as simply a natural process. Yet, as noted by M. N. Srinivas (1952), lower-caste groups have historically sought upward mobility in the caste hierarchy by emulating the rituals and practices of the upper or dominant castes, in a process he called “sanskritization.” Perhaps this is why many non-Hindu groups throughout Nepal are observed as practicing menstruating rituals like Hindus.

Nirmala Pariyar (23, Kathmandu) shared in that Dalit community, “We stay at another’s house for seven days. After the seventh day, mother would come to take me back home with new clothes to change. Before that, I should wash myself, then I would be purified (sprinkled) with gold water (water dipped with gold) and cow urine.”2 Goma Rai (23, Nuwakot) noted, “We have restriction for five days . . . We (can) stay in home, we don’t go near the stove, (but) we don’t separate the utensils with which we eat.” Likewise, Shradha Sunuwar (29, Dolakha), shared that, “My mother told me not to cook food for father and brothers . . . but not to hide. In Chhetri and Brahmin (families), they hide but we are Matawali (a lower caste) people like Rai and Sunuwar (and) people don’t hide.”

While some non-Hindu women in our study practiced restrictions in moderation under the influence of Hindus, other women (especially Gurung, Jirel, and Sherpa women) thought of menstruation as a natural phenomenon and focused instead on staying clean. Notably, women from these particular ethnic groups have historically enjoyed social standing on par with men as compared to Hindu groups. Kusum Tamang, aged 59, from Nuwakot explained, “In our Tamang culture we don’t have to abstain . . . I know these Chhetri and Brahmin (women) abstain during menstruation. I don’t believe in these things.” Samjhana Jirel (27, Dolakha) shared her experience, “When I told to my mother, she told (me) you must keep it clean and take bath.” Janajati women also shared that they had to continue working in the field and house as they normally do without any rest during menstruation.

Listening to the stories of women who are members of families and groups in which menstrual restrictions are not enforced and the reasons why they refrain from these cultural practices that are otherwise so common in rural areas of Nepal is significant, as these individuals could provide the key insights to designing more effective interventions to improve MHM nationally.

Navigating Culture and Pushing for Change

As women shared with us their life stories and talked about menstruation practices in the past as well as in the present, many believed that social practices are rapidly changing. Sometimes, practices were altered for practical reasons or logistical purposes; for example, requiring menstruating women to take a bath in the early morning every day while menstruating was just not possible for those who had to go to work or college. Some women, including high caste Hindus, reported making changes in the number of days of hiding to accommodate exam dates or school attendance. Srijhana Karki (30, Kathmandu) shared that her mother-in-law and grandmother-in-law had always been strict about her following the practice of not working the four days of her period, as prescribed by Hindu tradition. Yet, at the time when a relative passed away and death rituals needed to carried out and the workload became too much, Srijhana noted that her in-laws then decided it would be all right if she were only restricted three days. After that, she could go back to her domestic responsibilities. Importantly, Srijhana herself noted that cultural traditions, historically held steadfast, were being interpreted and implemented according to convenience.

Women and adolescent girls seem to be increasingly inquisitive, putting menstrual restrictions to the test and subsequently altering practices based on what they then realize. For example, Nayana (46, Kathmandu) shared, “There was also a prohibition during menstruation to not touch the plant. . . . so I always wondered what will happen if I touched . . . one day during menstruation I did touch a plant but nothing happened. So I do touch a plant during menstruation but other (religious) practices I do follow them.”

Women like Nayana noted restrictions being lessened and modified in significant ways, but she and others were still careful to maintain their religious purity and not sin by worshipping during menstruation. It would appear that women are trying to gain control of their bodies, their activities, and themselves, while also seeking a balance that does not interfere with their core beliefs.

Rekha (20, Kathmandu) noted, “ . . . We used to follow the house rule like not touching this and that and not coming in the kitchen . . . but now, we don’t follow this.” Education and increasing awareness have led to changing seclusion practices at her home. Rekha went on to explain,

I used to feel, why I should not touch here and there? . . . And why I am kept in this room? . . . Even during religious ceremonies, I didn’t go to places . . . I didn’t go myself into the kitchen . . . Now my mom has become a little more liberal . . . entering kitchen and other places . . . All I know is I should be clean . . . my mom also became aware by going to nearby health places and also she heard from others too.

And Champadevi Sapkota (33, Nuwakot) recalled,

They said . . . we could not touch food too. One day I was very hungry and nobody was home . . . I was feeling so hungry . . . so I couldn’t stop myself from taking out that food. I was also very curious about that. I thought what would happen even if I touched. But nothing happened . . . since I was a child I told them that I took the food from there and ate it but nothing happened. They said that it is a sin and I will have to face problem later. Then I told them I have already touched . . . where is the sin? What does the sin mean?

In the sharing of their life stories, women, both young and old, raised important questions about menstrual restrictions, and often connected these ideas with the ability to challenge existing patterns of discrimination and exclusion.

Conclusions and Implications

In Nepal, there is clearly a dire need for evidence-based, effective approaches to improve MHM. Policy planners and program implementers need a deeper understanding of the issues that Nepali women face today. Our life history interviews reveal that the knowledge and attitudes of family members determine and shape adolescent girls’ future actions and beliefs about menstruation and how menstrual health should be maintained. Sociocultural beliefs also transmit important messages about female roles in society more broadly. Specifically, after menarche, adolescent girls’ menstruation become increasingly subject to sanction and physical separation enforced by patriarchal attitudes regarding men’s and women’s roles.

Further, the restrictive attitudes and misinformation about menstruation carried over into other areas of women’s lives: education, family relations, and self-perceptions about their role and potential in society. Deep feelings of shame, coupled with poor MHM, meant that women’s potential to contribute to their existing environment and situations were greatly diminished. While we observed variation in families’ beliefs, taboos, and restrictive practices, many women in our study felt compelled to follow physical seclusion. These sociocultural practices instill shame and fear in menstruating women and serve as a control mechanism for policing gender norms and women’s sexuality. The Nepali government could institute change at the macro-level and has officially prohibited chaupadi, but seems reluctant to criticize sociocultural practices couched in Hindu beliefs common among its citizens.

What emerges strongly from women’s life stories is a scenario in which entire communities (and the country as a whole) become complicit in maintaining a patriarchal structure in which controlling adolescent girls and women is seen as essential to maintaining societal health. We find that such discriminatory beliefs, attitudes, and social norms around menstruation form a complex web of control that limits adolescent girls’ and women’s independence, and seeks to strengthen the position of men in society by placing the burden of responsibility for managing menstruation on women themselves, but without giving them authority and freedom to manage it responsibly and in a healthy manner. Therefore, women and their individual stories should be at the forefront of MHM research. And on the basis of the findings, effective policies and programs must be contextualized, designed, and implemented in order to create awareness and change people’s understandings of and practices surrounding menstruation not only in the context of Nepal, but elsewhere as well.

Micro-level stories illuminate what is possible at the broader societal level. Putting women at the center of our efforts gives way to a better understanding of individuals’ circumstances, limitations, daily struggles, motivations for change, hopes, dreams, and fears. This offers a holistic picture not just of MHM or even reproductive health, but of a perspective that could be the key to unlocking better health practices for all people.

Notes

  1. 1.

    According to the law enacted in August 2017 and purported to come into effect in 2018, anyone forcing a woman to follow the custom will face a three-month jail sentence or a fine (of approximately $30 USD) or both. “The bill criminalizing chhaupadi became law as the House endorsed two of the five bills formulated to replace decades-old Muluki Ain (General Code), in an attempt to modernize the country’s legal system” (“New Law Criminalises Chhaupadi Custom” 2017).

  2. 2.

    Cow and cow urine are considered pure and sacred in Hindu practice.