Menstrual hygiene management in India: The concerns

INTRODUCTION Menstruation is a normal physiological phenomenon that women and adolescent girls experience every month. Ability to manage menstruation hygienically is fundamental to the dignity and well-being of women and constitutes an integral component of basic hygiene, sanitation, and reproductive health services. Poor awareness of the physiology, unscientific attitude, myths, and misconceptions including the notion that menstruating women are “contaminated,” “dirty,” and “impure” adversely affect their health and social lives. Unfortunately, it continues to be treated as a taboo in many societies, shrouded in a culture of silence and shame. Issues and challenges related to menstrual hygiene management (MHM) in low and middle-income countries are gaining increased recognition in the water, sanitation, and hygiene (WASH) sector globally. WHO and UNICEF(2014) have defined MHM as “Women and girls are using clean menstrual hygiene management material to absorb or collect blood, that can be changed in privacy as and when necessary for the duration of the menstrual period, using soap and water for washing the body as required and having access to facilities to dispose of used menstrual management materials.”[1] Since 2014, May 28 is observed as the Menstrual Hygiene Day worldwide to raise awareness regarding the challenges women and girls face to deal with menstrual cycles and highlight solutions implementable at global, national, and local levels to address these issues.[2] Although there is no direct mention of any goal or indicator of menstrual health and hygiene in the UN Sustainable Development Goals (SDGs), it is well recognized that poor MHM practices will adversely affect the initiatives and performances of the countries toward achieving a number of important developmental goals (SDGs 3, 4, 5, 6, 8, and 12).[3] Menstrual hygiene management initiatives in India In India, number of women in the reproductive age group (15–49 years) is more than 31 crores (Census 2011).[4] Taking cognizance of the quantum of morbidity and poor quality of life that a woman would have to bear in the absence of proper MHM perception and practices in the country, Government of India has incorporated MHM into national policies and programs as part of initiatives for improving health, well-being, and nutritional status of adolescent girls and women, as well as for reducing school absenteeism of adolescent girls. UNICEF has also been instrumental in providing technical guidance and support toward raising awareness, addressing behavior change, capacity building of frontline community cadre, sensitization of key stakeholders, and creation of WASH facilities including safe disposal options. “Swachh Bharat: Swachh Vidyalaya” campaign has been launched to ensure that every school in India has a set of functioning and well-maintained WASH facilities including soap, private space for changing, adequate water for washing, and disposal facilities for used menstrual absorbents.[5] MHM has been made an integral part of the Swachh Bharat Mission Guidelines. Ministry of Drinking Water and Sanitation has published operational guidelines to be implemented by state governments, district-level officials, engineers, and school teachers for improved MHM in the country.[6] Ministry of Health and Family Welfare has also focused MHM as a priority area in National Health Mission[7] and in the RMNCH+A strategy.[8] High quality and highly subsidized sanitary napkins are being made available to the adolescent girls in rural areas by Accredited Social Health Activists (ASHAs)[9] and “Training Module for ASHA on Menstrual Hygiene” are also used for their capacity building.[10] The SABLA program of Ministry of Women and Child Development has incorporated awareness generation on MHM as an important initiative to improve health, nutrition, and empowerment for adolescent girls.[11] Efforts are being made to provide sanitary napkins to school-going girls by installing napkin-vending machines at schools and to increase accessibility of environmentally safe disposal mechanisms such as low-cost incinerators attached to the girls' toilets in schools for disposal of used MHM products. Very recently, on International Women's Day on March 8, 2018, Government has launched 100% oxy-biodegradable sanitary napkins “Suvidha” in packs of four priced at Rs. 10 which will be available shortly at Pradhan Mantri Bhartiya Janaushadhi Pariyojana Stores.[12] Despite the array of initiatives put up so far, a myriad of challenges still remain to be addressed. Ensuring healthy MHM for women would require a clear understanding of the intricacies related to the problem, the needs, and the influencing factors that could potentially affect the perception and practices of Indian women. The challenges Menstrual hygiene management awareness: Minimizing barriers Access to accurate and pragmatic information is an essential prerequisite to hygienic menstrual practices. Studies from different parts of the country have revealed that awareness and understanding of menstruation as a normal biological phenomenon is abysmally poor in different sections of the society.[13] Prevailing sociocultural norms, beliefs, and practices make it difficult for women and girls to talk freely about menstruation without fear or shame. It is such a taboo subject in the society that not only girls and women feel shy about menstruation, school teachers, and even health workers also feel uncomfortable to discuss MHM related issues. All-out efforts are needed to change the age-old social attitude toward menstruation and to break the culture of silence and inertness. Puberty education needs to include MHM at curricular level for healthy development of adolescents. Innovative IEC approaches like utilization of community contact opportunities (e.g. VHNDs) and proactive involvement of mass media and social media would further minimize barriers to MHM awareness. Capacity building of school teachers and health service providers including AWWs to disseminate timely and accurate information to both boys and girls on the biological and psychosocial aspects of puberty, menstruation, and MHM customized to local contexts, rather than focusing only on the practical aspects of managing menstruation, i.e. product use, would holistically improve the effectiveness of the awareness programs. Male sensitization at community level to increase their understanding and thereby foster supportive attitude will have stronger effect in removing discriminatory practices faced by women. Involvement of key cultural influencers, that is, social and religious leaders in countering the negative myths and misconceptions, would also help to build up support system at societal level. However, the challenge is to build on appropriate and effective communication methods to open dialog and make the stakeholders realize the importance of MHM. Furthermore, evaluation of the existing ongoing awareness interventions at programmatic level in shifting the community norms about menstruation would help in better understanding of the critical gaps that need to be filled in future for sustainable scaling up of MHM awareness. Improving access to hygienic menstrual hygiene management products Accessibility of hygienic menstrual absorbents at affordable cost is an important determinant of healthy menstrual management practice. Over the years, various initiatives have been taken in this direction, and the recent National Family Health Survey 4 (NFHS 4) data show that overall 57.6% of women are using hygienic methods for menstrual protection.[14] However, availability and accessibility of clean and safe menstrual absorbents for all women seem to be a distant dream in the current Indian context. NFHS 4 also reveals that about 62% women are using cloth which can be reused after washing, cleaning, and drying. However, these reusable materials are often not sanitized properly with soap and clean water in compelling circumstances or due to lack of awareness and social taboos also restrict women to dry them indoors, away from sunlight. Compostable disposables (e.g., sanitary pads made out of locally grown materials such as bamboo, banana stem fiber, and sugarcane waste, and reusable cloth pads) have limited availability and higher cost while noncompostable disposables (e.g., cellulose-based sanitary pads with plastic barriers) with the largest market share are a double-edged sword. Although they provide safe and hygienic MHM, they remain unaffordable for women from low-income household. In spite of government initiatives to provide low-cost disposable sanitary pads, for example, “Free Days” and “Suvidha,” requirement for safe MHM products far outweigh their availability and accessibility. Decentralized models for production of low-cost sanitary napkins by community-based organizations/self-help groups might be promoted as a viable solution to match the requirement. Corporate sectors can effectively contribute by supporting behavior change initiatives and manufacturing and/or disposal of low-cost sanitary pads. Importantly, mechanism for monitoring the quality of the products should be put into operation. Exemption from the goods and services tax: The need Sanitary napkins in no way can be considered as luxury items for women. However, the unfair bracketing of sanitary napkins for tax purposes limits access to this essential commodity to a large section of the needy women.[15] The government has declared Hindu marital signifiers such as sindoor, bangles, and bindis as tax exempt; condoms and contraceptives are already tax exempt, but sanitary napkins continue to be taxed. Removing the tax on sanitary napkins will not only increase their accessibility but also will facilitate a positive change in the personal hygiene of millions of women. Disposal infrastructure: Limited capacity Used napkins need to be disposed safely in environment-friendly manner. However, disposal of used napkins has become an increasing problem in India. It is not yet decided whether soiled absorbents will be classified as hazardous solid waste (due to the presence of plastic in disposable napkins) or as biomedical waste as it is contaminated with blood and body fluid. The decision will have implications in planning and implementing appropriate menstrual waste management in the country. Currently, about 42% of Indian women of 15–24 years are using sanitary napkins (NFHS 4) and it is obvious that the use of commercial sanitary products will continue to grow with time. If an estimated 121 million girls and women in India are currently using an average of eight disposable sanitary pads in a month, generation of waste load is estimated to be 1.021 billion pads per month, the safe disposal of which in an environment-friendly manner is a real challenge to the nation.[16] Due to lack of efficient disposal mechanism at the community and institutions (schools, colleges, work places, and hospitals), used sanitary pads are dumped into the urban sewerage system, landfills, rural fields, and water bodies.[16] Since the usual disposal practice at community level is along with the household garbage, appropriate innovations need to be designed to make the menstrual waste materials easily identifiable for segregation during routine waste collection, keeping exposure of the waste collectors in mind. While incinerators are favored options in schools and institutions, challenges still exist in terms of designing cost-effective incinerators without emission of toxic fumes from burning of plastics (e.g., furans and dioxins). Menstrual hygiene management in special situations Menstrual hygiene management often remains as a low-priority component in any emergency/humanitarian crisis situation, as it is not considered life-threatening and women and girls face formidable challenges to manage their menstruation safely and comfortably and with dignity. There is a strong need for international consensus and improved guidance across all relevant sectors for improving MHM response in emergency context. Database to influence program or policy: The gap Formulation and implementation of any national program is heavily dependent on availability of strong evidence base for effective advocacy, program planning, implementation, and evaluation at all levels of health care. MHM practices are known to be influenced by factors such as knowledge about the process, socioeconomic characteristics, cultural acceptability, personal preferences, perception of risks, and access to funds and WASH facilities, etc. Available data from isolated studies portray a curtailed picture of the pattern of usage and methods of disposal of used absorbents, emphasizing the urgent need of incorporating MHM related data generation through national-level surveys. Very recently, NFHS 4 has generated some data on the type of menstrual protection used by women of 15–24 years age;[14] but no nationally representative or state-specific data on methods of disposal of used absorbents are available till date. CONCLUSION Good menstrual hygiene triggers health, confidence, and self-esteem of women and is linked to gender equality and basic human rights. Concerns are manifold and calls for concerted multisectoral inputs and interventions to break the social taboos, myths, and misconception; support innovative sustainable solutions to manufacture and distribute low-cost, yet high-quality sanitary pads; and address the burgeoning problem of disposing menstrual waste in an environmentally safe manner. Ensuring menstrual hygiene for girls and women should be at the top of developmental agenda which calls for urgent and intensive action from all relevant stakeholders to change the scenario of menstrual hygiene in India. There is also emerging need for development of indicators under Swachh Bharat Mission Guidelines to measure the extent of achievement in MHM in India. Furthermore, setting up realistic time bound targets to indicate successful implementation of existing policy and programs would be a welcome endeavor for providing basic hygiene and reproductive services to girls and women.