Whether we talk about it or not, periods hold a lot of power.

Difficulty accessing menstrual hygiene products, availability of clean water, sanitation and hygiene (WASH) facilities, and societal norms that stigmatize menstruation create global inequity. It’s estimated that over 500 million women and girls around the world lack what they need to manage their time of the month. Evidence from low- and middle-income countries shows that girls start to drop out of schools at the onset of menstruation, jeopardizing their education and their health, including their nutrition.

COVID-19 compounds these existing challenges, as explored in a recent report by Plan International. WASH professionals surveyed identified the negative impact of COVID-19 on menstrual health and hygiene, including disruptions to the supply of sanitary hygiene products and restricted access to needed WASH facilities.

Empowering young people with knowledge on menstrual hygiene management can be the difference between a female student being in or out of the classroom. Girls who stay in school not only advance their education, but they continue to access critical school-based supports such as mid-day meals, weekly iron and folic acid supplementation (WIFAS) to prevent anaemia and nutrition education. Further, staying in school reduces global instances of early marriage and teen pregnancy.

This is why Nutrition International incorporates menstrual hygiene management into its adolescent health and nutrition programming. We support adolescents to become their own advocates by enhancing their knowledge. This is done through developing or revising existing school curriculum and community-based resources to include topics such as growth, puberty and nutritional needs, menstrual hygiene management, physical activity and overall health for girls and boys. It also incorporates WASH and discussions around access to menstrual products.

Below, we take a look at Nutrition International’s work in three countries to improve knowledge and empower adolescent girls and boys so that girls can confidently manage their monthly menses. Period.

Ethiopia

Why it matters: Lack of menstrual hygiene awareness has negatively impacted the school attendance rate for girls, and their participation in health and nutrition programming. A 2017/2018 regional survey produced by UNICEF reported 11 to 46 per cent of girls miss school when on their period depending on the region.

Particularly in rural Ethiopia, limited access to adequate WASH facilities at school is a deterring factor for school-aged girls. Poor menstrual knowledge has resulted in girls feeling isolated and facing discrimination when it’s their time of the month. A 2020 nationwide survey in Ethiopia reported only 28% of girls and women said they have everything they need to manage their periods. The report findings did not change by age, suggesting that those who lacked the resources and information they needed early on would continue to face those challenges into their adult years.

“Ending period problems shall not be considered as a complement, but as a core component within the package of adolescent nutrition interventions for Ethiopia.’’

What’s being done: Since 2019, Nutrition International supported and strengthened multi-sectoral coordination for gender-responsive nutrition interventions in 88 districts throughout the Amhara, Oromia, Southern Nations, Nationalities, and People’s (SNNP) and Sidama regions. This includes advocacy for girl-friendly latrines with WASH facilities and appropriate menstrual hygiene management information. Nutrition International has provided competency-based training to school principals, teachers, student adolescent nutrition champions, health extension workers, and health care providers. Training materials, including quick reference counselling cue cards, were produced in Amharic, Afaan Oromo and Tigrigna and are being used to improve knowledge, understanding and support on menstrual hygiene management.

The program is actively engaging boys as well. Boys are taught that menstruation is a normal biological process and a key sign for reproductive health; it is nothing bad, unhealthy, shameful or dirty. This program component has been critical to clear up misconceptions, reduce stigma and bullying, and positively support girls to develop their own menstrual hygiene practices.

“Ending period problems shall not be considered as a complement, but as a core component within the package of adolescent nutrition interventions for Ethiopia,’’ said Ermias Mekuria, Nutrition International’s senior program officer in the country.

India

Why it matters: When menstruation is stigmatized, the resulting real-world impacts have serious consequences. According to India’s National Family Health Survey (2015-16), in Uttar Pradesh, more than 50% of adolescent girls are not aware of safe and hygienic practices during menstruation and less than 30% of adolescent girls aged 15-19 years use sanitary pads when menstruating. There is a myriad of interconnected factors that create challenges, from the availability of period products to their quality and cost. In addition, studies show access to sanitary washrooms, disposal mechanisms for used products, myths and misconceptions around menstrual hygiene practices and limited nutrition knowledge can create an environment full of obstacles when a girl gets her period.

“A key to delivering better nutritional services to adolescent girls is by ensuring they remain in school or connected to outreach centres, and thereby have access to services.”

What’s being done: Nutrition International is focusing its efforts on menstrual hygiene management in the country with a pilot project in Chandauli district in Uttar Pradesh that aims to reach approximately 70,000 adolescent girls. The pilot started in 2020 and is building on its work with the Uttar Pradesh government to strengthen adolescent nutrition programs in the state through schools and local health centres. “A key to delivering better nutritional services to adolescent girls is by ensuring they remain in school or connected to outreach centres, and thereby have access to services,” said Kamalini Mukhopadhyaya, Nutrition International’s program officer in India.

The pilot is building capacity within teachers, principals, key government officials and other frontline health workers to improve their knowledge on menstrual hygiene management and increase their capacity to facilitate subsequent programs for adolescent girls. The initiative is also engaging state and district governments to build financial sustainability so the program can continue beyond the pilot phase.

A training of trainers took place in 2021 that developed lead trainers who will work closely with schools and anganwadis (nutrition and health centres) to empower adolescents with menstrual hygiene knowledge, destigmatizing menstruation through the process. Although the pilot remains adaptive to the COVID-19 context and on-going school closures, it is committed to improving menstrual hygiene practices in the district and removing the barriers that prevent girls from being able to readily manage their periods.

Senegal

Why it matters: Adolescent sexual and reproductive health is a taboo subject in Senegal. When a girl experiences her first period, she often has very little information on what is happening in her body and what to expect. “They feel ashamed and scared, which leads to a decrease in self-confidence among girls that can compromise their confidence, particularly with regard to their sexuality and sexual health,” said Amadou Moctar Ndiaye, Nutrition International’s adolescent health and nutrition program officer in Senegal. The lack of information also leads to lost hours, whether girls don’t attend school while they are menstruating or stop participating in other activities outside the home. In addition, some families struggle to afford sanitary pads, resulting in girls using pieces of cloth that can lead to infections if poorly maintained. COVID-19 has exasperated the economic burden on households, further challenging a girl’s ability to access essential products.

“At the end of this project, we hope to have adolescents who are better informed about their sexual health and menstrual hygiene, who are healthier, who are more fulfilled and reach their full potential.”

What’s being done: In 2019, Nutrition International started a project called “Fort pour le Futur” (Strong for the Future) in Thiès to improve the health and wellbeing of adolescents in the city. Its integrated approach combines nutrition education, WIFAS, and reproductive health services with menstrual management and knowledge. The project has set up three adolescent corners, three mobile health units and an adolescent counselling centre while also actively working through schools. Each touchpoint supplies washable and reusable sanitary pads, free of charge.

The project plans to impact 15,000 adolescent girls. It’s also actively engaging adolescent boys through discussions with a boys’ centre on good hygiene practices, nutrition, sexual and reproductive health, and understanding menstruation to reduce stigma. “At the end of this project, we hope to have adolescents who are better informed about their sexual health and menstrual hygiene, who are healthier, who are more fulfilled and reach their full potential,” said Ndiaye.

Participation was built into the program design. From the beginning, the project engaged youth and adolescent associations to participate in communication, education and advocacy activities. Although the COVID-19 pandemic disrupted the initial program plan for some outreach, the project has utilized social media and digital platforms to spread key messages that are reaching adolescent girls well beyond the city.

The onset of menstruation is an important growth milestone, but it has the potential to negatively affect a girl’s education and access to timely health and nutrition information. Until we live in a world where every adolescent girl and women can freely go about their day while they’re on their period, there’s still a lot of work to do.