Keeping girls in school is a vital part of any international aid program. It’s an issue important to highlight today, on the first ever United Nations International Day of the Girl. Over the past few decades, this has shown to have lasting effects, not only for the girls themselves, but also for their families, their communities and for the economic growth of their countries.
One recurrent issue, in extremely poor countries, is the absences caused by girls not attending school during menstruation. The non-availability of sanitary protection products in these regions of the world means that girls are forced to use other homemade solutions. These included cutting up old blankets, clothes or mattresses, and inserting leaves or other organic matter into their vaginas to stop the menstrual flow. The health risks associated with these practices are clear, but there are other less obvious risks.
The girls stay at home to prevent being embarrassed by bloodstained clothes, and because the onset of menstruation is seen in some communities as the girl becoming sexually mature. This puts the girls at risk of unwanted attention – 45 percent of young Kenyan women report that their first sexual experience was non-consensual.
Sanitary pads are expensive, even in Kenya, and very difficult to come by. Before visiting Kenya this summer, I asked an African-based blogger for gift ideas to take to the women and children we would be visiting and was surprised that the answer was sanitary pads. At a Dispensary (health clinic) in the Laikipia District, I cautiously took the packets out of my bag. Within seconds, I was surrounded by a crowd of women, who laughed delightedly at my present. I had also been told to take some packets of underpants, as some girls don’t have underwear in which to put san pro (or their homemade equivalent).
A few days previous, I had been discussing this issue with Dr. Kayla Laserson, of the CDC (Centers for Disease Control) Kenya. I had noted a sign on the door of the staff toilet advertising the Mooncup, “a menstrual cup.” I asked Dr. Laserson if it was something that they were considering.
A menstrual cup is a small silicone vessel that is inserted into the vagina. It collects menstrual blood and is emptied into a toilet several times a day, before being washed under clean water and re-inserted. In developed countries, it is sold as environmentally friendly, but for women living in poverty it would seem, at first glance, to be a solid alternative to disposable sanitary pads.
There are however several aspects of menstrual cup use than require further investigation. The most important issue is hygiene. Not all girls in Kenya have access to clean water, and facilities for the monthly sterilization required. There is also concern that the girls would share their menstrual cup with other family members. Toxic shock syndrome, which was associated with high absorbency tampons in the 1980’s, has never been reported with menstrual cups but is a concern, particularly in rural areas, where medical assistance could take hours to reach the afflicted.
To investigate both the medical issues, and cultural ones such as acceptance in the community, a collaborative study between Liverpool School of Tropical Medicine, KEMRI/CDC, Ministry of Health, and a number of other agencies and NGOs is underway in the Nyanza district of Kenya. It is funded by the British MRC/DfID/Wellcome Trust (Joint Global Health Trials; Protect Research) and headed by Dr. Penny Phillips-Howard.
750 girls between the ages of 14 and 16 years old are testing various methods of menstruation management in 30 schools across the district. I spoke with the researchers to find out what they were expecting to find.
Dr. Phillips-Howard explained that the acceptance of the parents and of the wider community, as well as the girls, is vital for the success of the project. The schools must have adequate sanitation, with a set ratio of school children per latrine, separate toilet areas for boys and girls, and locks on the doors to ensure that the girls have privacy.
The parents are informed of the possible risks and benefits of using menstrual cups, and of the importance of reporting illness or fever to the research nurses who are overseeing the project in the schools. The nurses teach the girls how to use the menstrual cups, and the importance of hygiene to prevent infection. They will closely monitor the girls’ progress.
The girls are split into three groups. One group will use Mooncups, the second group will use disposable san pro, the third is a control group using their normal methods (but with hygiene information). The girls will be screened every month to check if they are using the different solutions, any difficulties they may have, and any health problems. As well as keeping vigilant about toxic shock syndrome, they will also check for any reproductive tract infections like bacterial vaginosis or candida which may lead to inflammation or PID (Pelvic Inflammatory Disease), and could cause ectopic pregnancy or infertility.
At the same time there will be checks to see if the girls are attending school and document their reasons for being absent. The researchers are also keen to see if Mooncups improve girls’ wellbeing. Girls’ cups will be checked to see if they are really using them, and to make sure they are viable, are being cleaned properly, and haven’t torn (or been eaten by rats!). A sample of the cups will also be exchanged to test for any signs of infection.
According to Dr Phillips-Howard, “The outcomes from the proof of concept study will be used as a platform for larger scale studies, such as a trial to look at the cost-effectiveness of a menstrual solution to improve girls’ schooling.What we don’t know is if improving menstrual management alone will impact on school absenteeism, — it may nevertheless impact on engagement, ability to do schoolwork, and wellbeing.”
Studies like this one, and the investigation currently being undertaken by Dr. Vivian Hoffman of the University of Maryland (funded by the Gates Foundation) could well have a long-term positive effect on the lives of millions of women and young girls.
Lynn Schreiber traveled to Kenya on a reproductive health reporting trip with the International Reporting Project (IRP).