Menstruation as a taboo

Women’s rights to reproductive health have been reaffirmed by the United Nations as an individual human rights issue.5 Today there are places in Nepal where silence, shame and stigma surround menstruation and menstrual hygiene, suggesting a need for social change and further attention at the political level.6

Menstruation is considered to be dirty by many Nepalese, resulting in women being isolated and prohibited from carrying out rituals (entering temples, attending auspicious occasions) and certain household tasks as they are not permitted to enter the kitchen. This discrimination of untouchability varies among ethnic groups, cultures and communities.6 The most extreme example practised in rural western Nepal is isolating women and girls in rudimentary huts outside their homes, considering them untouchable until the seventh day of their menses (an outlawed practice known as Chhaupadi).7 The earthquake has shown the vulnerability of affected women with regard to menstrual hygiene and highlighted the taboo aspects. This taboo has silenced discussions on the topic in many cultures, as it is considered a strictly private matter that is shameful to discuss.2

Vulnerability of menstruating women and adolescent girls during disasters

Menstruation-related problems are some of the issues suffered by women of reproductive age affected by disasters in addition to physical injuries, shortage of food, lack of water, diseases, malnutrition, unemployment, harassment, crimes, lack of clothing, lack of privacy, gender-based violence, problems finding fuel wood, lack of toilets, eviction from their homes, and destruction of their houses.8 To address the immediate needs of people affected by the earthquake, many internal and external development partners supported Nepal through the provision of food, tents, general supplies and medications. Little attention was paid to menstrual hygiene while the efforts were being made to distribute supplies for the basic needs of food, shelter, protection and health. The existing cultural taboos surrounding menstruation practices further added to this situation, and menstrual hygiene needs remained an under-addressed issue.2 ,3

Unfortunately, the earthquake has not only dampened the hopes of improving education among females, but has also resulted in a vicious cycle of decreased attendance at school during menstruation. Moreover, the earthquake has led to an economic crisis, so most women and girls in rural areas do not have sufficient funds to buy pads and/or access to sanitary products. Those who cannot afford to buy sanitary pads resort to reusing materials such as old rags, leaves and toilet paper. In some instances, when these things are not available, they may not use anything at all.9 Infections such as lower reproductive tract infections, urinary tract infections and adverse pregnancy outcomes can result from the use of unhygienic materials, as the association between menstrual hygiene and reproductive health are strong.10

With 82% of females residing in a patriarchal society, with its disparity in education, human rights and socioeconomic status, women's freedom to choose and decide about their basic needs is limited, making them vulnerable to the challenges of menstrual hygiene management that are brought about by disasters.11

Women's hygiene: need of the hour in Nepal

While the government had called for and provided various necessities such as food, water, tents and clothes, the biological needs of female survivors in earthquake-affected areas were under-prioritised. Various international non-governmental organisations and national non-governmental organisations working to improve reproductive health had been providing disposable sanitary pads. However, using disposable sanitary pads can be a financial and environmental burden especially when proper waste management is not in place.12 During and immediately after disasters, local waste management can be a great challenge.

Studies have shown that more than half of adolescent school girls use cloth as menstrual pads in rural and peri-urban areas.13 Due to the increased accessibility and affordability of commercial sanitary pads, more affluent urban women have switched to them.14 A quarter (25%) of the Nepalese population lives below the poverty line. This highlights the need to focus on economic status during disasters, as a packet of 10 pads costs, on average, US$1.00 (NPR 60–140), which is more than the daily income of many adults, forcing poor women to resort to other means of protection during menstruation.15 This is in agreement with a study reporting that an overwhelming majority (97%) of women resort to reusable materials, especially cloths, for menstrual hygiene in low-income countries.16

At times of disaster (and other times as well) it seems reusable sanitary towels are an appropriate solution, with materials being scarce because of a disrupted market and limited resources. The reusable sanitary towel is appropriate for displaced populations, as it is user friendly, culturally acceptable, available and affordable.4

Reusable sanitary towels: responsibility and response go hand in hand

A group of academics working as volunteers in three cities, Kathmandu, Pokhara and Dharan, responded to the neglected needs of women and adolescent girls under a local initiative around reusable sanitary pads. The local kit contains four pieces of cotton cloth, two undergarments and one bar of soap sealed in a biodegradable bag (figure 1). Given the availability of water, these were expected to last for a year.17

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Figure 1

Contents of the reusable sanitary pad kit (four pieces of reusable cloth, two undergarments, one bar of soap and one biodegradable bag).

Studies have shown that the reusable sanitary pads initiative has a positive effect on school attendance of adolescent girls and it is the preferred choice.18 The use of reusable pads in post-earthquake Nepal addresses relief needs from an equity angle using a targeted approach, with use of local resources, opportunity for local volunteers to make a contribution to local needs, and minimal or no waste generated. While a sustainable plan is yet to be put in place at the national level, the reusable sanitary pads initiative has addressed some of the immediate needs in a culturally sensitive, technologically appropriate way at very minimal cost using local resources, which is in line with the principles of primary healthcare.19 This approach is not new; however, probably because of lack of preparedness, the basic needs of women that can be addressed with simple solutions/items may have been overlooked.4 Further research is needed to ensure that future disaster preparedness plans cover post-disaster menstrual hygiene.