Final paper
1 Introduction
As of 2020, women and girls made up 49.6% of the global population (The World Bank, 2021), which indicates that approximately two billion women will be in need of menstrual products during their lifetimes (House et al., 2013, p. 257). Menstrual products are personal care products used by women and girls to manage menstruation and menstrual health. In low and middle income countries (LMIC) the most commonly used products are reported to be sanitary napkins, sanitary paper and cloth (Elledge et al., 2018). The demand and access of disposable sanitary pads is also continually increasing (Alda-Vidal & Browne, 2021, p. 8; Goddard & Sommer, 2020, p. 4).
While several definitions of menstrual health are being discussed, a newer approach shows that menstrual health can be formulated as “an encompassing term that includes both menstrual hygiene management (MHM) as well as the broader systemic factors that link menstruation with health, well-being, gender, education, equity, empowerment, and rights” (Geertz et al., 2016, p. 2). This shows the comprehensive dimensions that dealing with menstruation can have.
The use of menstrual products as well as menstrual health is strongly influenced by the disposal and change of the products, which should ensure safety, comfort and dignity of women and girls. Nevertheless, in many LMIC the actions regarding menstrual waste management (MWM) are very limited, causing women and girls to face various barriers (Alda-Vidal & Browne, 2021, p. 10).
This paper examines the reasons for the lack of actions regarding the disposal in LMIC, the consequences for women and the environment and the solutions that could improve the situation.
2 Challenges in LMIC regarding MWM
2.1 Culture of silence
One challenge for women and girls can be found in the structures of the cultures. In many LMIC, menstruation is still a major taboo and is linked to many myths and rituals. These beliefs are strongly connected with menstrual hygiene management (Alda-Vidal & Browne, 2021, pp. 9–10; Umeora & Egwuatu, 2008, pp. 109–115).
Because a lot of cultures consider menstruation as dirty and polluting, many limits are placed on women and girls, which can be experienced regarding cooking, participation in religious activities or general interactions with males (Hennegan et al., 2019, p. 31; Kaur et al., 2018, p. 2). Women in some parts of rural Nepal are not allowed to live in the same house with men, because menstruating women are known as “untouchable being” (Tiwary, 2018, p. 378 f.). Also, the intimacy due to the links with sexuality increases the silence (Alda-Vidal & Browne, 2021, p. 10).
Restrictions in the handling of menstrual waste can also be identified within these communities. Taboos against the burial of bloodied menstrual cloths or the beliefs of a connection with black magic causing infertility, lead to nocturnal and hidden activities connected with fear and shame regarding menstrual waste. In some cultures females are not even allowed to use water and sanitation facilities (Kaur et al., 2018, p. 2). The restrictive gender norms also make it difficult for girls to get information and social support (Hennegan et al., 2019, p. 17).
2.2 Lack of infrastructure
In addition, women and girls in LMIC stated the absence of supportive infrastructure, which hinders them to perform „a range of menstrual tasks, including changing menstrual materials, washing and drying menstrual materials, and cleaning their hands and bodies“ (Hennegan et al., 2019, p. 22). In fact, only 27% of people in least developed countries have adequate hand- washing facilities at home and many schools are not equipped with sufficient sanitary facilities (UNICEF, 2018).
In some parts of LMIC one reason for the lack of facilities is the rapid growth of cities. Governments often cannot provide access to sanitation in the foreseeable future (Alda-Vidal & Browne, 2021, p. 9; Goddard & Sommer, 2020, p. 5). In addition, however, access to systems, including clean water, wastewater systems, and solid waste disposal, is often linked to a payment system, which is why “the presumed urban advantage systematically excludes hundreds of millions of people” (World Health Organization & UN-Habitat, 2016, p. 20). This has been discovered in cities in South America, Asia and Africa (Goddard & Sommer, 2020, p. 6).
Even when sanitation facilities are built, the private needs of females are often ignored, due in part to male-dominated engineering and planning. For example, openings face the street so that women are exposed. Also, there is often no waste option or water for flushing in public restrooms (Goddard & Sommer, 2020, p. 7; Schmitt, 2016).
Moreover, rural parts of countries are sometimes not included in the city governance policies and processes (Jones, 2017), which means that besides the lack of sanitary facilities, there is often no waste collection (Goddard & Sommer, 2020, p. 6). In fact, activities tend to focus on access to menstrual products rather than on the disposal (Alda-Vidal & Browne, 2021, p. 10).
3 Consequences of the lack of MWM
3.1 Environment
The lack of sanitary facilities and the beliefs in the impurity or power of menstrual blood influence disposal practices and lead women and girls to find their own ways of disposing (Alda-Vidal & Browne, 2021, p. 4; Hennegan et al., 2019, p. 21).
People who live near bodies of water throw waste into the water (Kaur et al., 2018, p. 4), leading to pollution in aquatic ecosystems. With the use of disposable sanitary pads microplastic can be ingested by marine life and chemicals, pesticide and diseases are entering the aquatic environments (Alda-Vidal et al., 2020, p. 3; Gabrielsson, 2018, p. 1).
If the waste does not end up in the water, it is often buried. Disposable menstrual products however often contain various chemicals and pesticides (Park et al., 2019; Singh et al., 2019), which is destroying the microflora of the soil and delaying the decomposition process (Gabrielsson, 2018, p. 1; Kaur et al., 2018, pp. 2 & 4; Kroesa, 1990).
However, when the plastic inlay is thrown away with the rest of the sanitary napkin and it ends up in latrines and landfills, which are either covered with soil or incinerated. When inorganic material is burned, harmful gases (dioxins) are released which are toxic and contribute to climate change (Gabrielsson, 2018, p. 1; Kaur et al., 2018, p. 4).
3.2 Health and education
First of all, the lack of feminine hygiene caused by inadequate access to water and sanitation can cause reproductive and urinary tract infections (Gabrielsson, 2018, p. 1; Hennegan et al., 2019, p. 28; UNICEF, 2018). Also, if the waste is buried or thrown into bodies of water, diseases such as hepatitis can be passed on in this way, as these viruses can live on in the soil for up to six months (Kaur et al., 2018, p. 4), affecting not only the health of women and girls. Burning menstrual waste can also produce various toxic emissions that might be inhaled (Alda- Vidal & Browne, 2021, p. 4).
In addition, however, women and girls often have to share sanitation facilities or manage their waste alone in the dark. When menstruation is visible to others, it could signal that a girl is available for sexual relations or marriage. These situations increase their vulnerability to rape and sexual harassment. Studies show that assaults by members of the community and also by operators of public toilets are increasing (Goddard & Sommer, 2020, p. 6; Jewitt & Ryley, 2014; Nallari, 2015).
Under the pressure caused by the difficult MWM, the mental health of women and girls suffers a lot. A study from India has shown that inadequate sanitation provision creates “sanitation- related psychosocial stressors”. Most restricted behaviors in combination with sanitation and hygiene-related behaviors are particularly stressful (Goddard & Sommer, 2020; Hulland et al., 2015, p. 7). Shame and distress are also exacerbated by harassment from peers in school. Due to the fear of the revealing of their menstrual status and with a lack of sanitary facilities and waste options, many girls stay away from school (Hennegan et al., 2019, pp. 21–26, 30; UNICEF, 2018). This general insecurity also excludes girls from other social activities (Hennegan et al., 2019, p. 24). The impact can for instance be seen in Tanzania, as 48% of girls miss on average two to four days of school due to their menstruation (Gabrielsson, 2018, p. 1), resulting in an educational disadvantage.
4 Case Study
4.1 Sustainable Development Goals
A good basis for evaluating the impact and solutions of MWM is provided by the Sustainable Development Goals (SDGs), which represent the aim of making the social, environmental, and economic challenges of the present more tangible (Hajer et al., 2015; United Nations, 2015).
The Stockholm Resilience Centre has evolved the order of the SDGs and divided them into the different dimensions, showing how the goals build on each other.
Although MWM is not a goal within the SDGs, links can nevertheless be found. These can help to determine how the issue might be addressed in the future. In the following, it is shown that MWM solutions can affect goals from all three dimensions and thus shows global importance. Limited by the scope of this paper one solution proposal and its effect on SDGs is analyzed below.
4.2 Menstrual Cup
The benefits of using reusable menstrual products in LMIC is well illustrated by the pilot study in Tanzania, where three different alternative menstrual products were examined (Gabrielsson, 2018). This study was deepened with regard to the menstrual cup (MC) as the preferred menstrual option (Gabrielsson & Rubli, 2021). A study from Zimbabwe supports this statement of preference in the Global South (Averbach et al., 2009). The MC is a nonabsorbent reusable barrier cup, which is usually made of flexible medical-grade silicone rubber and can be worn up to eight hours (Gabrielsson, 2018, p. 3).
The use of the MC can be associated with most SDGs. Some core goals are analyzed in the following. The MC first of all has an impact on biodiversity. The life on land (SDG 14) and in the water (SDG 15) would benefit from the implementation, because there is simply a reduction of waste polluting soil, animals or water bodies. The usage would also limit the waste that is entering sanitation systems, which would improve the sanitation situation in LMIC (SDG 6).
In the second level of society, the good health and well-being (SDG 3) of girls and women would benefit. On the one hand, the psychological health is improved as women feel less feelings of shame and more confidence. Stress is also reduced because women no longer have to worry about washing, hiding or disposing of the menstrual products. The lowered stress level also resulted in less menstrual pain. In addition, diseases such as urinary tract infections or menstrual ailments were diagnosed less frequently among cup users, which is why costs related to health treatment are also decreasing (Gabrielsson, 2018, p. 3; Gabrielsson & Rubli, 2021, p. 3). These consequences go hand in hand with the fact that women feel more confident in general, improving the gender equality (SDG 5) (Gabrielsson & Rubli, 2021, p. 4).
Moreover, the MC would regarding the economy level also improve women’s ability to work and the country’s economic growth (SDG 8). The World Bank estimates that limited educational opportunities for girls cost more than $30 trillion in lost productivity and income worldwide (Gabrielsson, 2018, p. 1). If women feel more confident and safe, they are more likely to go to work during their menstruation (Gabrielsson & Rubli, 2021, p. 4). Girls could also go to school despite unsuitable sanitary facilities (Gabrielsson, 2018, p. 3), giving them a better chance at a subsequent career.
5 Further actors and measures
Overall, the governments have a responsibility to their populations. So far, many governments do not include important issues in the planning process, such as “privacy, convenience, safety, and proper waste disposal options” (Goddard & Sommer, 2020, p. 7).
In general, data collection and the inclusion of women in statistics and planning processes should be improved. If more women and girls would be involved in the construction of sanitation facilities, their needs would be better met. Thereby it is also important to promote the education of men and women in order to overcome limiting beliefs and taboos (Kaur et al., 2018, p. 2). Comprehensive programs are necessary to make menstruation more visible.
Due to the fact that women have mostly been on their own, more and more women’s groups and sanitation committees have come together in recent decades to develop their own solutions to menstrual waste. Often they have been successful (Bowles & Gintis, 2002, p. 422; Goddard & Sommer, 2020, p. 7). If the local leaders (especially women) of these organizations were identified, partnering with local organizations could lead to more successful models for sustainable local solutions in the future, because local communities are more likely to trust native people (Goddard & Sommer, 2020, p. 7).
This collaboration could, for example, make the introduction of MC more realistic. A study has shown that the right approach can lead to a great acceptance of the cups (Beksinska et al., 2015, p. 157), which is why the knowledge and handling of MC need to be imparted efficiently among cultures.
Nevertheless, the government also plays a major role. Even though a study found that the MC would be financially viable for women after one year (Beksinska et al., 2015, p. 157), the initial financing can be a barrier for women and girls (Gabrielsson, 2018, p. 3). The South African government, for example, has set itself the target of providing free menstrual hygiene products (Beksinska et al., 2015, p. 157). Governments from other LMIC should follow this objective.
6 Conclusion
Disposing of menstrual waste confronts many women and girls living in LMIC with various challenges. Due to the lack of sanitary facilities, which is partly due to the general silence of the topic in cultures, many women and girls have no possibility to dispose their waste properly. Among other things, the environment is affected as a result since the waste often ends up in the soil or bodies of water. However, MWM also exposes the women and girls to various sources of danger, stressful situations, or infections, from which their physical and mental health suffers. One way to improve the situation is the MC. As studies have shown, improvements would be seen on the three levels of the SDG cake model, which shows how extensive the influence of menstrual waste is. However, to make the implementation realistic and generally give women a stronger voice in society, the government is an important player. Women must be more involved in decision-making processes and society must be further educated. A cooperation with female local leaders would be beneficial here.
However, there are still gaps in the research that need to be addressed to provide the best interventions. As one example, future studies should also focus on adult women in the workplace or be conducted at the household level, as most studies currently focus on girls in schools.
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