Assessing The Menstrual Hygiene Management Practices in Urban and Rural Areas of Madhya Pradesh

Education about menstruation changes everything
Project Report
Assessing the Menstrual Hygiene Management Practices in Urban and Rural

areas of Madhya Pradesh
2018
Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis
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Project Team
Project Coordinator and Author

 Dr. Kanika Sharma, Deputy Advisor, State Health Resource Center
Under the guidance of

 Akhilesh Argal, Director, AIGGPA
 Madan Mohan Upadhyay, Principal Advisor, Center for Social Sector
Development, AIGGPA
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Contents
Project Team ........................................................................................................................................... 2
Executive Summary ................................................................................................................................. 5
1. Introduction .................................................................................................................................... 6
1.1 Menstrual Hygiene Management Practices (MHMP) in India .................................................... 7
1.2 MHMP in Madhya Pradesh ....................................................................................................... 8
1.3 Demographics and Religious Affiliations of districts in the study .................................................... 8
2. Literature Review .......................................................................................................................... 10
2.1 Other studies on MHM ................................................................................................................ 10
2.2 Other organizations working on MHM in India ............................................................................. 11
2.3 Government schemes and initiatives on MHM ............................................................................. 11
2.4 Commercially available sanitary napkins and other products of female hygiene ........................... 12
2.5 Arunchalam Muruganantham: Indian Superhero “Padman” ......................................................... 13
2.6 Extraordinary Story in MP ............................................................................................................ 14
3. Objectives and Methodology ......................................................................................................... 16
3.1 Objectives of the study........................................................................................................... 16
3.2 Methodology ......................................................................................................................... 16
3.3 Limitations of the study .......................................................................................................... 17
3.4 Internal and External Validity of the study.................................................................................... 17
4. Findings ......................................................................................................................................... 19
4.1 Adolescent girls specific ......................................................................................................... 19
4.2 Adult women specific ............................................................................................................. 22
5. Conclusion ..................................................................................................................................... 26
6. Recommendations ......................................................................................................................... 30
7. References ........................................................................................................................................ 32
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Executive Summary
Menstruation is a biological and physiological process which naturally occurs in healthy

adolescent girls and premenopausal women. The process of menstruation is one of the key
determinants of human reproduction and consequently parenthood. The age for menarche and
menopause varies by geographical region, race and ethnicity, and other determinants but research
evidence suggests that the average age of menarche in Indian female population is 13.46 years (1).
Similarly, the average age for menopause is 46.8 years. Rounding off these figures, it can be
calculated that an average Indian female menstruates for about 2040 days in her lifetime between
menarche and menopause.
The process of menstruation should concern men and women alike, but unfortunately it is not the
case. In some communities of the Indian society, menstruation is still considered a taboo, and
women are considered “impure” during this time of the month by many societies, sometimes
even educated ones. Due to various religious, cultural and social norms, there has been
unbreakable silence on the matter until recently. Poor menstrual hygiene creates a huge impact
on the woman’s vulnerability to uro-genital tract infections.
Previous research in the field also points to the severe information and knowledge gap that exists
between girls in urban and rural areas(2). Therefore, one of the research hypothesis attempted to
be studied via this exercise is examining the role of education against various socio-cultural and
religious practices in the region.The primary aim of this study was to gauge the magnitude of
influence of socio-cultural and religious practices on women’s menstrual hygiene management
practices in the selected region of study. Secondary aim of the study was to examine the role of
education in enabling the adolescent girls to choose better health practices. And tertiary aim of
the study was to examine if there exists a correlation between distributions of low cost sanitary
napkins to women and if that translates to adoption of better and safe menstrual hygiene
management practices.
Based on the findings of the study, it is strongly recommended that the adolescent girls and
women be educated about the facts of menstruation. Lack of adoption of better practices is also
compounded by the traditional beliefs, traditional knowledge, religious and social practices,
taboos and misconceptions. Mothers and older women in the family should be encouraged to
break their inhibitions when it comes to discussing sex education and safe management during
menstruation, and that dialogue about the issue should promote inclusivity of the male members
of the family as well.
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1. Introduction
The world transitioning from Millennium Development Goals (MDGs) to Sustainable

Development Goals (SDGs), has witnessed the widening inclusion of menstrual hygiene
management as a crucial component of sanitation and environmental health. Most health
initiatives, including sanitation and environmental health, are aimed at reducing morbidity and
mortality in children by controlling agents that cause diseases such as pathogens, environmental
hazards and other such things. This is where the interplay between the importance of menstrual
hygiene management and health comes to surface.
Women, in general, spend about 2000 days of their lives menstruating. And, contrary to that, the
subject of menstruation and menstrual hygiene is neglected the most in developing countries, like
ours, owing to myths and misconceptions, religious and socio-cultural practices. Only recently
have we, as a society, been able to talk about such issues when Mr. Arunachalam
Muruganantham, a mechanic from the south of India, revolutionized the sanitary napkin
manufacturing industry to a point where his innovation earned him a prestigious national award.
India still doesn’t fare well when it comes to menstrual hygiene management.
With many debates and discussions came about the initiative wherein the government distributed
low-cost sanitary napkins to women in need in rural areas, but was that the solution to the myriad
of problems faced by such women when it comes to menstrual hygiene management? That’s a
critical question that needs to be asked, and, in addition, the case for maintaining individual
dignity of such women needs to be addressed. Apart from the need of a mechanism for ensuring
good quality of the sanitary product and a mechanism to address the environmental issues that
play along with the issue, this study also advocates for a change in the attitude of the society
towards menstruation as a taboo as well.
While designing the study, it was borne in mind that it’s crucial to take into account the
contemporary beliefs and practices of women in the state, including rural and urban areas.
Therefore, a study of 1200 participants (600 school going adolescent girls and 600 adult women)
was designed within 6 districts of the state, viz. Bhopal, Indore, Balaghat, Bhind, Rewa and
Jhabua. Inclusion criteria of the study included adolescent girls who have attained menarche and
are school going. For the adult women, we only asked married women. Using strategic random
sampling in the selection of adolescent girls in grade 8th through grade 12th in schools, we asked
every 3rd girl student to be a respondent for the survey, only after obtaining the consent from the
school. For adult women, we used the random sampling technique and the women were included
as participants after obtaining the consent.
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1.1 Menstrual Hygiene Management Practices (MHMP) in India

As a developing nation, we come across many socio-cultural practices in the country that are
not scientifically supported as in the western parts of the world. It is often said that superstitious
beliefs disguised as science work in the west and science disguised as magic works well in most
parts of the rest of the world. The socio-cultural, sometimes religious and often superstitious
practices pose a serious conundrum to the overall well being of the society when it’s met with
negative health outcomes and when the repercussions are sometimes even fatal.
One such muddle that’s often seen within India is the unhygienic and unsafe menstrual hygiene
management practices. Owing to the vast inter-state diversity in the country and secularity, the
MHMP differ from state to state and are also influenced based on the urban-rural setting of the
community. Other factors that influence MHMP in the country are affordability of the sanitary
hygiene product, accessibility to the product, knowledge about availability of such products,
correct usage and disposal and even educational status of the individual, mother and family
altogether in case of adolescent girls. This issue also requires immediate addressal as poor
water, sanitation and hygiene (WASH) facilities in school and in rural areas of India sometimes
even violate the right of a women to individual dignity as in non-availability of a proper place
to change herself during that time of the month, resulting in menstruation being a shameful and
embarrassing experience for the females.
As stated earlier, India is a country with wealth related disparities, gender related disparities,
owing to which there exists a significant variation in social indicators among girls between
various regions of the country. Of the 113 million adolescent girls, 68 million girls attend about
1.4 million schools, with cultural practices and taboos pertaining to MHM acting as
impediments to their attendance of the schools(3). Numerous studies have been conducted across
the country, examining the prevalence of unsafe MHM practices, their causes and implications.
One such study(4) conducted in Haryana concluded that feeling of sickness followed by
irritability and emotional disturbance was most commonly experienced by the adolescent girls
while on their periods. Also, it was found in the same study that more than 45% of the
respondents were not allowed to worship and cook in the kitchen and one-fourth followed
dietary restrictions. More than 16% of the respondents thought of menstruation as a sign of
onset of a severe disease and around 7% thought of it as a “curse”.
Another similar study(5) conducted in states of northern India found that the awareness of
menstruation before menarche was reported by 60% of the respondents and that awareness was
significantly associated with age. Another similar study from Gujarat (10), found that almost
50% of the girls had to sit separately during menstruation, 89% were restricted in what they
could touch, including worship material and cooking materials, almost half of the respondents
experienced changes in the behavior of their family members and almost a third of them were
not allowed to go outside alone during their periods.
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Another study that sheds more light on the issue at hand was conducted by the University of
Mysore(11) which found that the choice of sanitary napkin, storage place of the napkin, change
during night, school and college hours, safe disposal of the napkins were all a function the
socio-economic status of their family.
1.2 MHMP in Madhya Pradesh

The state of MP doesn’t fare well when it comes to safe and hygienic MHM practices by
adolescent girls and adult women in the state. In a study conducted by Amity Business
School(6), Gwalior, it was found that most of the respondents answered that menstruation was a
curse from God, along with other things, such as they were asked to restrict their activities
while on their periods every month, ranging from simply not being allowed to step out of the
house alone to not touching the males of the house. Another study assessing the menstrual
hygiene management practices of women in urban areas of Jabalpur district (13) found that out of
the 200 adolescent girls surveyed for the study, approximately 70% of the respondents used
sanitary pads and the remainder used old cloth as an absorbent, and reused the same cloth for
consequent period without washing it properly.
According to a study published in the JMSCR, conducted in Jabalpur district of Madhya

Pradesh, the most common social changes that came along after the onset of menarche for the
adolescent girl in the family was the increased strictness by the mother imposed upon the
daughter, cessation of schooling and initiation of marriage talks.
In another prospective study conducted by the National Institute of Public Cooperation and
Child Development (NIPCCD) in the year 2007 and repeated again 2012, it was concluded that
respondents from Delhi had significantly higher awareness and knowledge about menstruation
before menarche than that of the other districts in the study, viz. Dhar (Madhya Pradesh),
Barbanki (Uttar Pradesh), Kamrup (Assam) and Mysore (Karnataka).
A study conducted by the Department of Community Medicine, Vasantrao Medical College,

Maharashtra, reported that there is a stark difference in awareness and knowledge about
menstruation and hygiene management practices between urban and rural areas of the state.
1.3 Demographics and Religious Affiliations of districts in the study

Bhopal: District Bhopal serves as the administrative headquarters for the state of Madhya
Pradesh. According to the 2011 census, the total population of the district is 2,371,061, with
literacy rate of 80.37% and sex ratio of 918 for every 1000 males. Average literacy rate of the
distirct stands at 80.37% with male literacy rate and female literacy rate at 85.42 and 75.87
respectively. Religious affiliations in the district range from about 74% Hindus and 22.16%
Muslims to about 1% Christians and 1.09% Jains.
Indore: Indore is the most urbanized and populous district of the state, with a population of
3,276,697. The literacy rate in the district is 87.38%, with male and female literacy rates of
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91.84% and 82.55% respectively. About 84% of the total population of the district subscribes to
and practices Hindu religion, followed by 12.67% Muslims, 2.19% Jains and 0.78% Sikhs.
25.19% of the population of the district lives in rural areas.
Balaghat: According to Census 2011, the total population of the district is 1,701,198 with
842,178 males and 859,520 males. Sex ratio is at 1021 females per 1000 males. Female literacy
rate stands at 69.04% while the overall literacy rate is 77.09%. Out of the total population of the
district, about 14.39% of the population lives in urban regions of the district.
Rewa: Total population of the district is 2,365,106 with a sex ratio of 931females for 1000
males. Average literacy rate of the district stands at 71.62% with female and male literacy rates
at 81.43% and 61.06% respectively. It is interesting to note that the female literacy rate is
significantly lower than that of males in the district. A considerable part of the population, i.e.
95.93% subscribes to Hindu religion, followed by 3.61% Muslims and 0.08% Christians.
Jhabua: Jhabua district constitutes about 1.41% of the entire population of MP, with a total
population of 1,025,048. Population in this area is predominantly tribal. Average literacy rate is
43.30% with male and female literacy rates at 52.85% and 33.77% respectively. Similar to
Rewa, the literacy rate in the district is significantly lower. Also, the overall literacy rate of the
district is substantially lower than the state average which stands at 70.06%. About 94% of the
population is Hindu, 1.53% Muslims, 3.75% Christians and 0.87% Jains.
Bhind: The total population of Bhind district is 1,703,005, which constitutes about 2.5% of the
population of MP. Average literacy rate of the distirct is 75.26% with male and female literacy
rate at 85.40% and 63.14%, respectively. 93.68% of the population is Hindu, with Muslims,
Sikhs and Jains at 3.92%, 0.24% and 1.17%, respectively.
Based on the above characteristics of the population of individual districts, it can be inferred
that female literacy in the state is a challenge owing to various reasons. The etiology for this
scenario is compounded by many factors, viz. socio-economic status, religion, and other
cultural beliefs. It will be interesting to find out if the association between low education level
and practice of unsafe methods for MHM really exists.
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2. Literature Review
Knowledge gap and poor personal hygiene practiced by women in India during menstruation has
been a subject of interest for academicians. Also, what has been particularly interesting is the
disparity between urban and rural areas pertaining to MHM knowledge, practices, behaviors and
attitudes. A few of such studies and their findings are discussed below.
2.1 Other studies on MHM

While MHM has increasingly become an issue of paramount importance, it has led to intensive
actions by the public and private sectors. Recent initiatives at the global level, include an inter-
sectoral meeting convened by the Water Supply and Sanitation Collaborative Council (WSSCC)
in March 2013, release of first comprehensive manual on MHM by WaterAid foundation in
2012, titled “Menstrual Hygiene Matters: A resource for improving menstrual hygiene around
the world”. In September 2012, an online workshop on MHM was conducted by UNICEF in 13
countries, including India. A study by Sommer et. al. in 2013 found that girls attendance in
schools is directly proportional to availability of adequate sanitation facilities in school, for
instance, gender-segregated toilets, private washing and disposal facilities etc.
Most of the studies pertaining to MHM have been in geographically specific and small regions.
One large scale study was conducted by the center for global safe water and Emory University in
Georgia. In 2012, this collaboration began a multinational study in Bolivia, Philippines, Rwanda
and Sierra Leone. The theoretical design of the study focuses on societal, environmental and
religious factors influencing MHMP. In 2013, the project was expanded to include Mali. The
project yielded evidence-based programmatic recommendations to reduce MHM barriers and
challenges faced by school going girls.
Nationally, in the year 2010, a study was conducted in Saoner, Nagpur District in Maharashtra,
examining the knowledge and menstrual hygiene management practices of adolescent school
going girls in 8th and 9thstandard. The study reported that only about 37% of the girls in the study
knew about menstruation before menarche and the major source of this information was reported
to be their mothers. More than 75% of the girls had no clue about the cause and the source of
bleeding. About 50% of the girls knew about and used commercially available sanitary napkins.
Satisfactory cleaning of the external genitalia was practiced only by 33% of the participant
adolescent girls. Another similar study conducted in Dehradun, Uttarakhand reports that 64% of
girls were about menstruation before menarche, however, awareness amongst the rural
population was found to be more than that of the urban girls. In about 32% of the cases, the
primary informant was found to be a friend from school. Also, majority of the girls did not know
about the cause and source of bleeding during menstruation.
Beyond all this, there still exists a significant gap in knowledge and understanding of MHMP in
the state of Madhya Pradesh.
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2.2 Other organizations working on MHM in India

Many corporate and non-governmental organizations are doing their part towards the betterment
of MHM status of adolescent girls and women in India. Usually corporate sector does it under
the Corporate Social Responsibility (CSR) project. Since the revolutionary manufacturing of low
cost sanitary napkins, introduced by Mr. Arunachalam Muruganantham, there is a whole range of
organizations, working independently and with the governments, to procure, produce and
promote the usage of these low cost sanitary napkins. A few such initiatives include, Anandi
Pads by Aakar Innovations, Mukti Pads by Society for Rural Industrialization, Sasodashi by
Corporate Social Responsibility Project by Jindal Power and Steel Plant, and Freedays by
Government of India, that have catered to smaller pockets across the country.
Following is a summary of certain prominent organizations working towards MHM in India:
1. WaterAid: An NGO, with a mission “to transform the lives of the poorest and the most
marginalized people by improving access to Water, Sanitation and Hygiene
(WASH)”.WaterAid India recognizes that menstrual hygiene is fundamental to individual
dignity and well-being of adolescent girls and adult women. They employ the approach
of generating awareness amongst the adolescent girls and their families and providing
low-cost simple solutions which are locally appropriate. On international Menstrual
Hygiene Day, observed on May 28th every year, WaterAid, India launched a campaign
called “Thunderclap” to advocate for better menstrual hygiene. The primary objective of
the campaign was to address the menstruation related taboos, enhance the advocacy about
this issue to the governments and feminine hygiene product makers.
The campaign came with a hashtag “#noshameinmesntruation”.
2. Healthy Living Development Society (HLDS): V-care is a joint Initiative of Healthy

living Development Society (HLDS) and Women & Child Development (WCD) Indore,
which took place in 2011 by establishing sanitary napkin production unit Under SABLA
scheme of GOI. The main objective of their mission is to provide beneficiaries with
affordable, hygienic and convenient sanitary napkins.
2.3 Government schemes and initiatives on MHM

UDITA program was launched by the Government of Madhya Pradesh (GoMP) in 2015, to
assuage the culture of silence and social taboos around the subject of menstruation in the society,
to raise awareness about this matter which directly correlates with the individual dignity of
adolescent girls and women of the state, and to provide access to affordable sanitary napkins.
Under the Pradhan Mantri Bharatiya Jan aushadhi Pariyojana, Government of India (GoI)
launched “Janaushadhi Suvidha – Oxo biodegradable sanitary napkins”, in June 2018. The
affordable sanitary napkins will now become available at over 3600 Janaushadhi Kendras
functional in 33 States/UTs across India, as promised by Union Minister, Chemical & Fertilizers
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and Parliamentary Affairs, Shri Ananthkumar on March 8, 2018 (World Women’s day). These
suvidha sanitary napkins are priced at Rs. 2.50/pad.
This unique product would ensure Affordability, Hygiene as well as Ease of use and disposal for
them. Jan Aushadhi Suvidha comes with a special additive, which makes it biodegradable when
it comes in contact with oxygen after being discarded. This would ensure ‘Swachhta, Swasthya
and Suvidha’ for the underprivileged women of India and go a long way in the achievement of
Prime Minster Shri Narendra Modi’s vision of Affordable and Quality Healthcare for All.
2.4 Commercially available sanitary napkins and other products of female hygiene
A study conducted in Rajasthan by the Indian Institute of Health Management found direct
correlation between unsafe sanitation practices and prevalence/incidence of Reproductive Tract
Infections (RTIs). A whole range of sanitary napkins or pads (as they are commonly named) is
available in the market ranging from Rs. 20 to Rs 85 per packet. Some of the commercially
successful names include Whisper, Stayfree, Sofy, and Kotex.
Currently, the sanitary napkin market base in India and the state divides the product into three
categories, viz. disposable menstrual pads, cloth menstrual pads and biodegradable menstrual
pads, and from the three categories, disposable menstrual pads accounts for the majority of the
total share in the market.
The market is also segmented on a regional basis, predominantly functional in the urban states,
with the highest penetration in states of Maharashtra, Delhi NCR, and Tamil Nadu respectively.
The key players include Proctor and Gamble, Johnson & Johnson, Emami and Unicharm.
Some of the most common varieties commonly found on the shelves of the shops/stores in India
and the state are as follows:
S. Brand Name Type No. of pads/pack Cost (In Rupees)

No.
1 Whisper Ultra Clean 15 165
2 Stayfree Dry-Max All-Night 7 70
3 Sofy Side-walls 15 120
4 Stayfree Dry-Max Ultra-Thin 8 80
5 Whisper Ultra Nights 15 175
6 Whisper Regular Wings 8 26
7 Kotex Soft Smooth 8 25
It is noteworthy here that besides the last two names mentioned in the table, rest of the products
seem unaffordable by a lower-middle class family.
The cost implications are an important factor to consider as a study conducted by the AC
Nielsen, a marketing research firm, titled “Sanitary Protection: Every Woman’s Right”,
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concluded that the biggest barrier to using sanitary napkins by women is the affordability.
About 70% of women in India say that they resort to using unsanitary cloth because they
themselves or their family cannot afford to buy commercially available sanitary napkins.
The study surveyed 1,033 adult women and 151 gynecologists across the country. It is to be
noted that 97% of the gynecologists in the study said that use of sanitary napkins lowered the
risk of severe RTIs and 68% said that the use of sanitary napkins reduces the risk of cervical
cancer.
2.5 Arunchalam Muruganantham: Indian Superhero “Padman”

The man behind the first low-cost pad making machine is now a famously known social
entrepreneur, internationally and nationally. The extraordinary story began in 1998 when he
noticed his wife using an old rag during her time of the month. Determined to help her, he put in
many years of research (to the extent of wearing a sanitary napkin himself where he fashioned
an artificial uterus made of rubber and animal blood) and manufacturing trials and eventually
came up with a machine that can make up to 3,000 sanitary pads/day. This low-cost machine
can be operated with minimal training.
Mr. Muruganantham has developed a set of four different small machines namely de-fiberation
unit, core forming unit, sealing unit and UV sanitizing unit, which reduce the cost of production
making Sanitary Napkins affordable to all. In the first stage, by using de-fiberation unit, the raw
material in the form of wood fiber is de-fibred to produce soft pulp. In second stage, de-fibered
pulp is given required shape of the napkin in core forming units operated by a foot pedal. The
third stage involves sealing the pads. The fourth stage involves passing the sealed pads through
a dedicated Sterilization unit. Once the sterilization is complete, the pads are ready for the
finishing operations consisting of trimming, position strip fixing, packing and dispatch.
His invention revolutionized the sanitary napkin manufacturing industry as this machine costs
only about Rs. 65,000 (US$950) as opposed to commercially used machines, which cost around
Rs. 3,50,00,000 (US$ 500,000). His invention is widely praised across the nation and the world
as it substantially changed women’s lives in India, particularly in rural India. He has currently
sold 1300 machines across 27 states in India and to other developing countries as well.
He won some substantial accolades and awards for his absolutely worth invention including a
mention in the most influential people’s list of 2014 by TIME magazine. Mr. Muruganantham
was also conferred upon Padma Shri in the year 2016.
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Mr. Muruganantham also gave a TED talk on the subject which earned him much more
recognition around the world. His story was the subject of a prize-winning documentary titled
“Menstrual Man”. In the picture above, he is shown receiving the highest national award by the
Honorable President of India, Shri. Pranab Mukherjee.
2.6 Extraordinary Story in MP

Maya Vishwakarma, also commonly and dearly known as the padwoman of MP, hails from a
village in Narsinghpur district in MP. She’s a fine example to illustrate the taboos surrounding
menstruation in India as in an interview to New Indian Express she confessed that she hadn’t
heard of sanitary napkins until the age of 26. Coming from a family of agriculture farm
laborers, the family was struggling to make ends meet and for her first period she was asked to
use an old cloth by a female relative of the family.
Because Maya received full support from her family to study and was not rushed into marriage,
which is why she landed a research stint in AIIMS, New Delhi and then got a chance to work in
the US where she worked as a cancer researcher for Leukemia.
Maya started the “SUKARMA” foundation in her hometown two years before after her return
to India. This foundation manufactures sanitary napkins at low and affordable costs and sells it
to women in the area. In the two years since the beginning of the work of this foundation, they
have changed the lives of about 2,000 women. In another interview to the New Indian Express,
she told “the money of the machine and the unit was sourced through crowd funding, personal
savings and from friends working abroad for the California and India chapter of the Sukarma
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Foundation founded by me. It was while scouting for the best and cost-efficient machinery for
producing sanitary pads that I met the real ‘Padman’ (Muruganantham) two years ago and saw
the machine being used by him”.
In the picture above, Maya Vishwakarma, is shown in action at Sukarma Foundation.
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3. Objectives and Methodology

3.1 Objectives of the study
The fundamental purpose for the conception of the study was to have an enhanced
understanding of the various religious and socio-cultural practices pertaining to Menstrual
Hygiene Management Practices (MHMP). Keeping that in mind, the following objectives were
formulated:
1. To examine the role of education against various religious and socio-cultural practices in the
select districts of Madhya Pradesh.
2. To examine the existence of a correlation, if any, between the distribution of low-cost
sanitary napkins and the change to adoption of better menstrual hygiene management
practices.
3. To ascertain if women in rural areas have any knowledge of menstruation as a biological
and physiological process essential for reproduction.
The study also aims to add to the growing body of research in the field and help guide the
decisions of policy makers in the area. Also, if the study reaches the intended audience, i.e.
adolescent girls and adult women, it will educate them and directly impact their empowerment.
The secondary literature review for the study, includes, inter-alia:
1. National Guidelines for Menstrual Hygiene Management Practices, Drinking Water and
Sanitation Department, Government of India
2. Various studies in the area reflecting on the issues and concerns
3. Socio-cultural beliefs and taboos surrounding the subject
4. WASH indicators from Sustainable Development Goals
5. Current menstrual hygiene management practices
The study also aims at highlighting this issue of grave concern which can ipso facto lower the
burden on the healthcare economy of the state. Only when the healthcare governance is at
center stage in policy making can we really nip the problem in the bud. Peripherally, the study
also aims to understand the current provisions of menstrual hygiene management and
availability of sanitary products in the state run schools, or lack thereof.
This report looks into the current MHM practices among adolescent girls and adult females in
the 6 districts of MP, namely, Bhopal, Indore, Balaghat, Rewa, Jhabua and Bhind, and proposes
recommendations to alleviate the incidence and prevalence of uro-genital tract infections in the
female population in the area.
3.2 Methodology
The study was cross-sectional, block level, questionnaire based. From the identified target
population (N = 2,18,43,686 )[4], the sample population (n = 1200) was identified using random
sampling for identification of blocks and villages, and systematic random sampling for
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respondents in each village, keeping the Confidence Interval at 95%. The sample covered
adolescent girls and adult females. The distribution of the survey and data collection on the field
was assisted by a female Field Investigator (FI) in each block. The survey was primarily
focused on knowledge, attitude and behavior of women about menstruation in the selected
geographical areas. The sample covered the entire spectrum of targeted women beginning from
13 years to 47 years (rounded off from average age of menarche in India i.e. 13.46 years and
average age of menopause in India i.e. 46.2 years [5]). The sample was distributed among rural
and urban areas equally. The urban population was picked up from (Bhopal Block) Bhopal
District and (Indore Block) Indore District and the rural population will be from (Meghnagar
Block) Jhabua District, (Balaghat Block) Balaghat District, Gohad (Bhind District) and
(Hanumana Block) Rewa District. 200 respondents (100 adolescent girls and 100 adult women)
were picked up from all the six blocks/districts each.
Nodal Point for dissemination of surveys to adolescent girls was the schools run by government
in each block, and that for the adult women was the Aanganwadi centers. Timeline for
dissemination of surveys and completion of data collection was 1 month. The data was collected
using android supported mobile application called “e-sanchay” developed by the Department of
Economics & Statistics. The data was coded in Excel 2013 and data analysis was completed
using SPSS 18.
3.3 Limitations of the study
There is tremendous amount of research available on the issue of MHM in India. However, the
literature that studies the transformation of behavior, knowledge and attitude from unsafe to
safe menstrual hygiene management practices brought about by a scheme wherein low-cost
sanitary napkins were distributed, is scarce. Therefore, this study used an exploratory study
design.
Also, the study had to rely on the survey administering ability of the female field investigators
(FIs) for data collection, for which, the FIs had to visit government schools in the region. It was
reported that when the permission to leave the class to take the survey was obtained from a male
teacher, the student seemed uneasy while answering the questions on the survey.
We missed to include non-school going girls in this study. We also missed to ask the
respondents if they knew of the source of bleeding during menstruation, and there was
ambivalence in the question wherein we asked the respondents if they did or did not feel
embarrassed around male members of their family.
3.4 Internal and External Validity of the study

Internal validity refers to whether the results obtained in a study are due to the manipulation of
the independent variables or due to some other unknown variable. No threats to internal validity
of this study came across as the “Maturation” was fixed by shortening the duration of the
study to 4 months, “Diffusion of Information” may have been a possibility as the respondent
samples were taken from the same grade in the same school.
17
External validity refers to the extent to which the findings of a study can be generalized to other
situations and other people. “Sample characteristics” is no threat to the external validity of
this study as the rural-urban population is covered so the findings can be replicated to another
state with similar population and demographics. “Reactivity of study arrangements” can
potentially alter the way the respondent answers the questions on the survey as being aware of
participation in a study can greatly influence the way they think they should answer the
questions. “Selection bias” was not a threat to the external validity of the study as every 5 th
adolescent girl from grade 8th through grade 12th was selected and every 3rd adult women at the
Aanganwadi center was selected as a respondent for the study.
18
4. Findings
4.1 Adolescent girls specific
To meet every objective of the study, various hypotheses were formulated. The individual
objective and the hypotheses under it are described in the following section:
Objective 1: To examine the role of education against various religious and socio-cultural
practices in the select districts of Madhya Pradesh.
Hypothesis 1: Girls who knew about menstruation prior to menarche used sanitary napkins
only as an absorbent during menstruation.
Finding: We ran Cramer's V as the statistical tool of choice to determine the correlation
between the Independent Variable (knowledge prior to menarche) and the Dependent Variable
(Type of absorbent used during menstruation). Therefore, it can be safely inferred that
educating adolescent girls about menstruation during school years, and as a part of their school
curriculum leads to adoption of safe menstrual hygiene management practices.
Cramer's V correlation was found to be significantly strong with the value of 0.440 and α <0.05.
Symmetric Measures
Approx.
Value Sig.
Nominal by Phi .440 .000

Nominal
Cramer's V .440 .000
N of Valid Cases 600
Hypothesis 2: Educational status of the mother of the adolescent girls was inversely
proportional to attitude towards menstruation in it being considered a “curse from God”.
Finding: Cramer's V as the statistical tool of choice was used to determine the correlation
between the Independent Variable (mother's educational status) and the Dependent Variable
(knowledge of cause of menstruation).
Cramer's V correlation was found to be significant with the value of 0.144 and α <0.05.
However, the value of the correlation coefficient signifies a moderately weak correlation. Albeit
weak, the correlation directs us to inferring that adolescent girls with mothers with better
educational status knew that menstruation is not a “curse from God”.
19
Symmetric Measures
Approx.
Value Sig.

Nominal
Hypothesis 3: Girls with educated mothers did not feel embarrassed in the presence of their
male friends or family members while they were on their period.
Finding: Pearson’s correlation coefficient was the statistical tool of choice to determine the
magnitude of correlation between the independent variable (Mother's educational status) and
dependent variable (feeling of embarrassment), as the dependent variable is placed in true
dichotomy.
The correlation is found to be significant with the Pearson coefficient value at 0.178 and α
<0.05. The correlation however is found to be weak.
Correlations
embarrasseda
roundmalefa
Medu mily
Medu Pearson 1 .178**

Correlation
Sig. (2-tailed) .000
N 600 600
embarrassedaroundma Pearson .178** 1

lefamily Correlation
Sig. (2-tailed) .000
N 600 600
**. Correlation is significant at the 0.01 level (2-tailed).
20
Objective 2: To examine the existence of a correlation, if any, between the distribution of low-
cost sanitary napkins and the change to adoption of better menstrual hygiene management
practices.
Hypothesis 1: Girls who knew of UDITA scheme didn’t use rags anymore while on their
period.
Finding: The correlation coefficient obtained is strong and statistically significant (Cramer's V
0.386 and α<0.05).
It is essential to point out here that only 7.6% of the respondents in the study knew of UDITA
program and majority of those who knew were from Bhopal district.
Symmetric Measures
Approx.
Value Sig.

Nominal
Hypothesis 2: Girls who knew of UDITA scheme maintained cleanliness of external genitalia.
Finding: Correlation coefficient shows a negligible value with p value insignificant at α>0.05,
which suggests that adolescent girls did not clean there external genitalia even if they knew of
the UDITA scheme.
Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

biological and physiological process essential for reproduction.
Hypothesis 1: Urban girls knew of menstruation as a process essential for reproduction better
than their rural counterparts.
Finding: Based on the Chi Square value (ᵡ2 – 56.37) and p<0.05, it can be inferred that the
knowledge of menstruation as a physiological process essential for reproduction is a function of
residential area being rural or urban.
Hypothesis 2: Urban girls have better knowledge than rural girls about maintaining cleanliness
of the external genitalia well during menstruation.
21
Finding: According to the Cramer’s V correlation coefficient value, and p<0.05, there exists a
correlation between maintaining cleanliness of the external genitalia well during menstruation
and the residential area being urban or rural, implying that urban girls practiced better MHM.
4.2 Adult women specific

Objective 1: To examine the role of education against various religious and socio-cultural
practices in the select districts of Madhya Pradesh.
Hypothesis1: Women with better educational status practiced better MHM via using sanitary
napkins only.
Findings: Using Cramer's V as the statistical tool of choice to elucidate the correlation between
respondent's educational status and the absorbent commonly used by them during menstruation,
the correlation coefficient is found to be significant (Cramer's V - 0.283 and α<0.05), implying
that education does play a key role in empowering women to make better choices pertaining to
safe and hygienic MHM.
Symmetric Measures
Approx.
Value Sig.

Nominal
Hypothesis 2: Educated women didn't feel embarrassed to be around their male colleagues or
male family members during the time they were on their menses.
Findings: Women's educational status has a direct influence on the feeling of embarrassment
during menstruation while around their male colleagues and family members (Cramer's V -
0.361 and α<0.05), which directs us to the inference that education combats socio-cultural and
religious notions of “state of impurity” during menstruation thereby alleviating the feeling of
embarrassment.
Symmetric Measures
Approx.
Value Sig.
22

Nominal
Hypothesis 3: Educated women are aware of the cause of menstruation and did not consider it a
curse from God.
Findings: Correlation coefficient between educational status of women and menstruation being
considered a curse from God is significant but the coefficient value signifies extremely low
correlation (Cramer's V - 0.195, although α<0.05). This points to the fact that even if these
women as girls were not educated about menstruation in school, attaining higher education led
them to the understanding that menstruation is not a “curse from God”.
Symmetric Measures
Approx.
Value Sig.

Nominal
Objective 2: To examine the existence of a correlation, if any, between the distribution of low-
cost sanitary napkins and the change to adoption of better menstrual hygiene management
practices.
Hypothesis 1: Women who knew of UDITA scheme didn’t use rags anymore while on their
period.
Findings: Correlation coefficient holds moderately strong at 0.354 and significant at α<0.05,
implying that due to the remarkable outreach and innovative strategies of UDITA program,
adult women did adopt better menstrual hygiene management practices. Also, it can be safely
inferred that this correlation stands true for the target population as well. It should especially
noted here that the maximum penetration of UDITA outreach to the community was found in
Meghnagar Block of Jhabua District, whereas the awareness regarding the scheme in other
districts of the study was considerably nil.
23
Symmetric Measures
Approx.
Sig.
Value
Nominal
Hypothesis 2: Women who knew of UDITA scheme maintained cleanliness of external

genitalia.
Finding: Correlation coefficient shows a negligible value with p value insignificant at α>0.05,
which suggests that women did not clean there external genitalia even if they knew of the
UDITA scheme. The p value insignificance implies that this finding cannot be replicated to a
larger population.
Symmetric Measures
Approx.
Sig.
Value
Nominal
Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

biological and physiological process essential for reproduction.
Hypothesis 1: Urban women knew of menstruation as a process essential for reproduction
better than their rural counterparts.
Finding: As depicted by the Asymptotic Significance (p) which is <0.05, knowledge of
menstruation as a process essential for reproduction is a function of the residential area being
urban or rural, meaning that women in urban areas have better means of gaining knowledge on
the subject.
24
Chi-Square Tests
Exact Sig.
Asymp. Sig. Exact Sig. (2- (1-sided)
Value df (2-sided) sided)
Pearson Chi-Square 83.379a 1 .000
Continuity Correctionb 81.587 1 .000
Likelihood Ratio 115.707 1 .000
Fisher's Exact Test .000 .000
Linear-by-Linear 83.254 1 .000

Association
a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 48.26.
25
5. Conclusion
Numerous studies on MHM in India is a very encouraging practice which sheds light on the fact
that there is a growing interest on the subject matter amongst the academics, at least. It is to be
noted that majority of these studies found that girls are unaware of menstruation before
menarche and hence the feelings of stress, anxiety, depression, uneasiness, dirtiness and anger is
most commonly seen among them. While the importance of puberty and reproductive health
education is universally recognized, it becomes a topic of debate in our country when the
question arises “who should educate young girls in the country about it?”
Although menarche is celebrated in southern regions of the country, we found through our study
that in the state of MP this physiological change brings a substantial amount of physical and
psychological burden. This psychological burden is further compounded by societal beliefs in
restriction of activities such as not being allowed to go out of the house, not being allowed to
touch anything that’s considered holy and not being allowed to touch anything or sometimes
even enter the kitchen. While education about puberty and menarche may possibly dissipate the
taboos prevalent in the society, a holistic approach and an innovative strategy to counter the
negative attitudes towards menstruation is the need of the hour.
Government of India and Government of MP have taken initiatives to address the deeply
penetrated problem of menstrual hygiene management in the country and the state, but the
question remains “Is that enough?”, or “Is it making the desired impact?” and “Is distribution of
low-cost sanitary napkins just a band-aid to the wound?”. The study revealed that the most
crucial factor that needs to be addressed is the family support. While in approximately 90% of
the cases, the first confidant for the adolescent girl respondent was the mother, it is to be noted
that majority of the mothers were illiterate, hence, it can be inferred that mother’s education and
involvement in any scheme proposed and implemented by the government must be a sine qua
non.
According to the field experience report of the field investigators engaged in this study, the
most vital factor for not using the sanitary napkins was the affordability. FI from Bhind district
reported that the aanganwadis sold one packet of sanitary napkins at Rs. 6 earlier and now the
same packet is being sold at Rs. 25. The increase in the cost was found to be a discouraging
factor among both women and adolescent girls to continue using the sanitary napkins. About
60% of the girls responded that they didn’t use sanitary napkins because they were too
embarrassed to ask the shopkeeper about it. The same number among adult women was found
to be about 26.3%. Ease of access was the second common factor observed for non-usage of
sanitary napkins, about 28% of adolescent girls said that the shop was too far from their home
or that no one buys them the product. The same factor was reported as a hindrance by about
37% of adult women.
26
% of Educated Mothers
% ofrespondents' mothers with educational

40
35
35 32.83
30
25
20 17
status
15 13.16
10
5 2
0
Illiterate Primary Middle School High School Graduate and
above
Education Status
Another incidental yet interesting finding that the study came across is the flow of information
regarding better MHMP isn’t necessarily unidirectional (mother to daughter). In about 14 cases,
the study found out that daughters were the primary source of information for less educated
mothers, and the new information received by the mother from the daughter was more trusted
considering the source of the information and brought about changes in menstrual hygiene
management.
It has also been pointed out earlier that MHM should concern men and women alike. Following
is a graphical presentation of girls with educated fathers and their feeling embarrassed about
menstruation. If we take a look at the UDITA scheme proposed by the government of MP
which involves a provision of UIDTA CORNER in the local aanganwadi where adolescent girls
and women get together to learn about the physiology of menstruation and safe methods of
menstrual hygiene management, we recommend that fathers and brothers of adolescent girls be
also involved in such knowledge sharing and building thus empowering the female segment of
the society even more.
When asked about the disposal of the Methods of Absorbent Disposal

used absorbent, 46.3% of the adult
female respondents said they threw it 10.33
Trashcan
in a trashcan, about 42% (combined)
20.66
said they threw it outside the house or Threw outside the house 46.33
in drains and water bodies and only Drains and water bodies
10.3% said they burned it after use.
Burn it 21.16
Majority of the respondents were not
27
aware of the environmental hazard posed by the unsafe disposal of the absorbent. In pure
numbers if we calculate the burden on the environment, of unsafe and unsanitary disposal of the
absorbent, it comes to about 3,600 pads disposed by each female at a rate of 10 pads/cycle for
30 years of menstruation. The magnitude of the burden is further intensified when it is seen
within the context of state and national population. To put things a little more into perspective,
for the state female population of menstruating age, the number becomes (2,18,43,686 x 3600)
78,637,269,600. The number is much bigger for the entire country. For such numbers it is
reasonable to think the amount of plastic that goes into the environment is considerably
significant.
When adolescent girls were asked if they Cause of Menstruation

knew of the cause of menstruation,
15.1
majority of them knew (59.3%) that it was
a normal physiological process, 25.6% 25.6 59.3
answered that it is a pathological process
and 15.1% considered menstruation a
“curse from God”.
Physiological/Hormonal Disease Curse from God
% use of sanitary napkins vs education in adult

women
120
100 100 100
100
80
60
40
20 7.87
0
0
above
Also while analyzing the results of the study it was found out that educational status for
illiterate women and for women who only studied till primary school practiced poor menstrual
hygiene. 100% of the illiterate females used old rag as an absorbent during menstruation and
from those who studied till primary school, only about 8% used sanitary napkins; the remainder
used an old rag. Education as a socio-cultural determinant of poor MHM plays a significant
role, as is evident from the graph above, wherein 100% of the females with education of middle
school and higher used only sanitary napkins as the absorbent during menstruation.
28
Father's Education vs. Girl Feeling Embarrased

120
98.78 96.87
100 92.85
80 70
58.82
60
40
25.5 27.6 26.6
20 13.6
6.5
0
above
% of respondents' Fathers % of girls feeling embarrased
While it was observed that about 60% of the respondents’ fathers were educated from middle
school and above, a remarkable proportion of the adolescent girls in the sample said they were
embarrassed to be around the male members of the family.
29
6. Recommendations
Based on the findings and conclusion mentioned in the previous sections of this report, it stands
to reason that education should be used as a tool for social and behavior change. One of the best
ways to derive this societal change is communication for development strategy. While in a
conservative society, like within our state, we should encourage dialogue on this subject and try
to dissipate the wide knowledge gap that exists which is otherwise filled by socio-cultural and
religious taboos, superstitious practices and many other myths and misconceptions around the
subject matter.
Secondly, when the government proposes initiatives like UDITA program, inclusivity of all the
family members, including male members, should be encouraged.
Thirdly, education on menstrual cycle as a biological and physiological process essential for the
well-being of a girl and woman’s health should be introduced in the schools, along with the
appropriate education on maintaining proper hygiene and not exacerbating the uro-genital and
reproductive health of the individual female.
Fourthly and lastly, through this report, we also want to emphasize on the work being done by
the state government and WASH for better environment. Appropriate education for disposal of
used absorbent should be employed as a tool and also use of environmentally safe menstrual
cups should be encouraged, which will eventually lower the amount of non-biodegradable plastic
being thrown into the environment. Schools should install incinerators in the bathroom facility
for females and ensure the adolescent girls know the correct usage of the installed machine.
Often while discussing menstrual cups, the cost-factor usually gets some “raised eyebrows”,
however, a study conducted by the National Institute of Health and Centre for Disease Control
and prevention (CDC)(7) looked into the cost-effectiveness of sanitary napkins, tampons and
menstrual cups and concluded that menstrual cups are a satisfactory alternative to sanitary
napkins and tampons, and that they have the potential to be a sustainable solution to menstrual
management with moderate cost savings and much reduced environmental effects with sanitary
napkins or tampons.
Speaking of the cost factor as a function of encouraging the usage of safe methods for
management of menstrual hygiene, a recent development has been the exemption of sanitary
napkins as a product on which Goods and Services Tax (GST) is liable. Earlier, sanitary napkins
were liable for 12% GST. This step seems to be in the right direction.
In the previous year, much of the silence on menstruation and menstrual hygiene has been
overcome by the state, a few illustrations would include, installations of low-cost sanitary napkin
dispersal machines at a few railway stations in the state. This wave of social change is also
significantly brought about by the movie “Padman” released this year, which soon became a
topic of conversation among all sections of the society. Also, the hashtag “socialchange”
30
(#socialchange) was introduced by Bollywood stars on social media outlet such as Facebook,
Twitter and Instagram, wherein they posed for the camera holding a sanitary napkin in their
hands or their pockets. Much of this was followed by college students and it soon became a trend
in the urban sections of the state.
It is a much required start for the state but based on the findings of this study, we have to say that
we have a long way to go before we can say the battle has been won.
31
7. References
1. Menstruation: A taboo subject in India. An article from Business Standard. Retrieved from
http://www.business-standard.com/article/current-affairs/madhya-pradesh-fares-worst-in-
unhygienic-menstrual-practices-across-india-117061900188_1.html
2. Secular trends in menarcheal age in India: Evidence from the Indian Human Development
Survey. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219698/
3. Mahon. T, Fernandes M. Menstrual Hygiene in South Asia: A neglected issue for WASH
programs. Gend Dev 2010
4. Goel. M, Mittal. K. Psycho-social behavior of urban Indian adolescent girls during
menstruation. PMC 2011.
5. Kumar. D et. al. Menstrual pattern among unmarried women in northern India. PMC 2013.
6. Chakravarty D. Development communication perspective of menstruation in rural India.
Journal of content, community and communication.Vol. 4, year 2, Dec. 2016.
7. Howard, C., Rose, C. L., Trouton, K., Stamm, H., Marentette, D., Kirkpatrick, N., … Paget,
J. (2011). FLOW (finding lasting options for women): Multicentre randomized controlled trial
comparing tampons with menstrual cups. Canadian Family Physician, 57(6), e208–e215.
32

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Education about menstruation changes everything

Assessing the Menstrual Hygiene Management Practices in Urban and Rural

Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis

Project Coordinator and Author

Under the guidance of

Menstruation is a biological and physiological process which naturally occurs in healthy

The world transitioning from Millennium Development Goals (MDGs) to Sustainable

1.1 Menstrual Hygiene Management Practices (MHMP) in India

1.2 MHMP in Madhya Pradesh

According to a study published in the JMSCR, conducted in Jabalpur district of Madhya

A study conducted by the Department of Community Medicine, Vasantrao Medical College,

1.3 Demographics and Religious Affiliations of districts in the study

2.1 Other studies on MHM

2.2 Other organizations working on MHM in India

Following is a summary of certain prominent organizations working towards MHM in India:

The campaign came with a hashtag “#noshameinmesntruation”.

2. Healthy Living Development Society (HLDS): V-care is a joint Initiative of Healthy

2.3 Government schemes and initiatives on MHM

S. Brand Name Type No. of pads/pack Cost (In Rupees)

2.5 Arunchalam Muruganantham: Indian Superhero “Padman”

2.6 Extraordinary Story in MP

In the picture above, Maya Vishwakarma, is shown in action at Sukarma Foundation.

3. Objectives and Methodology

The secondary literature review for the study, includes, inter-alia:

3.4 Internal and External Validity of the study

Nominal by Phi .440 .000

Nominal by Phi .203 .046

Medu Pearson 1 .178**

Sig. (2-tailed) .000

embarrassedaroundma Pearson .178** 1

Sig. (2-tailed) .000

**. Correlation is significant at the 0.01 level (2-tailed).

Nominal by Phi .386 .000

N of Valid Cases 600

Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

4.2 Adult women specific

Nominal by Phi .567 .000

N of Valid Cases 668

Nominal by Phi .361 .000

N of Valid Cases 600

Nominal by Phi .390 .000

N of Valid Cases 600

N of Valid Cases 600

Hypothesis 2: Women who knew of UDITA scheme maintained cleanliness of external

N of Valid Cases 600

Objective 3: To ascertain if women in rural areas have any knowledge of menstruation as a

Continuity Correctionb 81.587 1 .000

Likelihood Ratio 115.707 1 .000

Fisher's Exact Test .000 .000

Linear-by-Linear 83.254 1 .000

% ofrespondents' mothers with educational

When asked about the disposal of the Methods of Absorbent Disposal

When adolescent girls were asked if they Cause of Menstruation

% use of sanitary napkins vs education in adult

Father's Education vs. Girl Feeling Embarrased

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