A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia.

Lack of knowledge about MHM was a source of anxiety among the girls in this study, and this can lead to inadequate menstrual hygiene management (e.g. to predict onset of next period).

“Lack of knowledge about MHM was a source of anxiety among the girls in this study, and this can lead to inadequate menstrual hygiene management (e.g. to predict onset of next period) [19, 27, 28].”

A comparative study in Tanzania, Ghana, Cambodia, and Ethiopia found some countries mandated sex-segregated school toilets, but adherence was inconsistent.

“A comparative study in Tanzania, Ghana, Cambodia, and Ethiopia, found some countries mandated sex-segregated school toilets, but adherence was inconsistent [253].”

Commercial menstrual products may be unavailable or too costly, prompting rural and poor women and girls to use available materials such as cloth from old clothing and cotton.

“Resources, like commercial menstrual products, may be unavailable or too costly, prompting rural and poor women and girls to use available materials such as cloth from old clothing and cotton [11, 12, 23–26].”

Structural challenges to MHM include inadequate provision of clean water and soap, sanitation infrastructure, private places to clean and change, and disposal facilities.

“Structural challenges include inadequate provision of clean water and soap, sanitation infrastructure, private places to clean and change, and disposal facilities [7, 8, 11–22].”

Women and girls face information and social support challenges: girls are often unprepared, uninformed, misinformed, and lack adequate support for understanding and managing menarche, menstruation, and puberty, resulting in fear, uncertainty, and potentially harmful behaviors.

“In addition to these structural and resource barriers, women and girls face information and social support challenges: girls are often unprepared, uninformed, misinformed, and lack adequate support for understanding and managing menarche, menstruation, and puberty, resulting in fear, uncertainty, and potentially harmful behaviors, like risky sex, reduced bathing, and limited food and water intake”

Inadequate facilities in schools for water, sanitation, private changing, and disposal, and gendered and unsupportive school environments can lead to school absenteeism and potential disruptions in academic engagement and progress.

“Inadequate facilities in schools for water, sanitation, private changing, and disposal, and gendered and unsupportive school environments can lead to school absenteeism and potential disruptions in academic engagement and progress [2–8, 11–13, 15–18, 21, 26, 30, 36, 37].”

The worry about infection from drying cloth in hidden and dark places is consistent with findings reported from India, Tanzania, and South Asia.

“which is consistent with findings reported from India, Tanzania, and South Asia [6, 8, 12, 20].”

Concerns for appropriate disposal have been voiced by girls in Ghana who worried about infertility if animals touched their pads and girls in Bolivia who believed they could get cancer if they burned their menstrual blood.

“Concerns for appropriate disposal have been voiced by girls in Ghana who worried about infertility if animals touched their pads and girls in Bolivia who believed they could get cancer if they burned their menstrual blood [12, 67].”

Many researchers have explored girls' fear and confusion at menarche due to insufficient information and preparation.

“Many researchers have explored girls’ fear and confusion at menarche due to insufficient information and preparation [4, 12, 21, 23, 67, 69].”

Beliefs that menarche indicated sexual initiation prompted girls to hide their status for fear of punishment, reported in studies from Ethiopia, Ghana, and Mali.

“Beliefs that menarche indicated sexual initiation prompted girls to hide their status for fear of punishment, reported in studies from Ethiopia [89, 100], Ghana [88], and Mali [95].”

This information was often provided without clarifying how or when girls were vulnerable to pregnancy.

“however, this information was often provided without clarifying how or when girls were vulnerable to pregnancy”

Girls expressed a strong desire for more practical information, including managing menses or pain relief.

“Girls expressed a strong desire for more practical information, including managing menses or pain relief”

Water scarcity altered behaviours where this resource was limited and was therefore conserved during washing absorbents or cleaning blood from hands or latrines.

“Water scarcity altered behaviours where this resource was limited and was therefore conserved during washing absorbents or cleaning blood from hands or latrines [88, 89, 100].”

Qualitative research has documented challenges girls face in managing their menses and indicated health, education and psychosocial well-being consequences of poor management.

“Qualitative research has documented challenges girls face in managing their menses and indicated health, education and psychosocial well-being consequences of poor management.1–4”

Negative psychosocial outcomes may also result from a lack of knowledge and information about menstruation, cultural stigma and taboos, and transactional or coercive sex undertaken to meet MHM needs.

“They may also result from a lack of knowledge and information about menstruation,14 cultural stigma and taboos,4 and as a result of transactional or coercive sex undertaken to meet MHM needs.15”