Beyond menstrual hygiene: addressing vaginal bleeding throughout the life course in low and middle-income countries
Open accessAbstract
Girls and women experience numerous types of vaginal bleeding. These include healthy reproductive processes, such as menstruation and bleeding after childbirth, but also bleeding related to health conditions, such as fibroids or cancer. In most societies, the management of menstruation is handled covertly, something girls are often instructed about at menarche. The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented. In many societies, cultural taboos frequently hinder open discussion around vaginal bleeding, restricting information and early access to healthcare. Additionally, the limited availability of clean, accessible water and sanitation facilities in many low and middle-income countries augments the challenges girls and women face in conducting daily activities while managing vaginal bleeding, including participating in school or work, going to the market or fetching water. This paper aims to highlight the key vaginal bleeding experiences throughout a woman’s life course and the intersection of these bleeding experiences with their access to adequate water and sanitation facilities, information and education sources, and supplies. The aim is to address the silence around girls and women’s vaginal bleeding and their related social, physical and clinical management needs across the life course; and highlight critical gaps that require attention in research, practice and policy around this neglected topic of health and gender equality.
AI snapshot
Written from the paper’s full text.
TL;DR
This paper argues that vaginal bleeding across the life course—not only menstruation—is a neglected health and gender-equality issue in low- and middle-income countries, shaped by secrecy, inadequate information, and insufficient water and sanitation. It calls for life-course research, policy, and programming to address bleeding-related social, physical, and clinical management needs.
Key findings
- Vaginal bleeding includes healthy reproductive processes and conditions such as fibroids, endometriosis, miscarriage, postpartum bleeding, and cancers; cultural taboos and limited WASH facilities restrict information, daily activities, and early healthcare access.
- If menarche occurs around age 12 and menopause at 51–52, women may experience over 40 years of monthly bleeding—480 months and an estimated 2400 menstrual-related bleeding days for an average 5-day cycle.
- An estimated 5%–15% of women of reproductive age globally have abnormal uterine bleeding; one Nigerian study suggested 29% of women of reproductive age have fibroids, and a cross-sectional internet study of 21,476 women in eight high- and middle-income countries found 33% of women with fibroids experienced bleeding between periods versus 14% without.
- Over 2.4 billion people lack access to improved sanitation, and more than 800 million girls and women aged 15–49 are menstruating on any given day; in Niger only 44% of women and in Kaduna State, Nigeria only 37% report having everything needed to manage menstruation.
Methods
- No formal design, sample, or primary data collection is described; the paper presents a life-course conceptual review/commentary synthesizing existing literature and including a table of bleeding types from menarche to menopause.
- The text draws on published studies and reports to illustrate prevalence, management challenges, and policy gaps related to vaginal bleeding in low- and middle-income countries.
- No systematic search strategy or analytic method is stated in the paper.
Limitations
- Stated: there is a significant empirical gap in evidence on episodes of vaginal bleeding and related information and management needs of girls and women in LMICs; minimal prevalence data exist across LMICs, and there is almost no literature on management of non-menstrual vaginal bleeding in LMICs.
- Stated: there is a gap in empirical evidence on the impact of inadequate WASH in the workplace and on violence-related challenges facing those using communal or household WASH facilities.
- Evident: the paper does not describe a systematic review methodology, search strategy, or primary data collection, so its findings rely on synthesis of existing literature and illustrative statistics rather than new empirical analysis.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
0 of 51 cited sources checked · 0 supported · 0 flagged
- Premisecitation
In many societies, cultural taboos frequently hinder open discussion around vaginal bleeding, restricting information and early access to healthcare.
“In many societies, cultural taboos frequently hinder open discussion around vaginal bleeding, restricting information and early access to healthcare.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6] Geertz A , Iyer L , Kasen P , et al . An Opportunity to Address Menstrual Health and gender equity, 2016.
Not checked in the free run.
- Rests on an assumption: Cultural taboos and silence around menstruation extend to other vaginal bleeding experiences.
- Premisecitation
Limited availability of clean, accessible water and sanitation facilities in many low and middle-income countries augments the challenges girls and women face in conducting daily activities while managing vaginal bleeding, including participating in school or work, going to the market or fetching water.
“Additionally, the limited availability of clean, accessible water and sanitation facilities in many low and middle-income countries augments the challenges girls and women face in conducting daily activities while managing vaginal bleeding, including participating in school or work, going to the market or fetching water.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
- cites [5] Sommer, 2016, Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries, Int J Equity Health source
Not checked in the free run.
- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
- Premisecitation
For women living in low and middle-income countries, support and water, sanitation and hygiene services are particularly lacking.
“For women living in LMICs, support and WASH services are particularly lacking.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
- cites [5] Sommer, 2016, Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries, Int J Equity Health source
Not checked in the free run.
- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
- Premisecitation
Frequent or prolonged bleeds add to girls' and women's risk of anaemia, particularly for those who are nutritionally compromised or have comorbidities such as HIV.
“Physically, frequent or prolonged bleeds add to girls and women’s risk of anaemia, particularly for those who are nutritionally compromised, or having comorbidities such as HIV.24”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [24] Adamu, 2017, Prevalence and risk factors for Anemia severity and type in malawian men and women: urban and rural differences, Popul Health Metr source
Not checked in the free run.
- Premisecitation
In some contexts, cultural practices restrict access to water or comfortable environments to manage vaginal bleeding, such as in Nepal where menstruating and postpartum girls and women are confined to sleeping in a cowshed or hut.
“In some contexts, there may be cultural practices restricting access to water or comfortable environments to manage vaginal bleeding, such as in Nepal where menstruating and postpartum girls and women are confined to sleeping in a cowshed or hut.39”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [39] Robinson, 2015, Chaupadi: the affliction of menses in Nepal, Int J Womens Dermatol source
Not checked in the free run.
- Premisecitation
Girls across low and middle-income countries are frequently not informed about menarche prior to their first bleeding episode.
“Girls across LMIC are frequently not informed about menarche prior to their first bleeding episode,31”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [31] Chandra-Mouli, 2017, Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries, Reprod Health source
Not checked in the free run.
- Interpretationcitation
Although minimal prevalence data exist across low and middle-income countries, there are likely to be significant numbers of women who experience vaginal bleeding related to reproductive health conditions such as fibroids or endometriosis.
“Although minimal prevalence data exist across LMIC, there are likely to be significant numbers of women who experience vaginal bleeding related to reproductive health conditions, such as fibroids or endometriosis.”
Quote in the paperSubstantial claim- Rests on an assumption: The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented.
- Interpretationreasoning
A significant number of women and girls likely do not have access to a place to manage both light and heavy episodes of bleeding.
“suggesting that a significant number of women and girls likely do not have access to a place to manage both light and heavy episodes of bleeding.”
Quote in the paperSubstantial claim- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
- Premisecitation
In some cultures, menstruating girls and women are prohibited from touching water sources or using sanitation facilities given the association of menstruation with impurity.
“In some cultures, menstruating girls and women are prohibited from touching water sources or using sanitation facilities given the association of menstruation with impurity.40”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [40] source
Not checked in the free run.
- Rests on an assumption: Cultural taboos and silence around menstruation extend to other vaginal bleeding experiences.
- Interpretationcitation
Given declining age of puberty and menarche and decreasing fertility rates in many parts of the world, the number of years during which a girl or woman experiences monthly menstrual bleeding has expanded along with the number of episodes.
“Given the declining age of puberty (and menarche) and decreasing fertility rates in many parts of the world,8–10 the number of years during which a girl or woman will experience monthly menstrual bleeding has expanded along with the number of episodes.”
Quote in the paperNot a substantial claim0 of 3 sources checked - Premisecitation
All vaginal bleeding episodes potentially cause subjective experiences of fear, discomfort and anxiety.
“All vaginal bleeding episodes potentially cause subjective experiences of fear, discomfort and anxiety.21–23”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [21] Sommer M . Where the education system and women's bodies collide: The social and health impact of girls' experiences of menstruation and schooling in Tanzania. J Adolesc 2010;33.doi:10.1016/j.adolescence.2009.03.008 source
Not checked in the free run.
- cites [22] Mason, 2013, 'We keep it secret so no one should know'--a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya, PLoS One source
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- cites [23] source
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- Premisecitation
Recent studies in India highlighted the 'sanitation-related psychosocial stress' girls and women experience around their sanitation needs, including urination, defecation and menstruation.
“More specifically, recent studies in India highlighted the ‘sanitation-related psychosocial stress’ girls and women experience around their sanitation needs (ie, urination, defecation, menstruation).52 53”
Quote in the paperNot a substantial claim0 of 2 sources checked - Interpretationreasoning
There is a significant empirical gap in the evidence on episodes of vaginal bleeding and the related information and management needs of girls and women in low and middle-income countries.
“There is a significant empirical gap in the evidence on episodes of vaginal bleeding and the related information and management needs of girls and women in LMIC.”
Quote in the paperSubstantial claim- The authors state this as an assumption: The evidence to date on menstruation represents the 'tip of an iceberg' regarding vaginal bleeding experiences and needs.
- Classified as probably not a substantial claim. 13
- May combine two claims. 22
Probably not a substantial claim: may not pass S2 (checkable), S4 (based).
Premisenone givenGirls and women require water, sanitation, information, education and supplies to correctly manage the numerous types of vaginal bleeding they experience.
“Girls and women require water, sanitation, information, education and supplies to correctly manage the numerous types of vaginal bleeding they experience.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationThroughout the life course, girls and women experience numerous episodes of vaginal bleeding, many of which remain hidden due to misinformation, fear, embarrassment, shame and taboo.
“Throughout the life course, girls and women experience numerous episodes of vaginal bleeding, many of which remain hidden due to misinformation, fear, embarrassment, shame and taboo.6”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6] Geertz A , Iyer L , Kasen P , et al . An Opportunity to Address Menstrual Health and gender equity, 2016.
Not checked in the free run.
- Rests on an assumption: The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented.
May combine two claims.
InterpretationreasoningCultural, societal and financial constraints negatively impact girls' and women's ability to adequately manage vaginal bleeding and to differentiate when such bleeds require health intervention.
“Cultural, societal and financial constraints negatively impact girls and women’s ability to adequately manage vaginal bleeding, and to differentiate when such bleeds require health intervention.”
Quote in the paperSubstantial claim- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
Probably not a substantial claim: may not pass S4 (based). May combine two claims.
Premisenone givenGirls and women experience numerous types of vaginal bleeding, including healthy reproductive processes such as menstruation and bleeding after childbirth, and bleeding related to health conditions such as fibroids or cancer.
“Girls and women experience numerous types of vaginal bleeding. These include healthy reproductive processes, such as menstruation and bleeding after childbirth, but also bleeding related to health conditions, such as fibroids or cancer.”
Quote in the paperNot a substantial claim- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
Probably not a substantial claim: may not pass S4 (based).
Premisenone givenTo manage vaginal bleeding hygienically and with dignity requires adequate clean, safe, private, affordable and accessible water, sanitation and hygiene facilities, and supplies.
“To manage vaginal bleeding hygienically and with dignity requires adequate (clean, safe, private, affordable and accessible at any time) water, sanitation and hygiene (WASH) facilities, and supplies (ie, soap, sanitary products, basins).”
Quote in the paperNot a substantial claim- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
May combine two claims.
PremisecitationIn most societies, the management of menstruation is handled covertly, and girls are often instructed about it at menarche.
“In most societies, the management of menstruation is handled covertly, something girls are often instructed about at menarche.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
- cites [29] Sommer M . MHM in ten: advancing the MHM Agenda in WASH in Schools Second annual meeting. New York, NY 2015.
Not checked in the free run.
- cites [33] McMahon SA , Winch PJ , Caruso BA , et al . 'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya. BMC Int Health Hum Rights 2011;11.doi:10.1186/1472-698X-11-7 source
Not checked in the free run.
May combine two claims.
PremisecitationEpisodes of vaginal bleeding may occur prior to menarche, during perimenopause, and postmenopause due to illness conditions.
“Episodes of vaginal bleeding may occur prior to menarche,13 14 occur during perimenopause15 and may occur postmenopause due to illness conditions.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [13] Albers, 20041931, Abnormal Uterine Bleeding, American Family Physician
Not checked in the free run.
- cites [14] Hill, 1989, The aetiology of vaginal bleeding in children. A 20-year review, Br J Obstet Gynaecol source
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- cites [15] Bhakta, 2014
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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
InterpretationreasoningIf the average girl reaches menarche around age 12 and the average age of menopause is 51-52 years, that is over 40 years of monthly bleeding, about 480 months and an estimated 2400 menstrual-related bleeding days for an average cycle length of 5 days, with exceptions for disrupted menstruation due to stress, travel, nutrition, pregnancy and breastfeeding.
“If the average girl reaches menarche around age 12, and the average age of menopause is 51–52 years old, that is over 40 years of monthly bleeding (480 months, estimated 2400 menstrual-related bleeding days for average cycle length of 5 days), with exceptions for disrupted menstruation due to stress, travel, nutrition, pregnancy and breast feeding (although many pregnancies include spotting).”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationAlthough almost no literature exists on management of other episodes of vaginal bleeding in low and middle-income countries, there is growing evidence on menstruation-related barriers facing adolescent girls and female teachers in school environments.
“Although there exists almost no literature on management of other episodes of vaginal bleeding in LMIC, there is growing evidence on the menstruation-related barriers facing adolescent girls and female teachers in school environments.4”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationOne study from Nigeria suggested that 29% of women of reproductive age have fibroids.
“One study from Nigeria suggested that 29% of women of reproductive age have fibroids.16”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [16] Ekine, 2015, Review of the clinical presentation of uterine fibroid and the effect of therapeutic intervention on fertility, Am J Clin Med Res
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Premisenone givenThe majority of girls and women will experience monthly menstruation.
“The majority of girls and women will experience monthly menstruation.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationThe structural realities of girls' and women's lives in many low and middle-income countries create a gap in information through minimum media exposure to health messages, lack of accessible reproductive health clinics, low rates of secondary and tertiary education, lower access to internet and media compared with boys and men, and health clinic staff who may be insufficiently trained to conduct差分
“The structural realities of girls and women’s lives in many LMICs create a gap in information through, for example, minimum media exposure to health messages, the lack of accessible health clinics that are focused on reproductive health43; the low rates of secondary and tertiary education persisting in many countries,44 45 the lower access to internet and media that girls and women have in compar”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [43] Mayhew, 2016, Innovation in evaluating the impact of Integrated Service-Delivery: the Integra indexes of HIV and Reproductive Health integration, PLoS One source
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- cites [44] UNESCO. EFA global monitoring Report: education for all: the Quality imperative, 2004.
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- cites [48] Black, 2012, The burden of health associated with benign gynecological disorders in low-resource settings, Int J Gynaecol Obstet source
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Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationOn any given day, more than 800 million girls and women between the ages of 15 and 49 are menstruating.
“And, on any given day, more than 800 million girls and women between the ages of 15 and 49 are menstruating,35”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [35] Unilever Domestos W . WSSCC) WS & SCC. We Can’t Wait: A report on sanitation And hygiene for women and girls 2013.
Not checked in the free run.
May combine two claims.
PremisecitationGirls' and women's access to services may differ depending on their age, marital status, geographical location and economic status, along with prevailing gendered norms in the household influencing the seeking of care.
“Girls and women’s access to services may also differ depending on their age, marital status, geographical location and economic status, along with the prevailing gendered norms in the household influencing the seeking of care.49 50”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [49] source
Not checked in the free run.
- cites [50] Wado YD . Women’s autonomy and reproductive healthcare-seeking behavior in Ethiopia: DHS Work Pap, 2013.
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May combine two claims.
PremisecitationStudies have highlighted misconceptions and shame shrouding menstruation in many societies, and the fear and anxiety many girls experience at menarche and when menstruating at school.
“studies have highlighted the misconceptions and shame shrouding menstruation in many societies,4 29 30 32 and the fear and anxiety many girls experience at menarche and when menstruating at school.21”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
- cites [29] Sommer M . MHM in ten: advancing the MHM Agenda in WASH in Schools Second annual meeting. New York, NY 2015.
Not checked in the free run.
- cites [21] Sommer M . Where the education system and women's bodies collide: The social and health impact of girls' experiences of menstruation and schooling in Tanzania. J Adolesc 2010;33.doi:10.1016/j.adolescence.2009.03.008 source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationOver 2.4 billion people living around the world do not have access to improved sanitation.
“Yet, over 2.4 billion people living around the world do not have access to improved sanitation.7”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [7] House S , Mahon T , Cavill S . Menstrual hygiene matters: a resource for improving menstrual hygiene around the world. London: WaterAid, 2012.
Not checked in the free run.
May combine two claims.
PremisecitationAs life expectancies increase, women across low and middle-income countries are more likely to experience uterine or cervical cancers, both of which cause vaginal bleeding.
“As life expectancies increase, women across LMIC are more likely to experience uterine or cervical cancers,19 both of which cause vaginal bleeding.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [19] Phillips-Howard PA , Laserson KF , Amek N , et al . Deaths ascribed to Non-Communicable diseases among rural kenyan adults are proportionately increasing: evidence from a Health and Demographic Surveillance System, 2003–2010. Vol. 9, PLOS ONE. Public Library of Science 2014:e114010. source
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May combine two claims.
PremisecitationIn Niger, only 44% of women, and in Kaduna State, Nigeria, only 37% of women report having everything they need to manage their menstruation.
“For example, in Niger, only 44% of women,7 19–45 and in Kaduna State, Nigeria, only 37% of women report having everything they need to manage their menstruation.36”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [7] House S , Mahon T , Cavill S . Menstrual hygiene matters: a resource for improving menstrual hygiene around the world. London: WaterAid, 2012.
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- cites [36] Johns Hopkins Bloomberg School of Public Health. Managing Menstrual Hygiene: Niger, 2016 2016.
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May combine two claims.
PremisecitationA cross-sectional internet study among 21,476 women in eight high and middle-income countries found that 33% of women with fibroids experienced bleeding between periods compared with 14% of women without, and significantly greater proportions of women with fibroids reported heavy menstrual bleeding, prolonged menstrual bleeding, and more frequent and irregular menses.
“A cross-sectional internet study among 21 476 women in eight high and middle-income countries found that 33% of women with fibroids experienced bleeding between periods compared with 14% of women without, and significantly greater proportions of women with fibroids reported heavy menstrual bleeding, prolonged menstrual bleeding, and more frequent and irregular menses as compared with their Counter”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [17] Zimmermann, 2012, Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women, BMC Womens Health source
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May combine two claims.
InterpretationcitationConcomitant weakness, fatigue and other symptoms may affect girls' and women's ability to complete the heavy burden of chores, a challenge compounded by insufficient access to safe, private and clean water, sanitation and hygiene facilities, disposal mechanisms, private spaces for washing and drying reusable soiled materials, and lack of adequate information and support.
“Concomitant weakness, fatigue and other symptoms may affect their ability to complete the heavy burden of chores,25 a challenge compounded by insufficient access to safe, private and clean WASH facilities, and mechanisms for disposal of bloody absorbent materials, or private spaces for washing and drying reusable soiled materials, as well as a lack of adequate information and support.4”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [25] Oruko, 2015, 'He is the one who is providing you with everything so whatever he says is what you do': A Qualitative Study on Factors Affecting Secondary Schoolgirls? Dropout in Rural Western Kenya, PLoS One source
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- cites [4] Sommer, 2016, A Time for Global Action: addressing girls' Menstrual Hygiene Management needs in Schools, PLoS Med source
Not checked in the free run.
- Rests on an assumption: Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationIt is estimated that 5%-15% of women of reproductive age globally have abnormal uterine bleeding.
“In addition, it is estimated that 5%–15% of women of reproductive age globally have abnormal uterine bleeding.12”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [12] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationCervical cancer, caused by certain strains of human papilloma virus, is the most common form of cancer currently reported among women in sub-Saharan Africa, with 34,000 out of 100,000 diagnosed each year, and limited screening suggests underdiagnoses.
“Cervical cancer, caused by certain strains of human papilloma virus (HPV), is the most common form of cancer currently reported among women in sub-Saharan Africa, with 34 000 out of 100 000 diagnosed each year (and limited screening suggests underdiagnoses).20”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [20] Barango P , Couillard C . Cervical cancer common amongst african women, 2015.
Not checked in the free run.
May combine two claims.
PremisecitationThere exists a gap in empirical evidence on the impact of inadequate water, sanitation and hygiene in the workplace for girls and women experiencing vaginal bleeding, and on the violence-related challenges facing those using communal and even household water, sanitation and hygiene facilities when using outside toilets at night or going for open defecation.
“There also exists a gap in empirical evidence on the impact of inadequate WASH in the workplace for girls and women experiencing vaginal bleeding,5 and on the violence-related challenges facing those using communal (and even household) WASH facilities when using outside toilets at night, or going for open defecation.37 38”
Quote in the paperSubstantial claim0 of 3 sources checked- cites [5] Sommer, 2016, Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries, Int J Equity Health source
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- cites [37] Jadhav, 2016, Household sanitation facilities and women's risk of non-partner sexual violence in India, BMC Public Health source
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- cites [38] source
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May combine two claims.
PremisecitationWomen are likely to experience episodes of bleeding for 4-6 weeks after a miscarriage and 4 weeks postpartum.
“Women are likely to experience episodes of bleeding for 4–6 weeks after a miscarriage and 4 weeks postpartum.11”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [11] source
Not checked in the free run.
Probably not a substantial claim: may not pass S4 (based). May combine two claims.
InterpretationreasoningThis silence hinders attention to the significant information and water, sanitation and hygiene-related needs that girls and women face to manage bleeding, and may hinder the seeking out of healthcare as needed.
“This silence hinders attention to the significant information, and WASH-related needs that they face to manage bleeding, and may hinder the seeking out of healthcare as needed.”
Quote in the paperNot a substantial claim- The authors state this as an assumption: The evidence to date on menstruation represents the 'tip of an iceberg' regarding vaginal bleeding experiences and needs.
Probably not a substantial claim: may not pass S4 (based).
Premisenone givenDespite international development priorities having targeted adolescence and reproductive health related to childbearing, there is a marked silence around vaginal bleeding that girls and women experience over 40-50 years of the life course.
“Though international development priorities have, to some extent, targeted adolescence and reproductive health related to childbearing, there is a marked silence around vaginal bleeding that girls and women experience over 40–50 years of the life course.”
Quote in the paperNot a substantial claim- The authors state this as an assumption: The evidence to date on menstruation represents the 'tip of an iceberg' regarding vaginal bleeding experiences and needs.
Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.
InterpretationreasoningIt is likely that many girls in low-income contexts are inadequately informed about irregular monthly bleeding, or that women feel inadequately informed about how to manage heavy bleeding and discomfort from fibroids or endometriosis.
“For example, it is likely that many girls in low-income contexts are inadequately informed about irregular monthly bleeding, or that women feel inadequately informed about how to manage heavy bleeding and discomfort from fibroids or endometriosis.”
Quote in the paperNot a substantial claim- Rests on an assumption: The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented.
May combine two claims.
PremisecitationWhile episodes of vaginal bleeding beyond menstruation are not noted, menstruation-related behaviours were considered the most stressful for women.
“While episodes of vaginal bleeding beyond menstruation are not noted, menstruation-related behaviours were considered the most stressful for women.52”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [52] source
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May combine two claims.
PremisecitationGirls and women may fear disclosing new bleeding from a misconception that they would be punished, as found with girls in Ethiopia, Ghana and other countries, or fear disclosing irregular menstruation out of concern they will be perceived as infertile and unmarriageable.
“They may fear disclosing new bleeding from a misconception that they would be punished, as has been found with girls in Ethiopia, Ghana and other countries; or fear disclosing irregular menstruation out of concern they will be perceived as infertile and unmarriageable.51”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [51] Sommer, 2014, A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia, Comp A J Comp Int Educ [Internet]
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May combine two claims.
InterpretationcitationGiven that the density of obstetricians across low-income countries ranges from 0.042 to 12.5 per 100,000, with many healthcare workers who may not have quality training in reproductive health conditions and illnesses, girls and women may struggle to access healthcare to understand what is happening in their bodies, receive treatment for their conditions, and openly discuss an increased need forhy
“Given the density of obstetricians across low-income countries ranges from 0.042 to 12.5 per 100 000,54 with many healthcare workers who may not have quality training in reproductive health conditions and illnesses, girls and women may struggle to access healthcare to understand what is happening in their bodies and to receive treatment for their conditions, and to openly discuss an increased need”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [54] source
Not checked in the free run.
The paper relies on this without support.
The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented.
“The management of other vaginal bleeding is often similarly discreet, although behaviours are not well documented.”
The authors state this as an assumption.
The evidence to date on menstruation represents the 'tip of an iceberg' regarding vaginal bleeding experiences and needs.
“this paper hypothesises that the evidence to date represents the ‘tip of an iceberg.’”
The paper relies on this without support.
Cultural taboos and silence around menstruation extend to other vaginal bleeding experiences.
“This may have implications for the ability to hygienically manage other vaginal bleeding.”
The paper relies on this without support.
Women and girls in low and middle-income countries have similar needs for information, supplies, water and sanitation across all vaginal bleeding episodes.
“A life course approach is required, one that looks at vaginal bleeding including and beyond menstruation, to comprehensively address the critical needs of girls and women for information, supplies, water and sanitation in LMICs.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
With the principal focus of MHM research centered on adolescent girls in school settings, considerably less attention has been given to women's experience of MHM at other life stages.
“With the principal focus of MHM research centered on adolescent girls in school settings, considerably less attention has been given to women’s experience of MHM at other life stages, outside of a few key papers that focus on menstruation in the workplace and in emergency contexts, along with other types of vaginal bleeding [38–43].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [38]
Outside of a few key papers that highlight the menstrual experiences of women in the workplace, emergency context, or vaginal bleeding throughout the life course, experiences of menstruation among adult women and outside of school settings remains underexplored.
“Outside of a few key papers that highlight the menstrual experiences of women in the workplace, emergency context, or vaginal bleeding throughout the life course, experiences of menstruation among adult women and outside of school settings remains underexplored [38, 39, 43, 70].”
From ’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India. (2019) · cites this paper as [38]
The inability of women to freely talk about menstruation within their communities suggests that there are still taboos associated with menstruation.
“The inability of women to freely talk about menstruation within their communities suggests that there are still taboos associated with menstruation [40].”
From Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal (2018) · cites this paper as [40]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Survey sample size differs from its cited reference
MinorThe text describes a survey of 21 476 women, but the title of the cited survey reports 21,746 women.
“A cross-sectional internet study among 21 476 women in eight high and middle-income countries”
“Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women.”
Conflicting durations of bleeding after miscarriage
MinorThe text says women are likely to bleed for 4-6 weeks after a miscarriage, while the table gives up to 2 weeks as the normal duration of post-miscarriage spotting.
“Women are likely to experience episodes of bleeding for 4–6 weeks after a miscarriage and 4 weeks postpartum.”
“Can spot for up to 2 weeks after miscarriage; can result in haemorrhage”
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“The inability of women to freely talk about menstruation within their communities suggests that there are still taboos associated with menstruation [40].”
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Self-citationJahan, I., Hossain, M., & Paul, S. (2026) · Cureus · doi:10.7759/cureus.112998
Manoshi, D., Ashok, H. S., & War, R. J. (2026) · Journal of Psychosexual Health · doi:10.1177/26318318261474612
Adelia, H., Nur’aini, N., Betriana, F., Rizona, F., & Soriano, G. P. (2026) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph23091229
- Authors
- Sommer, M., Phillips-Howard, P. A., Mahon, T., Zients, S., Jones, M., & Caruso, B. A.
- Affiliations
- Columbia University (US)
- Liverpool School of Tropical Medicine, Liverpool, UK
- WaterAid, London, UK
- Emory University (US)
- Corresponding author
- Sommer, Marni
- Venue
- BMJ Global Health
- Publisher
- BMJ
- Published
- 2017-07
- Volume
- 2
- Issue
- 2
- Pages
- e000405
- ISSN
- 2059-7908 (ISSN-L)
- PMC
- PMC5717954
- OpenAlex
- W2739829725
- Cited by
- 54
- References
- 44
- Citations by year
- 2026: 6 · 2025: 9 · 2024: 8 · 2023: 6 · 2022: 5 · 2021: 7 · 2020: 5 · 2019: 5 · 2018: 3
- FWCI
- 0.58
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ Global Health (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- LSTM Online Archive (Liverpool School of Tropical Medicine) (acceptedVersion)
- Funders
- Medical Research Council (MR/N006046/1)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- vaginal bleeding, menstrual hygiene, menstruation, postpartum hemorrhage, uterine fibroids, gynecologic cancer, cultural taboos, water and sanitation, life course, gender equality, health care access, low- and middle-income countries
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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