Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

In the paper

“Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience.”

In the paper

“Studies captured the experiences of over 6,000 participants from 35 countries.”

• Also stated in: § Results · plain

  “Included studies captured experiences from 35 countries and over 6,000 participants.”

In the paper

“This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia.”

• Also stated in: § Results · plain

  “Using World Bank regional groupings [24], most studies were conducted in sub-Saharan Africa (n = 45); this was followed by 21 studies undertaken in South Asia, 8 in East Asia and the Pacific, 5 in Latin America and the Caribbean, 5 in the Middle East and North Africa, and 1 study from Europe and Central Asia (Kyrgyzstan).”

What the sources say

• Not checked yetcites [24] 2017, World Bank Country and Lending Groups

In the paper

“and shame and distress at the potential of having menses exposed”

In the paper

“Others did not address the impacts of menstruation on such outcomes, exploring only the experience itself.”

In the paper

“Focus Group Discussions (FGDs) were the most common data collection method used, particularly when working with adolescent girls.”

In the paper

“Studies focused on stigma, knowledge, and social support as antecedents of experience.”

In the paper

“These studies were often those using individual interviews or engaging adult women to provide reflexive insights into their experiences.”

In the paper

“Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness.”

• Also stated in: § Results · plain

  “Study quality was varied, with 18 studies rated as high, 35 as medium, and 23 as low trustworthiness.”

In the paper

“Menstrual stigma was a pervasive influence on women and girls.”

In the paper

“We found that studies varied along a continuum in the extent to which they approached menstrual experiences as a result of the sociocultural context, particularly menstrual stigma, or focused on resource deficits in the environment.”

In the paper

“Menstrual experiences were characterised by shame and a lack of confidence to engage socially when menstruating.”

In the paper

“Other studies were orientated towards poverty and resource limitations as causes of menstrual experiences and impacts.”

In the paper

“Negative attitudes to menstruation were internalised”

In the paper

“Where resource limitations were discussed in these studies, they were considered problematic because they failed to support socially proscribed discretion.”

In the paper

“It meant that menstrual topics were not openly discussed”

In the paper

“Across cultures, menstruation was stigmatised”

In the paper

“Sampling and analysis tended to be untrustworthy in lower-quality studies.”

In the paper

“This included an emphasis on menstrual hygiene practices such as the use of materials poorly suited to absorbing menses.”

In the paper

“Studies with a more stigma-centric orientation conceptualised menstrual experiences and negative outcomes as resulting from the stigmatised and gendered nature of menstruation.”

In the paper

“and shrouded in silence”

In the paper

“After initial analysis of high- and medium-quality studies, analysis and integration of lower-quality studies did not elicit any new themes nor changes to the integrated model.”

In the paper

“Menstrual hygiene, the hygienic and effective management of menstrual blood, lay at the centre of experience in these studies”

In the paper

“Restrictive gender norms also underlay the knowledge, behavioural expectations, and social support that influenced experiences of menstruation.”

In the paper

“Themes centred around the pressure to suppress evidence of menses and control the body.”

In the paper

“manifested across multiple themes represented in the model, including as self-imposed expectations to keep menstrual status hidden”

In the paper

“constructed as something that was ‘dirty’ or ‘impure’”

In the paper

“interacting with more immediate contributors to menstrual experience”

In the paper

“All studies reported an influence of knowledge about menstruation on women’s and girls’ experiences.”

In the paper

“In contrast, girls who had received information before menarche described more positive experiences.”

In the paper

“Knowledge deficits varied in content.”

In the paper

“or whether it was needed to rid the body of ‘dirty blood’”

What the sources say

• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [14] S Garg, 2001, Socio-cultural aspects of menstruation in an urban slum in Delhi, India, Reproductive Health Matters source
• Not checked yetcites [34] A Al-Sabir, 1998, Hygiene practices during menstruation: women’s beliefs and restrictions
• Not checked yetcites [71] MA Morowatisharifabad, 2018, Cultural beliefs on menstrual health in Bam city: a qualitative study, International Journal of Pediatrics
• Not checked yetcites [72] J Morrison, 2016, Menstrual hygiene management in Udaypur and Sindhuli districts of Nepal
• Not checked yetcites [77] M Nechitilo, 2016, Menstrual Hygiene Management Impacts Girls’ School Experience in Kyrgyzstan
• Not checked yetcites [84] F Scorgie, 2016, "Bitten By Shyness": Menstrual Hygiene Management, Sanitation, and the Quest for Privacy in South Africa, Med Anthropol source

In the paper

“Many authors stated that most of their study population had deficits in knowledge of menstrual biology”

What the sources say

• Not checked yetcites [37] D Behera, 2015, Menarche and Menstruation in Rural Adolescent Girls in Maharashtra, India, Journal of Health Management source
• Not checked yetcites [44] J Chinyama, 2019, Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls, BMC Public Health source
• Not checked yetcites [47] M Crawford, 2014, 'This is a natural process': managing menstrual stigma in Nepal, Cult Health Sex source
• Not checked yetcites [55] MC do Amaral, 2011, Menarche among Brazilian women: memories of experiences, Midwifery source
• Not checked yetcites [57] J Haver, 2013, WASH in Schools Empowers Girls’ Education in Masbate Province and Metro Manila, Philippines: An assessment of menstrual hygiene management in schools
• Not checked yetcites [68] AM Lahme, 2016, Factors impacting on menstrual hygiene and their implications for health promotion, Global Health Promotion source
• Not checked yetcites [69] AM Lahme, 2017, Factors That Affect Menstrual Hygiene Among Adolescent Schoolgirls: A Case Study From Mongu District, Zambia, Women’s Reproductive Health source
• Not checked yetcites [71] MA Morowatisharifabad, 2018, Cultural beliefs on menstrual health in Bam city: a qualitative study, International Journal of Pediatrics
• Not checked yetcites [73] Z Mumtaz, 2016, Formative Menstrual Hygiene Management Research: Adolescent Girls in Baluchistan
• Not checked yetcites [77] M Nechitilo, 2016, Menstrual Hygiene Management Impacts Girls’ School Experience in Kyrgyzstan

In the paper

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

What the sources say

• Not checked yetcites [3] M Sommer, 2009, Ideologies of sexuality, menstruation and risk: girls’ experiences of puberty and schooling in northern Tanzania, Cult Health Sex source
• Not checked yetcites [8] M Sommer, 2010, 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 source
• Not checked yetcites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools
• Not checked yetcites [57] J Haver, 2013, WASH in Schools Empowers Girls’ Education in Masbate Province and Metro Manila, Philippines: An assessment of menstrual hygiene management in schools
• Not checked yetcites [72] J Morrison, 2016, Menstrual hygiene management in Udaypur and Sindhuli districts of Nepal
• Not checked yetcites [73] Z Mumtaz, 2016, Formative Menstrual Hygiene Management Research: Adolescent Girls in Baluchistan
• Not checked yetcites [83] ML Schmitt, 2017, Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon, Confl Health source
• Not checked yetcites [88] M Sommer, 2014, A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia, Compare: A Journal of Comparative and International Education source
• Not checked yetcites [89] D Smiles, 2017, “I Didn’t Tell Anyone Because I Was Very Afraid”: Girls’ Experiences of Menstruation in Contemporary Ethiopia, Women’s Reproductive Health source
• Not checked yetcites [93] TK Tegegne, 2014, Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia, BMC Public Health source

In the paper

“Where investigated, women and girls also lacked clarity on what constituted normal and abnormal (i.e., disordered) menstruation”

What the sources say

• Not checked yetcites [47] M Crawford, 2014, 'This is a natural process': managing menstrual stigma in Nepal, Cult Health Sex source
• Not checked yetcites [73] Z Mumtaz, 2016, Formative Menstrual Hygiene Management Research: Adolescent Girls in Baluchistan
• Not checked yetcites [85] M Secor-Turner, 2016, Adolescent Experience of Menstruation in Rural Kenya, Nurs Res source
• Not checked yetcites [105] DK Hemachandra, 2009, Menstrual problems and health seeking in Sri Lanka, Women Health source
• Not checked yetcites [109] LP Wong, 2011, Premenstrual syndrome and dysmenorrhea: urban-rural and multiethnic differences in perception, impacts, and treatment seeking, J Pediatr Adolesc Gynecol source

In the paper

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

What the sources say

• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [32] A Adegbayi, 2017, Blood, joy and tears: menarche narratives of undergraduate females in a selected in Nigeria Private University, Int J Adolesc Med Health source
• Not checked yetcites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools
• Not checked yetcites [58] C Girod, 2017, Physical, Social, and Political Inequities Constraining Girls’ Menstrual Management at Schools in Informal Settlements of Nairobi, Kenya, J Urban Health source
• Not checked yetcites [59] E Guerry, 2013, An Assessment of Menstrual Hygiene Practices and Absenteeism in Western Uganda
• Not checked yetcites [64] S Jewitt, 2014, It’s a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya, Geoforum source
• Not checked yetcites [77] M Nechitilo, 2016, Menstrual Hygiene Management Impacts Girls’ School Experience in Kyrgyzstan
• Not checked yetcites [84] F Scorgie, 2016, "Bitten By Shyness": Menstrual Hygiene Management, Sanitation, and the Quest for Privacy in South Africa, Med Anthropol source
• Not checked yetcites [88] M Sommer, 2014, A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia, Compare: A Journal of Comparative and International Education source

In the paper

“At menarche, many girls were told they were now fertile and to avoid males”

In the paper

“In some studies, younger girls were unaware of their reproductive organs and that menstrual bleeding originated from this system, rather than elsewhere such as the digestive tract”

What the sources say

• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools

In the paper

“Even when aware of menstruation, participants often had insufficient information to understand the relationship between menstruation and reproduction.”

In the paper

“In some studies, knowledge was more varied, with those who had attended secondary education or schools with more comprehensive reproductive health education having adequate knowledge”

What the sources say

• Not checked yetcites [62] 2017, The Last Taboo: Research on menstrual hygiene management in the Pacific
• Not checked yetcites [63] Y Mohamed, 2018, A qualitative exploration of menstruation-related restrictive practices in Fiji, Solomon Islands and Papua New Guinea, PLoS ONE source
• Not checked yetcites [64] S Jewitt, 2014, It’s a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya, Geoforum source
• Not checked yetcites [83] ML Schmitt, 2017, Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon, Confl Health source

In the paper

“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].”

What the sources say

• Not checked yetcites [89] D Smiles, 2017, “I Didn’t Tell Anyone Because I Was Very Afraid”: Girls’ Experiences of Menstruation in Contemporary Ethiopia, Women’s Reproductive Health source
• Not checked yetcites [100] LL Wall, 2018, Tending the ‘monthly flower:’ a qualitative study of menstrual beliefs in Tigray, Ethiopia, BMC Women’s Health
• Not checked yetcites [88] M Sommer, 2014, A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia, Compare: A Journal of Comparative and International Education source
• Not checked yetcites [95] V Trinies, 2015, Uncovering the challenges to menstrual hygiene management in schools in Mali, Waterlines source

In the paper

“Beliefs about the impurity or power of menstrual blood influenced management practices.”

In the paper

“while others were uncomfortable or punitive if girls soiled themselves at school”

In the paper

“In studies of those with dysmenorrhea or menstrual disorders, some participants were embarrassed to seek help.”

In the paper

“Other behavioural expectations stemmed from beliefs that different foods or activities would negatively impact women’s and girls’ health during menstruation.”

In the paper

“In many settings, mothers served as the primary support and source of information for girls”

In the paper

“Teasing or harassment by female, but especially male, peers was highly distressing for adolescent girls.”

In the paper

“Social support, or lack thereof, strongly dictated menstrual experiences.”

In the paper

“Across studies, menstrual experience was impacted by internally and externally enforced behavioural expectations, i.e., expectations women and girls placed on themselves or those enforced by others.”

In the paper

“In Zambia, Lahme and colleagues reported that participants experienced a single instance of seclusion during their first period that many girls found embarrassing and distressing”

What the sources say

• Not checked yetcites [68] AM Lahme, 2016, Factors impacting on menstrual hygiene and their implications for health promotion, Global Health Promotion source

In the paper

“However, individuals’ access to support sources often varied more according to personal circumstances than country.”

In the paper

“Explicit cultural restrictions varied across and within countries according to region, religion, caste, and individual family expectations.”

In the paper

“Teachers provided mixed support to girls during menstruation.”

In the paper

“Others reported pursuing multiple avenues such as doctors and herbalists or community healers in attempts to receive effective treatment for their pain”

What the sources say

• Not checked yetcites [103] L Aziato, 2015, Dysmenorrhea Management and Coping among Students in Ghana: A Qualitative Exploration, J Pediatr Adolesc Gynecol source
• Not checked yetcites [104] L Aziato, 2014, The experience of dysmenorrhoea among Ghanaian senior high and university students: pain characteristics and effects, Reproductive Health source
• Not checked yetcites [105] DK Hemachandra, 2009, Menstrual problems and health seeking in Sri Lanka, Women Health source
• Not checked yetcites [109] LP Wong, 2011, Premenstrual syndrome and dysmenorrhea: urban-rural and multiethnic differences in perception, impacts, and treatment seeking, J Pediatr Adolesc Gynecol source

In the paper

“Girls in many studies sought clarity on the accuracy of taboos such as appropriate foods or practices during menstruation.”

In the paper

“Parents, siblings, peers, partners, and teachers were sources of information, resources, comfort, or assistance to accomplish menstrual tasks.”

In the paper

“Family members enforcement of behavioural expectations such as religious or culturally proscribed menstrual restrictions greatly influenced the extent to which these were adhered to and thus women’s and girls’ menstrual experience.”

In the paper

“Manifestation of mother–daughter communication was context dependent.”

In the paper

“Less explicit taboos such as expectations of cleanliness, female propriety, and secrecy around menstruation were ‘enforced by adults in the community through signals and gestures’”

What the sources say

• Not checked yetcites [33] O Al Omari, 2016, Experience of Menarche Among Jordanian Adolescent Girls: An Interpretive Phenomenological Analysis, J Pediatr Adolesc Gynecol source

In the paper

“In the most severe cases, subpopulations in Nepal practiced Chhaupadi, ritual seclusion from the community and home during menstruation”

What the sources say

• Not checked yetcites [36] P Amatya, 2018, Practice and lived experience of menstrual exiles (Chhaupadi) among adolescent girls in far-western Nepal, PLoS ONE source
• Not checked yetcites [101] 2009, A comparative study of four schools in different settings in Nepal

In the paper

“as well as individuals’ perceptions of their practices”

In the paper

“Practical knowledge about menstruation influenced the practices undertaken”

In the paper

“So too did the extent to which such restrictions directly impacted women’s and girls’ social participation.”

In the paper

“In many settings, menstrual blood—and by extension, menstruating women—were considered ritually impure or polluting”

What the sources say

• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [14] S Garg, 2001, Socio-cultural aspects of menstruation in an urban slum in Delhi, India, Reproductive Health Matters source
• Not checked yetcites [16] BA Caruso, 2017, Understanding and defining sanitation insecurity: women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India, BMJ Glob Health source
• Not checked yetcites [34] A Al-Sabir, 1998, Hygiene practices during menstruation: women’s beliefs and restrictions
• Not checked yetcites [37] D Behera, 2015, Menarche and Menstruation in Rural Adolescent Girls in Maharashtra, India, Journal of Health Management source
• Not checked yetcites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools
• Not checked yetcites [43] SJ Chebii, 2018, Menstrual Issues: How Adolescent Schoolgirls in the Kibera Slums of Kenya Negotiate their Experiences with Menstruation, Women’s Reproductive Health source
• Not checked yetcites [47] M Crawford, 2014, 'This is a natural process': managing menstrual stigma in Nepal, Cult Health Sex source
• Not checked yetcites [60] AS Seyed Hosseini, 2018, Unpreparedness, impurity and paradoxical feeling: Menstruation narratives of Iranian women, International Journal of Adolescent Medicine and Health
• Not checked yetcites [62] 2017, The Last Taboo: Research on menstrual hygiene management in the Pacific

In the paper

“Expectations were enforced by others, such as teachers or family, through instruction, discipline, or teasing.”

In the paper

“Some were sensitive to girls’ needs and provided information or support such as emergency supplies”

In the paper

“with a lack of clarity around what was required for ‘hygiene’ causing concern”

In the paper

“Several studies noted distress resulting from conflicting advice from different sources (e.g., parents, teachers, nongovernmental organisations [NGOs])”

What the sources say

• Not checked yetcites [3] M Sommer, 2009, Ideologies of sexuality, menstruation and risk: girls’ experiences of puberty and schooling in northern Tanzania, Cult Health Sex source
• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [44] J Chinyama, 2019, Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls, BMC Public Health source
• Not checked yetcites [71] MA Morowatisharifabad, 2018, Cultural beliefs on menstrual health in Bam city: a qualitative study, International Journal of Pediatrics
• Not checked yetcites [73] Z Mumtaz, 2016, Formative Menstrual Hygiene Management Research: Adolescent Girls in Baluchistan

In the paper

“Characteristics of the infrastructure such as the distance to or availability of soap and water, as well as the presence of locks or lights, influenced the menstrual practices that could safely be undertaken.”

In the paper

“Reading across studies, authors consistently noted improved confidence to manage menstruation when participants had access to preferred materials and environments, greater knowledge, and access to social support [10, 15, 34, 38, 41, 51, 56, 58, 64, 70, 72, 75, 79, 84, 95, 103, 104].”

What the sources say

• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source
• Not checked yetcites [34] A Al-Sabir, 1998, Hygiene practices during menstruation: women’s beliefs and restrictions

In the paper

“Women and girls reported genital discomfort, irritation, rashes, and bruising during menses stemming from the properties of menstrual materials or inadequate frequency of change [9–11, 15, 37, 41, 44, 51, 56, 57, 68, 69, 72, 75].”

What the sources say

• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [11] L 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
• Not checked yetcites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source
• Not checked yetcites [37] D Behera, 2015, Menarche and Menstruation in Rural Adolescent Girls in Maharashtra, India, Journal of Health Management source

In the paper

“In some studies, authors noted that participants, typically a small minority, expressed a positive sentiment regarding their menstruation as affirmation of their womanhood and fertility [5, 8, 32, 43, 47, 51, 52, 55, 60, 71, 78, 85, 109].”

What the sources say

• Not checked yetcites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source
• Not checked yetcites [8] M Sommer, 2010, 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 source
• Not checked yetcites [32] A Adegbayi, 2017, Blood, joy and tears: menarche narratives of undergraduate females in a selected in Nigeria Private University, Int J Adolesc Med Health source

In the paper

“The availability of a bin or incinerators or community waste disposal or the use of pit latrines influenced disposal choices.”

In the paper

“Adolescent girls in poor households noted that requesting money for menstrual needs could cause friction in the household [10, 11].”

What the sources say

• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [11] L 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

In the paper

“Participants expressed fear of judgement from others should they fail to comply.”

In the paper

“Across settings and studies, menstruation was overwhelmingly associated with feelings of shame and distress.”

In the paper

“Girls regularly undertook paid employment to generate funds.”

In the paper

“In 3 studies, authors reported myths that pharmaceutical pain relief would result in health detriments or infertility [62, 70, 79].”

What the sources say

• Not checked yetcites [62] 2017, The Last Taboo: Research on menstrual hygiene management in the Pacific
• Not checked yetcites [70] G Miiro, 2018, Menstrual health and school absenteeism among adolescent girls in Uganda (MENISCUS): a feasibility study, BMC Womens Health source
• Not checked yetcites [79] SP Pillitteri, 2011, School menstrual hygiene management in Malawi: More than toilets

In the paper

“Two studies undertaken in a cold climates found that latrines were too cold to be used during winter months [35, 77].”

What the sources say

• Not checked yetcites [35] SH Al-Shurbji, 2017, Pain beyond Period
• Not checked yetcites [77] M Nechitilo, 2016, Menstrual Hygiene Management Impacts Girls’ School Experience in Kyrgyzstan

In the paper

“Studies with greater interpretive depth noted that a lack of confidence to manage menses influenced how women and girls perceived themselves and their bodies, internalising a sense that ‘their bodies are beyond their control’ [5, 16, 47].”

What the sources say

• Not checked yetcites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source
• Not checked yetcites [16] BA Caruso, 2017, Understanding and defining sanitation insecurity: women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India, BMJ Glob Health source
• Not checked yetcites [47] M Crawford, 2014, 'This is a natural process': managing menstrual stigma in Nepal, Cult Health Sex source

In the paper

“In most studies, some participants reported experiences of intense distress recalling incidents when menstrual status was revealed.”

In the paper

“In humanitarian contexts, changed access to materials was salient in women’s experiences as they adapted to new management practices or were unable continue their past preferred behaviours [40, 83].”

What the sources say

• Not checked yetcites [40] SS Budhathoki, 2018, Menstrual hygiene management among women and adolescent girls in the aftermath of the earthquake in Nepal, BMC Womens Health source
• Not checked yetcites [83] ML Schmitt, 2017, Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon, Confl Health source

In the paper

“Participants reported fears of infertility or cancer resulting from unhygienic menstrual management [11, 44, 97].”

What the sources say

• Not checked yetcites [11] L 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
• Not checked yetcites [44] J Chinyama, 2019, Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls, BMC Public Health source
• Not checked yetcites [97] OUJ Umeora, 2008, Menstruation in rural Igbo women of South East Nigeria: attitudes, beliefs and practices, African Journal of Reproductive Health

In the paper

“Stock shortages and inflated pricing of menstrual products due to remote locations, retailer mark-up, and taxes were noted in some studies [5, 62, 63, 104].”

What the sources say

• Not checked yetcites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source
• Not checked yetcites [62] 2017, The Last Taboo: Research on menstrual hygiene management in the Pacific
• Not checked yetcites [63] Y Mohamed, 2018, A qualitative exploration of menstruation-related restrictive practices in Fiji, Solomon Islands and Papua New Guinea, PLoS ONE source

In the paper

“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].”

What the sources say

• Not checked yetcites [88] M Sommer, 2014, A comparison of the menstruation and education experiences of girls in Tanzania, Ghana, Cambodia and Ethiopia, Compare: A Journal of Comparative and International Education source
• Not checked yetcites [89] D Smiles, 2017, “I Didn’t Tell Anyone Because I Was Very Afraid”: Girls’ Experiences of Menstruation in Contemporary Ethiopia, Women’s Reproductive Health source
• Not checked yetcites [100] LL Wall, 2018, Tending the ‘monthly flower:’ a qualitative study of menstrual beliefs in Tigray, Ethiopia, BMC Women’s Health

In the paper

“Wet seasons and weather presented challenges for thoroughly and discretely drying reusable menstrual materials [16, 79].”

What the sources say

• Not checked yetcites [16] BA Caruso, 2017, Understanding and defining sanitation insecurity: women’s gendered experiences of urination, defecation and menstruation in rural Odisha, India, BMJ Glob Health source
• Not checked yetcites [79] SP Pillitteri, 2011, School menstrual hygiene management in Malawi: More than toilets

In the paper

“Similarly, in humanitarian contexts, participants expressed that material provision was inconsistent [15, 35, 83].”

What the sources say

• Not checked yetcites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source
• Not checked yetcites [35] SH Al-Shurbji, 2017, Pain beyond Period
• Not checked yetcites [83] ML Schmitt, 2017, Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon, Confl Health source

In the paper

“Physical symptoms during menstruation—particularly menstrual pain such as cramping of the abdomen, back, and legs—was a prominent part of women’s and girls’ experiences.”

In the paper

“Some studies linked social exclusion, restriction of travel, and infrastructure deficits to impacts on formal or informal employment [39, 62, 63, 98].”

What the sources say

• Not checked yetcites [39] R Boosey, 2014, Menstrual hygiene management amongst schoolgirls in the Rukungiri district of Uganda and the impact on their education: a cross-sectional study, Pan Afr Med J source
• Not checked yetcites [62] 2017, The Last Taboo: Research on menstrual hygiene management in the Pacific
• Not checked yetcites [63] Y Mohamed, 2018, A qualitative exploration of menstruation-related restrictive practices in Fiji, Solomon Islands and Papua New Guinea, PLoS ONE source

In the paper

“In addition, confidence to manage menstrual bleeding and to undertake other activities during menses, as well as experiences of shame and fear, were salient contributors to psychological, social, and educational outcomes.”

In the paper

“Some studies reported that teachers would send girls home from school, or punish them, if they detected odour or soiled outer garments, directly linking enforced behavioural expectations to education [41, 43, 81].”

What the sources say

• Not checked yetcites [41] BA Caruso, 2013, WASH in Schools Empowers Girls’ Education in Freetown, Sierra Leone: An assessment of menstrual hygiene management in schools
• Not checked yetcites [43] SJ Chebii, 2018, Menstrual Issues: How Adolescent Schoolgirls in the Kibera Slums of Kenya Negotiate their Experiences with Menstruation, Women’s Reproductive Health source
• Not checked yetcites [81] T Rheinlander, Secrets, shame and discipline: School girls’ experiences of sanitation and menstrual hygiene management in a peri-urban community in Ghana, Health Care Women Int

In the paper

“Studies noted the potential for negative menstrual experiences to have broader psychological impacts [9, 10, 43, 44, 47, 68, 89, 93, 107].”

What the sources say

• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [43] SJ Chebii, 2018, Menstrual Issues: How Adolescent Schoolgirls in the Kibera Slums of Kenya Negotiate their Experiences with Menstruation, Women’s Reproductive Health source

In the paper

“Qualitative studies identified different relative contributions of antecedents such as the physical environment, knowledge, or behavioural expectations (particularly explicit restrictions) for girls in different settings, which have implications for programming in those areas.”

In the paper

“Studies of those with menstrual disorders highlighted feelings of powerlessness in addressing dysmenorrhea or associated symptoms that may negatively impact psychological outcomes for these individuals [60, 103–105].”

What the sources say

• Not checked yetcites [60] AS Seyed Hosseini, 2018, Unpreparedness, impurity and paradoxical feeling: Menstruation narratives of Iranian women, International Journal of Adolescent Medicine and Health
• Not checked yetcites [103] L Aziato, 2015, Dysmenorrhea Management and Coping among Students in Ghana: A Qualitative Exploration, J Pediatr Adolesc Gynecol source
• Not checked yetcites [104] L Aziato, 2014, The experience of dysmenorrhoea among Ghanaian senior high and university students: pain characteristics and effects, Reproductive Health source
• Not checked yetcites [105] DK Hemachandra, 2009, Menstrual problems and health seeking in Sri Lanka, Women Health source

In the paper

“Menstrual pain made school attendance challenging.”

In the paper

“Social support enhanced or diminished experiences.”

In the paper

“Most studies relied on FGDs.”

In the paper

“Girls lacking knowledge and confidence to manage menstruation were reluctant to be around others [3–5, 8, 39, 70, 75, 77, 89].”

What the sources say

• Not checked yetcites [3] M Sommer, 2009, Ideologies of sexuality, menstruation and risk: girls’ experiences of puberty and schooling in northern Tanzania, Cult Health Sex source
• Not checked yetcites [4] CS Dolan, 2014, A Blind Spot in Girls’ Education: Menarche and Its Webs of Exclusion in Ghana, Journal of International Development source
• Not checked yetcites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source
• Not checked yetcites [8] M Sommer, 2010, 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 source
• Not checked yetcites [39] R Boosey, 2014, Menstrual hygiene management amongst schoolgirls in the Rukungiri district of Uganda and the impact on their education: a cross-sectional study, Pan Afr Med J source

In the paper

“Where menstrual restrictions forbade girls from travelling outside the home or being around males, these also directly impacted school attendance.”

In the paper

“Behavioural expectations in many settings also restricted interactions with males, food preparation, or participation in religious gatherings or activities.”

In the paper

“Experiences captured in qualitative studies revealed knowledge of the biological, reproductive, and practical aspects of menstruation as a source of confidence, shame, and perceived acceptability of practices and environments.”

In the paper

“Women’s and girls’ perceptions of their menstrual practices and environments emerged as a critical independent theme connecting practices to other impacts such as school absenteeism.”

In the paper

“Many studies that focused on girls of school age reported consequences for education [3–5, 8–11, 15, 37, 39, 41, 44, 51, 56–59, 62–64, 67–70, 72, 75, 77, 79, 85, 87–89, 91, 93, 94, 100, 101, 104, 106, 107].”

What the sources say

• Not checked yetcites [3] M Sommer, 2009, Ideologies of sexuality, menstruation and risk: girls’ experiences of puberty and schooling in northern Tanzania, Cult Health Sex source
• Not checked yetcites [4] CS Dolan, 2014, A Blind Spot in Girls’ Education: Menarche and Its Webs of Exclusion in Ghana, Journal of International Development source
• Not checked yetcites [5] SA McMahon, 2011, 'The girl with her period is the one to hang her head’ Reflections on menstrual management among schoolgirls in rural Kenya, BMC International Health And Human Rights source
• Not checked yetcites [8] M Sommer, 2010, 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 source
• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [10] J Crichton, 2013, Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: a qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi, Health Care Women Int source
• Not checked yetcites [11] L 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
• Not checked yetcites [15] A Parker, 2014, Menstrual management: a neglected aspect of hygiene interventions, Disaster Prevention and Management: An International Journal source

In the paper

“Poorly perceived menstrual practices such as unreliable absorbents that girls felt were liable to leak or expose odour reduced attendance and engagement [8, 9, 11, 37, 39, 41, 56–59, 64, 68, 69, 72, 75, 79, 80, 85, 91, 93, 94, 100, 101].”

What the sources say

• Not checked yetcites [8] M Sommer, 2010, 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 source
• Not checked yetcites [9] J Long, 2013, WASH in Schools Empowers Girls’ Education in Rural Cochabamba, Bolivia: An Assessment of menstrual hygiene management in schools
• Not checked yetcites [11] L 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

In the paper

“Experiences of adult women, particularly in the workplace, were under-researched.”

In the paper

“The majority of included studies came from sub-Saharan Africa, and findings may be more representative of this context.”

In the paper

“In sum, extant qualitative studies have identified consistent negative impacts for health and social participation resulting from poor menstrual experience.”

In the paper

“We identified no studies from China, and studies from the Middle East and North African countries were more frequently undertaken in urban, more highly educated populations, though this reflects the global focus on menstrual hygiene research in specific geographical areas.”

In the paper

“We identified no studies from China, and studies from the Middle East and North African countries were more frequently undertaken in urban, more highly educated populations, though this reflects the global focus on menstrual hygiene research in specific geographical areas.”

In the paper

“This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being.”

In the paper

“the model views resource limitations and the sociocultural context, including menstrual stigma, as determinants of menstrual experience and negative impacts”

In the paper

“These orientations influenced the focus of studies, topics covered, and author interpretation of the relationships between antecedents, experience, and impacts.”

In the paper

“Our review is limited by the available studies.”

In the paper

“Confidence to undertake other activities during menstruation was frequently the mechanism through which poorly perceived menstrual practices and shame translated into impacts on social participation and well-being.”

In the paper

“Internalised expectations of menstrual etiquette, keeping clean and discrete, meant that failures to contain menstrual blood or odour were viewed as personal failings imbued with embarrassment and distress.”

In the paper

“This approach was often selected to source priorities for intervention but meant that studies more often captured shared experiences of the school environment, rather than deep understanding of individual experiences that may yield greater sociological or psychological insights.”

In the paper

“Amongst this group, we achieved early saturation of impacts and antecedents.”

In the paper

“The integrated model produced illustrates pathways through which distal and proximal antecedents influence menstrual experience and ultimately result in impacts on physical and psychological health, education, employment, and social participation.”

In the paper

“Distal antecedents—the sociocultural context and resource limitations—underlay more proximal factors.”

In the paper

“Some restrictions were interconnected with expectations of propriety placed upon girls as they sexually matured, to protect from sexual advances, as they could now become pregnant.”

In the paper

“Such expectations and broader menstrual stigma were internalised, influencing experience and self-concept.”

In the paper

“Our integrated model suggests that this is an indirect relationship and is unlikely to capture the true effects of menstrual experience on psychological, educational, and social outcomes without attention to the other components of experience that mediate this relationship.”

In the paper

“The majority of included studies came from sub-Saharan Africa, and findings may be more representative of this context.”

In the paper

“To date, these have evaluated links between menstrual practices and impacts (e.g., sanitary pad use and school attendance) [18, 114].”

What the sources say

• Not checked yetcites [18] AM van Eijk, 2016, Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis, BMJ Open source
• Not checked yetcites [114] J Hennegan, 2016, Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda, BMJ open source

In the paper

“Our integrated model suggests that changes to girls’ perceptions of their practices may cause distress as they struggle to adopt new practices advised in education interventions in an unsupportive physical environment.”