HEALTH IN ACTION

A Time for Global Action: Addressing Girls’

Menstrual Hygiene Management Needs in
Schools
Marni Sommer1*, Bethany A. Caruso2, Murat Sahin3, Teresa Calderon4, Sue Cavill3,
Therese Mahon5, Penelope A. Phillips-Howard6
1 Mailman School of Public Health, Columbia University, New York, New York, United States of America,
2 Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America, 3 UNICEF
Headquarters, New York, New York, United States of America, 4 UNICEF Bolivia, La Paz, Bolivia,
5 WaterAid, London, United Kingdom, 6 Liverpool School of Tropical Medicine, Liverpool, United Kingdom

* ms2778@columbia.edu
a11111

Summary Points
• There is an absence of guidance, facilities, and materials for schoolgirls to manage their
menstruation in low- and middle-income countries (LMICs).
• Formative evidence has raised awareness that poor menstrual hygiene management
OPEN ACCESS (MHM) contributes to inequity, increasing exposure to transactional sex to obtain sani-
Citation: Sommer M, Caruso BA, Sahin M, Calderon tary items, with some evidence of an effect on school indicators and with repercussions
T, Cavill S, Mahon T, et al. (2016) A Time for Global for sexual, reproductive, and general health throughout the life course.
Action: Addressing Girls’ Menstrual Hygiene
• Despite increasing evidence and interest in taking action to improve school conditions
Management Needs in Schools. PLoS Med 13(2):
e1001962. doi:10.1371/journal.pmed.1001962
for girls, there has not been a systematic mapping of MHM priorities or coordination of
relevant sectors and disciplines to catalyze change, with a need to develop country-level
Published: February 23, 2016
expertise.
Copyright: © 2016 Sommer et al. This is an open • Columbia University and the United Nations Children's Fund (UNICEF) convened
access article distributed under the terms of the
members of academia, nongovernmental organizations, the UN, donor agencies, the pri-
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any vate sector, and social entrepreneurial groups in October 2014 (“MHM in Ten”) to iden-
medium, provided the original author and source are tify key public health issues requiring prioritization, coordination, and investment by
credited. 2024.
Funding: The authors received no specific funding • Five key priorities were identified to guide global, national, and local action.
for this work.

Competing Interests: The authors have declared

that no competing interests exist.

Abbreviations: HPV, human papillomavirus; LMIC,

low- and middle-income country; M&E, monitoring
and evaluation; MHM, menstrual hygiene Introduction
management; NGO, nongovernmental organization;
A lack of adequate guidance, facilities, and materials for girls to manage their menstruation in
SRH, sexual and reproductive health; UNESCO,
United Nations Educational, Scientific and Cultural
school is a neglected public health, social, and educational issue that requires prioritization,
Organization; UNICEF, United Nations Children's coordination, and investment [1]. There are growing efforts from academia, the development
Fund; WASH, water, sanitation and hygiene; WinS, sector, and beyond to understand and address the challenges facing menstruating schoolgirls
WASH in Schools. in low- and middle-income countries (LMIC) [1]. A body of research has documented men-
Provenance: Not commissioned; externally peer struating girls’ experiences of shame, fear, and confusion across numerous country contexts
reviewed and the challenges girls face attempting to manage their menstruation with insufficient

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 1/9

 information, a lack of social support, ongoing social and hygiene taboos, and a shortage of suit-
able water, sanitation and waste disposal facilities in school environments [2–7]. The accruing
evidence reveals the gender discriminatory nature of many school environments, with female
students and teachers unable to manage their menstruation with safety, dignity, and privacy,
negatively impacting their abilities to succeed and thrive within the school environment [7–9].
Poor school attainment reduces girls’ economic potential over the life course, impacts popula-
tion health outcomes [9–12], and also extends to girls’ sexual and reproductive health out-
comes, self-esteem, and sense of agency [4,7,8].
Despite increasing evidence about the challenges girls face managing menstruation in school
in LMIC countries and growing efforts to address these challenges, there has not been a con-
centrated effort at global or national levels to identify key priorities to catalyze action to trans-
form the school-going experiences of girls. The “MHM in Ten” initiative was organized by
Columbia University and the United Nations Children's Fund (UNICEF) in New York City
in October 2014 to systematically map out a ten-year agenda for overcoming the menstrual
hygiene management (MHM)-related barriers facing schoolgirls.
Significant recent events supported the rationale for organizing such a meeting, illustratively
including intense discussion around the inclusion of MHM in the post-2015 sustainable devel-
opment goals, the investment by the Canadian government (Global Affairs Canada) to support
MHM research and programming in 14 countries, the annual cohosting of the MHM in Water,
Sanitation and Hygiene (WASH) in Schools virtual conference by UNICEF and Columbia Uni-
versity, designation of May 28 as “Menstrual Hygiene Day,” and the development of a new
puberty policy for the education sector with a focus on menstruation education and MHM by
the United Nations Educational, Scientific and Cultural Organization (UNESCO). This paper
briefly describes the state of the evidence on MHM in schools, the remaining knowledge gaps,
and potential action for making progress on the ten-year agenda.

Current Evidence: Knowledge and Gaps

In 2014, there were over 250 million girls aged 10–14 years of age living in less-developed
countries, and nearly 56 million living in least-developed countries [13]. Although reliable evi-
dence on the average age of menarche in many countries is lacking [14], the vast majority of
girls will experience their first menstruation during this age range.
Growing evidence suggests the gendered impacts of inadequate WASH facilities in LMIC
schools influence the participation of girls [15,16]. Much of the MHM research, conducted
across sub-Saharan Africa, Asia, and South America, has concentrated on understanding girls’
experiences of the onset of menstruation and the subsequent WASH challenges they face man-
aging their menstruation in school [1]. Girls have indicated receiving inadequate guidance
prior to their first menstrual period and experiencing fear, shame, and embarrassment manag-
ing menstruation, particularly while in school [4,6,7,17,18]. Studies have shown girls lack
water, soap, privacy, and space to change [19]; adequate time to manage their menses comfort-
ably, safely, and with dignity [20–22]; and hygienic sanitary products and sometimes under-
wear [7,23,24]. The latter lack may increase girls’ vulnerability to coercive sex and subsequent
sexual and reproductive health harms to obtain money to buy sanitary products [25,26].
Female schoolteachers in many contexts also struggle to manage their menstruation comfort-
ably and privately in schools and may be hard to retain in the absence of adequate WASH facil-
ities; less evidence and action exist in relation to female teachers [27], but such work is needed.
Many school systems have a predominance of male administrators and teachers, who may be
unaware of or reluctant to talk about the challenges that schoolgirls and female teachers are fac-
ing [28]. Further contributing to unsupportive social environments at school, boy students

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 2/9

 report having little understanding about menstruation, and some tease and bully girls because
they do not understand girls’ behaviors during menstruation [28–30]. This evidence has pro-
vided insights for some nascent programming and policy actions generally focused on three
key MHM elements in school: the provision of MHM guidance, fostering an enabling physical
and social school environment, and the distribution of menstrual products [2,31].
However, there remains a paucity of empirical evidence quantifying the extent and intensity
of girls’ challenges managing menstruation, with few studies examining causal associations and
little experimental evidence available to demonstrate the effectiveness of MHM interventions
for health and schooling [32]. There has also been insufficient research examining the impact
of inadequate MHM guidance or environments on schoolgirls’ levels of self-esteem, their self-
efficacy to manage their menstruation in school, and their ability to concentrate in class when
menstruating in schools that lack adequate WASH facilities or sensitized teachers and peers.
There is also insufficient research examining the impact of interventions aimed at reducing
menstrual-related bullying and improving girls’ self-confidence. This lack of evidence makes it
difficult to promote recommendations to national governments, nongovernmental organiza-
tions, and others interested in integrating MHM into education and health strategies, and it
reduces global buy-in to move this agenda forward. Lastly, while policy makers have called for
increased measurement of school attendance, dropout, and educational attainment in relation
to MHM, demonstrating quantitative associations with school absence in limited studies to
date has shown minimal effect [5,33,34], despite strong qualitative evidence from girls’ narra-
tives [4,7,17,26,35]. Similarly, self-reporting of reproductive tract infections among adolescent
schoolgirls has also been shown to be unreliable without laboratory confirmation [36].
There are currently two distinct arguments put forward in relation to generating attention
and resources to address inadequate MHM in schools. One frames the issues in relation to
meeting the basic human rights and dignity of girls (and female teachers), while the second
focuses on how ongoing barriers to effective MHM may contribute to negative health and edu-
cation outcomes for girls. The global community has to some degree achieved consensus on
the importance of the first but now needs to focus increased resources on generating adequate
evidence for action on the second.

A Need for Collaboration across Sectors: MHM in Ten Aimed at

Catalyzing Discussions across Sectors
Both the human rights argument and the need to improve MHM for health and educational
reasons provide strong rationales for engagement from multiple sectors. However, while the
MHM challenges facing pubescent girls in LMIC require cross-sectoral responses, funding
streams and structures are needed to support sustainable activities by institutions and govern-
ment ministries. Convergence between departments to prevent duplication and gaps similarly
requires attention [37].
To date, much of the leadership and activities on MHM in schools has been through the
WASH sector. The education sector has been less engaged, even though girls’ school experi-
ences are negatively impacted if they are distracted, uncomfortable, or unable to participate
because of anxiety over menstrual leakage and odor [7] or without the support of teachers, ade-
quate latrines [20], or a place to rest if menstrual cramps become painful [4,31]. Girls’ sexual
and reproductive health underscores the importance of engagement from the education sector
given the evidence showing that educated girls are more likely to delay first sex, have fewer
sexual partners, and use contraception and are less likely to become infected with HIV/AIDS.
In terms of other population health gains, they are also more likely to have their children

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 3/9

 vaccinated and attend school and have healthier families [9,38–41]. MHM has yet to be
included within the numerous activities underway to improve girls’ educational outcomes in
LMICs.
There exists a window of opportunity to reach girls at menarche, as their bodies are biologi-
cally changing and they are encountering profound new social dynamics within their families
and communities [42,43]. Many girls in LMIC receive no or factually incorrect guidance prior
to menarche about the normal physiological process of menstruation or the pragmatics of
MHM [8]. This in turn results in numerous misconceptions about their own fertility, creating
vulnerability to adolescent pregnancy if girls are sexually active [7,9]. The adolescent sexual
and reproductive health (SRH) sector is called on to expand its focus and intervention timing
beyond contraception (i.e., family planning) and disease prevention to include puberty and
menstrual care guidance.
A range of stakeholders (see S1 Table) [44] discussed school environments, educational out-
comes, SRH, gender, social beliefs, menstrual management products, and political commitment
at the local, national, and global levels. The group included an array of expertise, comprising
academics with varied experience conducting qualitative studies as well as randomized trials,
nongovernmental organizations (NGOs) working in both advocacy and policy roles, bilateral
donors and foundations, small and global level private sector corporations, and a range of UN
agency perspectives. The under-representation of LMIC government representatives (i.e., Min-
istries of Education), country program managers, engineers, youth voices, and other key stake-
holders at this first initiative was identified, and the organizers made a commitment to address
this in subsequent meetings.

Priorities for Action

MHM in Ten participants defined a joint aim for the ten-year agenda: “Girls in 2024 around
the world are knowledgeable about and comfortable with their menstruation and able to man-
age their menses in school in a comfortable, safe, and dignified way.”
Five key priorities were identified to achieve this vision by 2024 (Table 1). The priorities are
not intended to be sequential as some may happen in parallel:
1. Build a strong cross-sectoral evidence base for MHM in schools for prioritization of pol-
icies, resource allocation, and programming at scale. Specifically, rigorous impact evalua-
tions of the most essential, cost-effective, and efficient interventions to implement in
schools are needed, as well as a broader array of appropriate measures to capture the health
and educational impacts of inadequate MHM. National-level research is still required to
assure that policies, resources, and programs are appropriate and effective.
2. Develop and disseminate global guidelines for MHM in schools with minimum stan-
dards, indicators, and illustrative strategies for adaptation, adoption, and implementa-
tion at national and subnational levels. The absence of accepted global guidelines and
indicators for what to implement in schools and how to monitor interventions is paralyzing
governments, school systems, and other practitioners who want guidance for action.
3. Advance MHM in schools activities through a comprehensive evidence-based advocacy
platform that generates policies, funding, and action across sectors and at all levels of
government. There is a need for improved advocacy around MHM given taboos in many
countries that hinder open discussion about addressing MHM in schools and the stake-
holder engagement needed at all levels (i.e., governments, donors, parents teachers, and
students).

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 4/9

 Table 1. Illustrative cross-sectoral actions to meet priorities.

Stakeholder Group Role

Governments Work with their own constituents to “break the silence” on menstruation
within their respective institutions and populations
Allocate resources to implement structural changes in schools
UN agencies Provide technical support on the development of policies, guidelines, and
standards for improving MHM in schools
Researchers Work with donors, governments, and NGOs to fill the gap in empirical
evidence on the relationship between poor MHM and lost schooling,
attainment, dropout, self-esteem, self-efficacy, sexual and reproductive
health harms, and girls’ inequity
Provide research evidence on the utility and cost-effectiveness of
interventions, operational research on implementation strategies, and
support of the policy agenda
Nongovernmental Work with governments, donors, the private sector, and communities to
organizations implement sustainable programming that reaches girls at all income
levels
Collaborate with researchers to rigorously monitor and evaluate
programs
Private sector and social Use extensive marketing and product distribution skills and
entrepreneurs entrepreneurial approaches to build momentum for social change
Construct messages that provide accurate and nondiscriminatory
information to girls
Donors Support research that aims to quantify the extent and severity of girls’
MHM-related challenges and the impact of programs created to
ameliorate them
doi:10.1371/journal.pmed.1001962.t001

4. Allocate responsibility to designated government entities for the provision of MHM in

schools (including adequate budget and monitoring and evaluation [M&E]) and the
reporting to global channels and constituents, recognizing that scalable impact on MHM
in schools will only occur when national governments take responsibility for and perceive
MHM as a priority for education systems, which highlights their role for change in the com-
ing ten years.
5. Integrate MHM and the capacity and resources to deliver inclusive MHM into the edu-
cation system. The education sector recognizes and demonstrates MHM as an integral
part of its resources, plans, budgets, services, and performance monitoring and delivers
inclusive educational service to all children and adolescents. Numerous components of
action are needed within a given educational system to assure action and monitoring of
MHM interventions in schools, and such actions need to be inclusive of vulnerable groups,
including girls with disabilities.

Recognized Challenges and Opportunities to Achieving Goals

There are challenges to moving forward the MHM agenda in the next ten years; however, there
is reason for optimism.
There are competing priorities in the health and education spheres for the existing develop-
ment resources for adolescent girls. Integrating MHM into existing programming and policy
could be a noncompetitive and cost-effective approach. The provision of puberty and menstru-
ation education booklets to girls getting the human papillomavirus (HPV) vaccine has been
suggested as a potential integrated strategy.

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 5/9

 The majority of existing efforts aimed at addressing MHM have emerged from the WASH
community, yet the WASH sector alone cannot advance the MHM agenda in schools. MHM in
schools must be supported by a diverse range of actors globally and within countries (i.e., Minis-
tries of Education, Health, Finance, Sanitation and Water, and Women and Children’s Affairs),
including any other government specific entities at the country level holding responsibility due
to the legal and competence frame of each country (see Table 1 for examples). The current
14-country WASH in Schools (WinS) for Girls program led by UNICEF with support from the
Canadian government aims to conduct local research and use findings to generate a platform
for action. To ensure multisector involvement, the program has required participating countries
form in-country working groups with representatives from the government, local research insti-
tutions, and NGOs so varied feedback can be integrated throughout the process. The lessons
learned from this effort can serve as a model for multiactor efforts moving forward.
Evidence-based interventions require robust research to support cost-effective program-
ming, and the latter will require an increase in dedicated resources to support the trials needed
to generate the data for decision making. Funding is now occurring; for example, the UK-based
Department for International Development, Medical Research Council, and Wellcome Trust
are supporting a large-scale trial evaluating the effect of menstrual cups on Kenyan girls’ school
and SRH outcomes.

The Way Forward

Participants identified key next steps to reach these priorities:
• A first step is for stakeholders to develop an operational strategy for the MHM in Ten agenda
that includes a M&E component for assessing current status and progress in addressing the
five priorities. This includes collection of standardized indicators generated at the national
level. Buy-in from national governments and schoolgirls themselves is essential.
• A second step is to build collaboration and strengthen research capacity across countries and
regions of the world on MHM. It is critical to identify existing, or foster new, MHM experts
and actors in each country, whether through strengthening research capacity of in-country
academics to conduct local research on MHM or through efforts to mobilize MHM stake-
holders within the country to generate collaboration and activity. A global repository for
existing evidence, programs, and policies on MHM in schools will provide a platform for
decision making. Fostering essential research would be supported through a research consor-
tia. A research concept note detailing the existing gaps in the evidence has been developed
[45]; however, a collation and review of the lessons learned to date from existing program-
ming and policy is needed.
• A third step is to coordinate progress and share outcomes, bringing together country- and
global-level stakeholders. A steering group comprising global and local expertise, meeting at
least annually, and supported through a UN agency would facilitate this.

Conclusion
There have been numerous early accomplishments in the nascent MHM field in the last few
years. In order to reach the vision of girls around the world being knowledgeable about and
comfortable with their menstruation and able to manage it safely and with dignity in school,
global support of the priorities identified at MHM in Ten is required to make sustainable
change by 2024.

PLOS Medicine | DOI:10.1371/journal.pmed.1001962 February 23, 2016 6/9

 Supporting Information
S1 Table. Organizations participating in the first MHM at Ten Meeting.
(DOCX)

Acknowledgments
Organizations participating in the first MHM at Ten Initiative are listed (see S1 Table). Partici-
pants attending are thanked for their valuable contribution: Rockaya Aidara, Asanthi Balapi-
tiya, Clarissa Brundage, Abigail Bucuvalas, Lizette Burgers, Teresa Calderon, CeCe Camacho,
Venkatraman Chandra-Mouli, David Clatworthy, Emily Deschaine, Anna Ellis, Sarah Fry,
Nora Fyles, Velvet Gogolbennet, Greg Keast, Jackie Haver, Min Jeong Kim, Claudia Mitchell,
Relebohile Moletsane, Jeanne Long, Melissa Opryszko, Susan Papp, Archana Patkar, Rosemary
Ropp, Amritpal Sandhu, Tom Slaymaker, Belen Torondel, Elynn Walter, and Erin Wheeler.
The second MHM in Ten meeting took place in late October 2015, with increased partici-
pation from LMIC governments, researchers, and other stakeholders. A meeting report is
forthcoming.

Author Contributions
Wrote the first draft of the manuscript: MSo PPH BAC. Contributed to the writing of the man-
uscript: MSo PAPH BAC SC MSa TM TC. Agree with the manuscript’s results and conclu-
sions: MSo PAPH BAC SC MSa TM TC. Co-wrote the MHM at TEN proceedings document:
MSo, SC, TM. Extensively edited the manuscript: MSo, SC, TM, MSa, TC. All authors have
read, and confirm that they meet, ICMJE criteria for authorship.

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