While there has been great success and strides made in human rights, particularly for women, the glass ceiling is nowhere close to being shattered. The lack of ability and support for women and young girls in managing their menstrual health is holding them back from achieving economic empowerment and independence, especially in developing states. The stigma associated with menstruation, despite it being a very natural and healthy function exacerbate the issues around menstrual hygiene management. When there’s a lack of awareness compounded by the lack of affordability and access to resources, girls either miss weeks of schooling or they drop out entirely. A woman’s ability to complete her education is a large factor in her ability to have economic empowerment and have power within her family and community. These also help her to move her family out of a crisis economic situation and towards more resilient sources of income. While analyzing the plethora of challenges women and girls face in their schools and communities, realistic programming and policy can be implemented to create a better society for women and measurable change.
Background
Over a quarter of the global population are women of reproductive age, and the other 25% have either gone through menstruation or will in the future. Despite half of the global population experiencing a very normal and healthy bodily function, there are still taboos and stigmas attached to it. The ability to manage menstruation hygienically and with dignity is a human and woman’s right. However, in many states, women do not have the ability to manage their menstrual health due to lack of access to resources (including financial means), local infrastructure, education, and extreme stigma engrained in society.
Gender equality has been recognized in the Universal Declaration of Human Rights, adopted by the United Nations General Assembly, in 1945. Gender equality has not been reached, even with such a document being supported by the international community; so the goal of Gender Equality has been expressed in both the Millennium Development Goals and now the more recent Sustainable Development Goals(SDGs). In addition to supporting the pursuit of gender equality, the SDGs have acknowledged the importance of the role of education in the lives of women and girls. In the SDG of education, a specific goal outlines: “By 2030, ensure that all girls and boys complete free, equitable and quality primary and secondary education…”[1]. The country with the highest primary school enrollment rates in Africa, Rwanda, still has many obstacles to overcome in their efforts to ensure the same quality education for girls as it does the boys. Girls on average miss about 10-20% of school days because of their inability to manage their menstrual health while at school[2][3].
Taboo
A challenge has presented itself for women and the goal of reaching equality in the form of deeply ingrained stigma and taboo concerning menstruation. Many cultures and religions have myths, views, and traditions that not only present a woman as “unclean”, but also often controls her participation within the community. Just some of the restrictions placed on women include not being allowed to bathe due to the belief that she will become infertile[4], women are not allowed to tend to crops or livestock for fear of them dying[5], they are unable to cook or be with family members[6], and many other actions that are unfounded in medicine or physiology. African countries and cultures are not the only ones who have these beliefs surrounding menstruating women. Christianity, Judaism, and Hinduism, are among religions that perceive women as impure during this time[7]. Interestingly, there are a few cultures that do see this as a time to highly respect women, their wisdom, and increased spirituality; in these cultures, women often confined themselves to menstrual huts with other women, not in shame but to grow and purify together. However, there is more often than not, a lot of shame that is placed on young girls when they start menstruation.
Due to the lack of education surrounding menstruation, it is often believed that the young woman was intimate with a man or she somehow dishonored the family[8], because of this belief some girls are abused[9] when parents discover that she has started bleeding. These misconceptions, restrictions, and abuse put a strain on communication between girls and their parents, which encourages girls to feel shame, and for them to feel very secretive concerning their periods. All of the issues concerning the perception of menstruation create a foundation of shame that impacts the community and especially the education of girls.
Impact of Successful Women on Communities
When women do not succeed, the whole community is held back. Local and state economies are missing out when women are unable to contribute to their greatest potential.
As women are given the opportunity to attend both primary and secondary school without interruptions and difficulty with menstrual hygiene management (MHM), their education rises. With a rise in education comes increased earning potential, greater contributions to the local and national economy, and overall more empowerment within the community[10] [11]. In fact, the World Bank estimates that for every additional year of schooling, a woman’s income will rise between 10-20%[12] and a “1% increase in the level of women’s education generates .3% in additional economic growth”[13]. Having empowerment and socio-economic mobility allows for women to take a greater role in community leadership and decision making positions, which ultimately helps divert money back to programming to help more girls. Something as simple as ensuring that young women have the resources they need to manage their menstrual health & hygiene, greatly impacts the overall well being of a community and helps to end poverty cycles. As Chief Economist of the World Bank explains, “… investment in girls’ education may well be the highest return investment available in the developing world”[14].
Rwanda and School Absenteeism
Rwanda has been pursuing universal education for primary school-aged children, and has largely been successful in their efforts; currently, they have the highest enrollment rates in Africa[15]. Despite the success of Rwanda’s primary education initiatives, the state is still struggling to support young women in MHM. Per market research from Sustainable Health Enterprises, girls miss upwards of 50 days of school a year and about 18% of girls and women miss days of either school or work due to the complications of MHM[16]. On average, Rwandan girls experience menarche between the ages of 12-14[17], which is at the tail end of primary school and the beginning of lower secondary school.
According to data collected by the Ministry of Education of the Republic of Rwanda, in 2014 and 2015, enrollment for girls in both primary and secondary school has surpassed boys, these statistics, however, do not reflect the number of days that boys and girls were absent (table I below).
[18]
In table II, data is broken down by school level and by gender. In the primary level, a higher percentage of girls completed their grade levels, and a less percentage of girls dropped out compared to boys between 2012-2014. However, percentage-wise girls are transitioning to secondary school less than boys and nearly 5% less in 2014(table II). This is the point where girls may not be transitioning to secondary school due to a lack of support for MHM. In lower secondary school the percentage margins are close to each other for both the promotion rate and dropout rate (excluding the year 2012 for lower secondary), but these margins widen in upper secondary school; making the girls fall even more behind the boys. It’s important to note that the percent of girls passing the primary school exams, and both upper and lower secondary school exams, never surpassed the percentage of boys passing since 2012. This could be an indicator of the effects of absenteeism of girls due to MHM. Missing on average of 50 days a school year will have a drastic impact on girls keeping up with class materials. Fortunately, in 2015 more girls passed exams in primary and secondary school, lessening the percentage margin compared to boys the previous years.
Community and Family Support
Without discussing how infrastructure and access to resources impact MHM just yet, it’s imperative to acknowledge the role that communities and families play. In narratives collected throughout different countries, common themes were woven through each of them. A feeling of unpreparedness, and with that the feelings of fear and shame, along with the need for secrecy. Due to the stigmas and taboos concerning menstruation, sexual education is not taught in schools, and if it is taught, it is very limited, especially if there are no female teachers available[20]. Often, however, this education comes after young girls have already experienced menarche and so the best time to discuss what to expect and how to feel, has already gone and past. When young girls bleed for the first time and they never knew what to expect, they often don’t know or understand what’s happening, it isn’t uncommon for girls to keep it a secret from their parents[21]. Referring back to the stigmas and taboos; often when fathers find out, (either by seeing the young girl secretly washing clothing etc), he will punish her because men often do not understand menstruation is something natural and healthy[22]. Most misunderstandings come from thinking that it only begins when a person becomes sexually active, which is not the case at all. Some girls do get support from mothers, sisters, or friends, this support though is often very minimal because menstruation is still considered a very private matter. This breakdown of communication within the family unit is detrimental to the confidence and self-esteem of a young girl, especially at a very important physical and mental moment developmentally. This lack of support and trust spills further over into the community and schools.
Due to a complete lack of guidance prior to menarche, girls have no idea how to properly manage their periods. This causes fear in school that they will stain their clothing, that classmates or teachers will know they’re bleeding, which then turns into an embarrassment. If clothing is stained, girls have reported that they’re laughed at or made fun of by boys, and requesting to use facilities to clean clothing or take care of themselves, further embarrasses them[23]. Additionally, they do not know proper menstrual hygiene management like changing often and washing hands, which could lead to infections and other serious health complications. If the girls have had guidance in MHM, and there’s a lack of facilities, privacy or proper resources, girls are still unable to properly take care of themselves. This again exacerbates the feelings of shame, discomfort, embarrassment, and fear. These complications often become so overwhelming, it is easier for girls to stay home from school for the few days of their period.
If more support came from families, teachers, and community members, it would give girls their dignity back when experiencing menstruation. This would involve moving beyond stigmas and taboos that may have become engrained in a community, and educate the community on the realities of menstruation. Educating communities doesn’t just extend to women, girls and female teachers, male teachers, men, and boys should also be included in workshops to learn how they can offer support to their daughters, sisters, students, and friends. Careful consideration needs to be carried out because of cultural sensitivities. This is not something that is easily accepted, especially when including men, however, when similar programming[24] was implemented in other countries, women were reporting more support not only at school but also home.
School Infrastructure
The Ministry of Education of Rwanda collected data concerning the average number of students per toilet (table III) and what kind of water systems (table IV) are available at schools. In Rwanda as a whole, the average amount of female students per toilet in primary school is 58, there are also two provinces that surpass this average. For men in primary school, the country average is 60 students per toilet, and three provinces surpass this average as well. The secondary schools have substantially less students so the country average of female students per toilet is 16, with three provinces going over this average. Finally, for secondary school men the country average is 17 students, with only one province surpassing this average. Overall, only 61% of the Rwandan population[25] has access to sanitation facilities, which makes it even more important for facilities to be available at both primary and secondary schools. International standards set by the World Health Organization recommend having one toilet per 25 female students minimum and one toilet plus one urinal per 50 male students[26]. There should also be one toilet designated for female staff and one for male staff members[27]. Currently, the primary schools do not have enough toilets and sanitation facilities available for their students. In addition to not having enough, these numbers do not reflect the condition of the facilities, which is very important when addressing MHM.
Rwanda has expressed commitment to increasing sanitation and hygiene throughout the country, with a lofty goal of achieving 100% household sanitation and hygiene coverage by 2020[29]. Additionally, the President launched a community initiative for sanitation which included guidelines and regulations for communities to follow[30]. Despite, the written commitment of the president and government to support sanitation and hygiene efforts, the Stockholm Environmental Institute found clear contradictions in the standards of facilities[31]. The report created by the Ministry of Education glosses over how many toilets and sanitation facilities meet state sanitation and hygiene policy regulations and guidelines. This brings up questions of the amount of privacy these facilities have if there are doors, and availability of soap and water. The report did break down the average toilets per gender but there is no information regarding how far away these facilities are from one another and if students use the facilities they’re designated to.
When interviewed for surveys, girls expressed that toilet facilities were not conducive for MHM, which contributes to the decision to stay home from school. The few important standards that facilities need to have, that has been noted by young women, are doors on all toilets, a clear separation of gendered facilities, a designated place to throw away used sanitary products, and water being easily accessible. Not having doors or clear separation of facilities, doesn’t allow for girls to have privacy at all when needed and leaves them open to harassment and humiliation. Ensuring that some form of trash bin or incinerator is also key for MHM and keeping facilities clean; if girls are unable to appropriately and discretely dispose of products they may not feel comfortable even attending school for fear of humiliation. Finally, having water and soap in the same private area as toilets are also necessary if washing stations are available but are too far away and girls must walk through a public space to get there will not be able to privately wash the blood from their hands, clothes and sanitary products[32]. As noted in table IV, only 87.6% of primary schools and 89% of secondary schools have access to either a rain harvesting system or tap water system. It is unclear in the data collected if the schools that do not have access to either of these systems, have access to water another way. It is clear though, that girls need a reliable source of clean water to help with MHM.
International organizations and non-governmental organizations that have partnered with schools have been successful in filling the gaps from the government for sanitation and MHM facilities. The government of Rwanda needs to take a more active role in supporting and creating programming for MHM but students and communities cannot wait. MHM needs to be made a priority at the state level because there are realistic and sustainable solutions but something is holding the government back from implementing these solutions. UNICEF found that when girls have access to clean and private toilets[34], private clean water, showers and changing rooms; the attendance rates for girls went up[35]. These are changes in infrastructure, which costs money, however putting resources into these areas not only help the students, especially girls, but in the long run the community and state.
Access to Resources
Each culture has their own take on what is and is not an acceptable form of sanitary products and resources to use during menstruation. It is widely accepted that pads are the ideal product to use because they’re sanitary and they do come in a reusable form, however, availability is an obstacle. Girls and women from poorer or rural communities, do not have the same access to products due to both availability and the cost[36]. Women and girls would need to purchase disposable sanitary items either once a month or purchase a reusable pad yearly. This cost is a burden to some families and when women do not have financial power in their homes, it’s even more difficult to afford these very necessary items. It is also common that marketplace shops run by men choose not to carry such products[37]. The issue of access to resources is especially concerning because girls need to be using sanitary materials for their periods. When asked about what resources are available to them, girls in Rwanda, Kenya, Tanzania, Ghana, and Ethiopia shared similar solutions. In place of pads, it was not uncommon to use found cloth[38], pieces of a mattress, tissues, and natural materials like mud, leaves, dung, and animal hides[39]. Using materials and resources like these are heavily concerning the health risks that they may cause. Many schools find it difficult to employ sexual education and develop proper sanitary facilities; they also often do not provide emergency sanitary products[40] for girls to request if they need to, forcing girls to endure their period without a product (and ultimately being humiliated by classmates) or leave school for the day. Sustainable Health Enterprises(SHE), is a non-profit that has been working within Rwanda to increase access to reusable pads by helping women develop their own eco-friendly reusable pad businesses. The non-profit trains women in how to create reusable pads out of banana tree fibers, and then they sell the pads at a very affordable price within their communities[41]. This model is sustainable and gives economic empowerment to women. SHE has also expanded their programming to include workshops, training for teachers, and increased advocacy to push school budgets to fund more sanitary facilities and MHM projects[42].
Going through WASH and MHM programming from UNICEF, UNESCO, SHE, and many others, there is an interesting option that isn’t being discussed often enough. This option is the use of reusable menstrual cups rather than reusable pads. Menstrual cups are designed to be affordable, long-lasting, and discrete. The reason why it’s not often discussed is that organizations are trying to find options that are most culturally sensitive for communities so menstrual cups are quickly taken off the list of options. Menstrual cups though could be very beneficial to women and girls who lack access to appropriate facilities and funds. They are inserted and can be worn for up to 12 hours which would give girls the ability to change in the morning, go to school for a full day and change when they get back home. Given the nature of the menstrual cup, girls will be able to attend school without worrying about leaking or staining clothing (which can happen with pads), their full attention can be put on their studies and they can even fully participate in outdoor activities. There are very few restrictions on this product and it is much easier to clean when away from home compared to reusable cloth pads which need time to dry and are more easily sterilized. Cups are made of flexible medical grade silicone[43] which allows the device to be boiled to be sanitized and the ability to last upwards of 10 years[44]. According to Canadian Family Physician, a menstrual cup has an initial cost of $37 usd and on average using disposable pads cost about $36 a year; the difference is that women are able to keep their cups up to 10 years, making it more cost effective[45]. However, being able to afford this upfront cost is difficult when someone is already struggling to afford pads. Studies were held in Nepal and South Africa concerning the acceptability and likelihood of women and girls wanting to use menstrual cups and the results were very promising. Across both studies, women were reluctant to try them at first but with encouragement and support from peers[46] women did decide to use them for the duration of the study. In the study in South Africa, at the conclusion of the study 96%[47] of the women preferred menstrual cups over other MHM options even with limited access to resources like water. The obstacles concerning this option is that there is no community business component available (like what SHE implemented) due to the necessity of the menstrual cups being made in a sterilized facility and the initial cost is unaffordable. The best solution is finding something that is most manageable for girls to ensure that they’re able to attend schools, finances is a clear obstacle so it is possible that the government will have to step in.
Recommendations for Success
With all the different factors that prevent women from successfully managing their menstrual hygiene, the biggest key is for the government to begin implementing programming rather than just recommending it or writing it into policy. When it’s time to discuss budgets for schools, there needs to be a substantial amount of money dedicated to improving the sanitation facilities and emergency supplies (pads, pain medication, etc.) at the school. This budgeted money must be earmarked to ensure it goes to MHM rather than classroom upkeep. Additionally, there need to be school inspections of the sanitation facilities, which tracks sanitation, access to privacy (doors), separate and enough toilets, access to private wash area with soap and water close to girls facilities. While improvements are being made on the infrastructure of the school, the instructors will also need attention. Quarterly training should be implemented to train teachers in sexual education materials and in MHM support strategies. Teachers should be able to build trust with all their students, especially if they lack support at home. Schools also need to be given an additional budget to fund workshops for community members to help break stigmas and to educate both men and women. Prior to the implementation of workshops, anonymous baseline surveys should be conducted to better understand the needs of girls, boys, parents, and community members. Some communities may need more education how hygiene whereas some may need to address stigma; developing baseline surveys will help curtail each workshop to specific community needs. With the obstacle of affordability of MHM products, the government needs to address a way to help school-age girls in particular, to obtain them. Providing schools with funds to provide students who are in a financial situation at home free reusable pads or a menstrual cup may be most cost-effective and impactful.
Rights for women have come a long way but when it comes to menstrual health, women are still stigmatized and shamed. The inadequate support from the government, communities, schools, and families, push young women further from their goals. When girls are unable to manage their menstrual health while at school in a comfortable, sanitary, and dignified manner, they go home or they don’t come back. For every year that a girl doesn’t go to school, that’s a strike against her future career, her income, and the economic well-being of her community. Sustainable and successful solutions to address MHM and absenteeism can be implemented. Such solutions include creating better sanitation facilities at schools, addressing the stigma and lack of sexual education in communities and address the obstacle of access to MHM products. This is all able to be implanted successfully if the government of Rwanda makes MHM a state priority.
[1] “Education-United Nations Sustainable Development,” 2016, United Nations, United Nations, Accessed November 7.
[2] Sommer, M. 2010. “Where the Education System and Women’s Bodies Collide: The Social and Health Impact of Girls’ Experiences of Menstruation and Schooling in Tanzania.” Journal of Adolescence. U.S. National Library of Medicine. August.
[3] Tjon A Ten, Varina. 2007. “Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goals.” Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goals: IRC. Europe External Policy Advisors. October 10.
[4] Sommer, Marni, Nana Ackatia-Armah, Susan Connolly, and Dana Smiles. 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 45 (4): 599.
[5] Tjon A Ten, Varina. 2007. “Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goals.” Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goal : IRC. Europe External Policy Advisors. October 10: 6.
[6] House, Sarah, Thérèse Mahon, and Sue Cavill. 2012. “Menstrual Hygiene – Sanitary Protection Materials and Disposal.” WaterAid. WaterAid: 27.
[7] Tjon A Ten, Varina. 2007. “Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goals.” Menstrual Hygiene: a Neglected Condition for the Achievement of Several Millennium Development Goals : IRC. Europe External Policy Advisors. October 10: 6.
[8] Sommer, Marni, Nana Ackatia-Armah, Susan Connolly, and Dana Smiles. 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 45 (4): 599.
[9] Ibid.560.
[10] “Girls’ Education and Gender Equality.” 2015. UNICEF. UNICEF. July.
[11] Roudi-Fahimi, Farzaneh, and Valentine M. Moghadam. 2003. “Empowering Women, Developing Society.” Empowering Women, Developing Society. Population Reference Bureau . November.
[12] Murphy, Shannon, Wivina Belmonte, and Jane Nelson. 2009. “Investing in Girls Education.” Investing in Girls Education, September, 7.
[13] Ibid, 5.
[14] Summers, Lawrence H. 1994. Investing in All the People: Educating Women in Developing Countries. Washington, D.C.: World Bank: 1.
[15] “Rwanda.” 2016. UNICEF Rwanda – Education. UNICEF. Accessed November 25. https://www.unicef.org/rwanda/education.html.
[16] Hitimana, Health And Hygiene Manager, Rwanda, Nadia, and Cece Camacho. 2014. “SHE28: The Intersection between Innovation, Health, WASH &Amp; Economic Development for Girls and Women in Rwanda .” Sustainable Health Enterprise, October, 3.
[17] Kakoma, JB, J Nkurunzinza, JP Ngirinshuti, and GK Gasana. 2010. “Dysmenorrhea and Other Menstrual Characteristics in Rwandan Female Students at National University of Rwanda.” Rwanda Medical Journal 68 (3): 27.
[18] Ministry of Education. 2016. 2015 Statistical Education Yearbook. Kigali: Republic of Rwanda: 1-132.
[19] Ministry of Education. 2016. 2015 Statistical Education Yearbook. Kigali: Republic of Rwanda:1-132.
[20] Mason, Linda, Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, and Penelope A. Phillips-Howard. “We Keep It Secret So No One Should Know:” A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation.” PLoS ONE 8, no. 11 (November 14, 2013): 5.
[21] Mason, Linda, Elizabeth Nyothach, Kelly Alexander, Frank O. Odhiambo, Alie Eleveld, John Vulule, Richard Rheingans, Kayla F. Laserson, Aisha Mohammed, and Penelope A. Phillips-Howard. “We Keep It Secret So No One Should Know:” A Qualitative Study to Explore Young Schoolgirls Attitudes and Experiences with Menstruation.” PLoS ONE 8, no. 11 (November 14, 2013): 5.
[22] Sommer, Marni, Nana Ackatia-Armah, Susan Connolly, and Dana Smiles. “A Comparison of the Menstruation and Education Experiences of Girls in Tanzania, Ghana, Cambodia and Ethiopia.” Compare: A Journal of Comparative and International Education 45, no. 4 (January 24, 2014): 598.
[23] Sommer, Marni, Bethany A. Caruso, Murat Sahin, Teresa Calderon, Sue Cavill, Therese Mahon, and Penelope A. Phillips-Howard. “A Time for Global Action: Addressing Girls” Menstrual Hygiene Management Needs in Schools.” PLOS Medicine 13, no. 2 (February 23, 2016): 2.
[24] Sommer, Marni, Emily Vasquez, Nancy Worthington, and Murat Sahin. “WASH in Schools : Empowers Girls’ Education : Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference 2012.” WASH in Schools: Empowers Girls’ Education : Proceedings of the Menstrual Hygiene Management in Schools Virtual Conference 2012: IRC. UNICEF & Columbia University, 2012:27.
[25] “World Bank Open Data.” 2015. Data | The World Bank. The World Bank.
[26] Adams, John. 2009. Water, Sanitation and Hygiene Standards for Schools in Low-Cost Settings. Geneva, Switzerland: World Health Organization: 32.
[27] Ibid.
[28] Ministry of Education. 2016. 2015 Statistical Education Yearbook. Kigali: Republic of Rwanda: 1-132.
[29] Ekane, Nelson, Marianne Kjellén, Stacey Noel, and Madeleine Fogde. “Sanitation and Hygiene Policy – Stated Beliefs and Actual Practice: Burera District, Rwanda.” Sanitation Updates. Stockholm Environment Institute, January 6, 2014: 5.
[30] Ibid, 9.
[31] Ibid,1-18.
[32] Sommer, Marni, and Murat Sahin. “Overcoming the Taboo: Advancing the Global Agenda for Menstrual Hygiene Management for Schoolgirls.” American Journal of Public Health 103, no. 9 (2013): 1556.
[33] Ministry of Education. 2016. 2015 Statistical Education Yearbook. Kigali: Republic of Rwanda: 1-132.
[34] “WASH in Schools for Girls: Voices from the Field Advocacy and Capacity Building for Menstrual Hygiene Management through WASH in Schools Programmes.” UNICEF Resources – Voices from the Field: Improving Menstrual Hygiene Management in Schools. UNICEF Programme Division / WASH, December 2015: 12
[35] “Real Lives.” UNICEF Rwanda – Real Lives – Improving Access to Education for Rwanda’s Children. UNICEF. Accessed November 24, 2016.
[36] Millington, Kerry A., and Laura Bolten. 2015. “Improving Access to Menstrual Hygiene Products.” GSDRC Helpdesk Research Report, 4.
[37] Ibid.
[38] Sommer, Marni, Nana Ackatia-Armah, Susan Connolly, and Dana Smiles. “A Comparison of the Menstruation and Education Experiences of Girls in Tanzania, Ghana, Cambodia and Ethiopia.” Compare: A Journal of Comparative and International Education 45, no. 4 (January 24, 2014): 602.
[39] UNESCO. “Good Policy and Practice in Health Education. Booklet 9: Puberty Education and Menstrual Hygiene Management.” UNESCO HIV and Health Education. UNESCO, (2014): 33.
[40] Sommer, Marni, Nana Ackatia-Armah, Susan Connolly, and Dana Smiles. “A Comparison of the Menstruation and Education Experiences of Girls in Tanzania, Ghana, Cambodia and Ethiopia.” Compare: A Journal of Comparative and International Education 45, no. 4 (January 24, 2014): 603.
[41] Hitimana, Health And Hygiene Manager, Rwanda, Nadia, and Cece Camacho. 2014. “SHE28: The Intersection between Innovation, Health, WASH &Amp; Economic Development for Girls and Women in Rwanda .” Sustainable Health Enterprise, October, 1–14.
[42] Ibid.
[43] Howard, Courtney, Caren Lee Rose, Konia Trouton, Holly Stamm, Danielle Marentette, Nicole Kirkpatrick, Sanja Karalic, Renee Fernandez, and Julie Paget. “FLOW (Finding Lasting Options for Women): Multicentre Randomized Controlled Trial Comparing Tampons with Menstrual Cups.” Canadian Family Physician. College of Family Physicians of Canada, (June 2011): 213
[44]Howard, Courtney, Caren Lee Rose, Konia Trouton, Holly Stamm, Danielle Marentette, Nicole Kirkpatrick, Sanja Karalic, Renee Fernandez, and Julie Paget. “FLOW (Finding Lasting Options for Women): Multicentre Randomized Controlled Trial Comparing Tampons with Menstrual Cups.” Canadian Family Physician. College of Family Physicians of Canada, (June 2011): 213
[45]Ibid.
[46] Oster, Emily, and Rebecca Thornton. “Determinants of Technology Adoption: Private Value and Peer Effects in Menstrual Cup Take-Up.” Journal of the European Economic Association, (December 2009): 1291.
[47] Beksinska, Mags E., Jenni Smit, Ross Greener, Catherine S. Todd, Mei-Ling Ting Lee, Virginia Maphumulo, and Vivian Hoffmann. “Acceptability and Performance of the Menstrual Cup in South Africa: A Randomized Crossover Trial Comparing the Menstrual Cup to Tampons or Sanitary Pads.” Journal of Women’s Health 24, no. 2 (2015): 156.
