FIGO Ethics And Professionalism Guideline 082: Menstrual Hygiene Management

Background

1. Menstrual Hygiene Management (MHM) has been defined as: “women and adolescent girls using a clean menstrual management material to absorb and collect blood, that can be changed in privacy as often as necessary for the duration of the period, using soap and water for washing the body as required and having access to facilities to dispose of used menstrual management materials.”1

2. FIGO has always held sexual and reproductive health and rights (SRHR) of women around the world as high priority issues. MHM is an important ingredient of SRHR, because it has a huge impact on the development of the life of girls and women, not only in health but education, security, and gender equality. In the last 10 years MHM rightly has become a globalised public health topic. FIGO seeks to provide global ethical guidance on this vitally important subject.

3. In many low- and middle-income countries (LMICs), where girls receive very limited puberty guidance, and the cost of mass-produced sanitary materials is high, the inadequacy (or complete lack) of safe, private, clean water, sanitation, and disposal facilities creates substantial additional environmental barriers to MHM.

4. The lack of proper sanitation facilities, and proper and affordable hygiene materials for the use of adolescent girls and women at home, at school and at workplaces, affects their health, their potential to access education, employment, overall safety and quality of life.

5. Unsafe and unhygienic materials to absorb menstrual blood can lead to vaginal infections, with possible long-term effects on reproductive health.

• Psycho-social effects: Menstruation is often associated with shame and disgust, resulting in negative attitudes. Restricting socio-cultural practices surrounding menstruation is common. In many LMICs women are practically treated as being ‘impure’ and ‘untouchable.’ In some instances, because they have to stay outside their homes, in so called ‘menstrual huts,’ they have suffered and even died due to snake bites and so on. In conservative religious countries like India they are not allowed to enter many religious places during menstruation. They are made to desist from taking part in even household religious ceremonies.

• Education: In many cases, girls will not attend school for the duration of their periods.  This is particularly evident in schools with inadequate water, sanitation, and hygiene (WASH) facilities.2,3   In most of LMICs especially in village schools due to lack of privacy and wash facilities girls do not attend schools during menstrual periods. In many places they are made to cease their education once they start their menses.

• Productive work time: Women will be constrained to pursue and maintain employment when they are not able to manage their menstruation hygienically and in privacy at work4.  Among the contractual workers working in the paddy fields in India, it was a common practice to seek hysterectomy to avoid missing wages during menstruation period.

• Environment: With lack of or limited waste management, non-reusable and commercial items are often disposed of directly into the environment.

6. Although menstruation remains a socially stigmatised condition in most contexts, and one that is infrequently discussed in coeducational (or even female-only) encounters, a girl or woman’s menstruating status can easily be hidden in high-resource contexts which is unfortunately not so in low resource situations.

7. In emergency/humanitarian crisis situations, e.g., refugees during war time or immigration crisis, women and girls are particularly vulnerable. MHM is often not properly addressed, resulting in many women and girls confronting barriers to access adequate hygienic and absorbent menstrual materials and WASH facilities or the absence of these resources. 

8. Well designed, culturally competent, and adequately funded research is needed to provide an evidence base regarding the positive overall effects on society and economic development based on of the provision of proper MHM. 

Ethical Framework

1. The ethical principle of beneficence in professional ethics in obstetrics and gynecology creates the prima facie ethical obligation of the obstetrician-gynecologist to identify and provide clinical management of the patient’s condition or diagnosis that, in deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment is predicted to result in net clinical benefit.  Such clinical management is known as medically reasonable.

Recommendations

1. MHM is a concern not only for women, but for women and men equally, and for societies. FIGO member societies should invoke the ethical principles of beneficence and healthcare justice to advocate for the development of coordinated health policy by all levels of government, to support the development and implementation of effective MHM programmes.
   
   Health policy should be country-specific and culturally competent. In countries with high awareness concerning reproductive health, it might be most effective to address MHM directly. In other settings it might be most effective to start approaching MHM indirectly from the WASH sector. While implementing a standard around gender/MHM-friendly infrastructure is possible, the design of interventions and policies need to take into account important factors such as local cultural practices, different needs of different age groups etc.

2. FIGO member societies should invoke the ethical principles of beneficence and healthcare justice to advocate for effective international efforts in public health emergencies and humanitarian crisis situations, where women and girls should have access to appropriate resources, which should include:

• Provision for discreet laundering or disposal of menstrual hygiene materials.
• Adequate access to water and soap for daily hygiene as well as for the increased needs during menstruation.

3. FIGO member societies should invoke the ethical principles of beneficence and healthcare justice to advocate for the evidence-based development and deployment of culturally competent, effective programmes that provide medically reasonable MHM to women and girls. There is a growing body of research, particularly around knowledge, attitudes, and practices. However, some of the gaps are:

• Health effects of poor MHM, health risks associated with the use of certain products and certain practices.
• Socio-economic impacts of product donation/tax reduction programmes.
• Product standards and new sustainable and affordable innovations.
• Effectiveness and standards for different low-cost disposal options.

Virtual Meeting from New York, July 2020

References

1. Unicef (2013, and 2014) Proceedings of the MHM Virtual conference, https://www.unicef.org/wash/schools/files/MHM_vConf_2014.pdf
2. http://www.unicef.org/esaro/7310_Gender_and_WASH.html
3. WHO and Unicef Progress on sanitation and drinking water 2013 – update, https://apps.who.int/iris/bitstream/handle/10665/81245/9789241505390_eng.pdf;jsessionid=B71A15387427613DC0A70498AE020396?sequence=1 
4. https://www.sida.se/English/publications/142804/menstrual-hygiene-managementfeb-2016/

Citation:

FIGO Committee on Ethical and Professional Aspects of Human Reproduction and Women’s Health.  FIGO Ethics and Professionalism Guideline 082: Menstrual hygiene management. London: FIGO 2020: https://www.figo.org/figo-ethics-and-professionalism-guideline-082-menstrual-hygiene-management

• Obstetrician-gynecologists and their member societies have the professional responsibility to advocate for the impartial application of criminal law to perpetrators of criminal violence against healthcare professionals with especially vigorous advocacy in the case of lethal criminal violence.

About FIGO

FIGO is a professional organisation that brings together obstetrical and gynecological associations from all over the world.

FIGO’s vision is that women of the world achieve the highest possible standards of physical, mental, reproductive and sexual health and wellbeing throughout their lives. We lead on global programme activities, with a particular focus on sub-Saharan Africa and South East Asia.

FIGO advocates on a global stage, especially in relation to the Sustainable Development Goals (SDGs) pertaining to reproductive, maternal, newborn, child and adolescent health and non-communicable diseases (SDG3). We also work to raise the status of women and enable their active participation to achieve their reproductive and sexual rights, including addressing FGM and gender based violence (SDG5).

We also provide education and training for our Member Societies and build capacities of those from low-resource countries through strengthening leadership, good practice and promotion of policy dialogues.

FIGO is in official relations with the World Health Organization (WHO) and a consultative status with the United Nations (UN).