World Water Week 2019 – Women and Safe Water, Sanitation, & Hygiene

Women and water: WASH and menstrual health in urban communities

This article is the second in a three-part series focusing on urban water, hygiene and sanitation (WASH). Part one discusses the detrimental effects of water  insecurity on pre- and postpartum women, tying into overarching themes of WASH and gender inequality. Find it here. 

by Gaby Alfieri

Nearly every woman will menstruate in her life, regardless of geographic or socioeconomic status. Every day, over 300 million women and adolescent girls are on their periods, and females of reproductive age account for a quarter of the global population. The international development community increasingly recognizes that the near-universality of menstruation means menstrual hygiene management (MHM) must be a core focus for the wellbeing of women, girls, and society as a whole. 

International agencies, such as the United Nations Office of the High Commissioner on Human Rights (OHCHR) and the World Bank, argue that safe MHM is indispensable to ensure the protection of human rights. Earlier this year, OHCHR noted that MHM has “severe impacts on all aspects of women’s and girls’ human rights, including their human rights to equality, health…water [and] sanitation.” In a 2018 World Bank sanitation report, the Bank emphasized the importance of both menstrual health and WASH in urban settings for women and girls’ economic, social, and educational opportunities. But the challenge is a difficult one—MHM and WASH are intricately tied to issues of accessibility, infrastructure, education, and sociocultural norms. Improving MHM is both deeply necessary and dauntingly complex.

Menstrual health and WASH

MHM and WASH are inextricably linked as during a woman or girl’s period access to water and sanitation facilities is vital. In rapidly urbanizing spaces, especially in crowded informal settlements and slums, women and girls struggle to access safe water and hygienic facilities. Often, using these facilities comes at the cost of privacy. Many women and girls rely on reusable pads, which require clean water and proper sanitary systems to wash and dry. Disposable pads also require secure sanitation system to prevent the transmission of diseases. Since informal settlements are often disconnected from basic city services, these WASH services are usually lacking or absent. 

Furthermore, latrines must be both accessible and private to ensure that menstruating women and girls are able and willing to change pads and either clean or dispose of old ones. In a study of a West Bengal urban community, the vast majority of school-aged female respondents reported issues with washing and drying reusable cloth pads. Roughly half cited a shortage of water and facilities as a contributing factor, and nearly all cited a lack of privacy. A fifth of the girls reported sharing a toilet with up to 20 other community members, and another global report found that, in some schools, public toilets lack doors—a clear barrier to a girl’s privacy needs.

The effects of poor WASH and MHM vary significantly among and within countries. While more data are needed to explore variations in poor WASH and MHM and its effects, existing evidence points to the dangers of poor menstrual health for girls’ school participation. A World Health Organization report on the former Yugoslav Republic of Macedonia found that 75% of urban menstruating students are absent from school for at least a couple of days while on their periods. A study by the Women’s Health Group at Boston Medical Center that examined secondary school children in peri-urban Uganda, also saw an association between school absenteeism and menstruation. Both publications cited improper WASH facilities as an issue. Menstruation does not, however, always entail absenteeism; many girls continue to go to school while on their periods. But, to avoid attention and subsequent embarrassment, they may choose to not participate while in class. Furthermore, the discomfort caused by unclean pads and inadequate pain management can serve as a distraction for girls while they are trying to learn.

Beyond magic bullets


Ostensibly straightforward solutions to these problems include greater distribution of pads and increased installment of WASH facilities. A 2014 report by the United Nations Educational, Scientific and Cultural Organization (UNESCO), for example, promoted accessible latrines and sanitary products. But, critics say that this approach falls short. While free and accessible pads offer some short-term relief, critics argue that it is far from a magic bullet. 

When researchers from the University of Leeds and University of Sheffield interviewed girls who received free pads in Uganda, many of the girls stated that the pads went unused. A common sentiment emerged from these interviews: pads do nothing to address issues of privacy, clean water, and the painful symptoms of menstruation. The availability of pads did not mean girls were able to wash and dry the pads, or to do so in a private and dignified manner. In fact, most of these girls had the same rates of absenteeism as before they received the materials. One respondent explained:

My sister gets very anxious whenever on her period because she is worried about leaking and what people will think. This makes her not want to leave the house.”

Some efforts and interventions attempt to account for the need to wash sanitary products by installing latrines and other forms of sanitary systems. Again, this approach can alleviate some problems, but the effects are often ephemeral. Without consistent maintenance, toilets and other facilities will simply fall into disrepair and disuse. 

Perhaps most importantly, these magic bullet solutions ignore context. Toilets and pads simply do not negate the stigma surrounding menstruation, and they do nothing to educate communities about the topic. A more complete and holistic approach would take into account the infrastructural issues surrounding MHM, namely those related to WASH, as well as the deeply complex socio-cultural factors affecting menstrual health. These approaches should be bottom-up, employing greater community involvement and grassroots advocacy in cities. Meanwhile, the research and academic worlds should look more extensively at this issue, contributing to the growing body of work surrounding MHM. The challenge is a tough one, but it is absolutely necessary to foster healthier, more inclusive cities. 

The relationship between MHM and girls’ and women’s education underscores the exigency of the issue. It is a matter of human rights and wellbeing for women and girls, and it is a matter of the positive ripple effects on cities as a whole. Educated, healthy, and dignified girls can more fully participate in the economic, political, and social spheres of their cities. The case for MHM is not only a moral one—it is a pragmatic one. 

Author Gaby Alfieri is an intern at IHC Global. She is a rising sophomore at Northwestern University studying history and global health.