Inserting informed choice into global menstrual product use and provision
Authors: Julie Hennegan
Journal: The Lancet Public Health (2019)

Each day millions of girls and women experience menstruation. Despite this ubiquity, menstrual experiences have received little attention as a public health and equity issue.1Sommer M Caruso BA Sahin M et al.A time for global action: addressing girls' menstrual hygiene management needs in schools.PLoS Med. 2016; 13e1001962Crossref PubMed Scopus (135) Google Scholar A growing evidence base has reported that menstruation is a negative experience, beset with challenges for many in low-income and middle-income countries,2Hennegan J Shannon AK Rubli J Schwab KJ Melendez-Torres GJ Women's and girls' experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.PLoS Med. 2019; 16e1002803Crossref PubMed Scopus (115) Google Scholar as well as for those in high income countries.3Plan InternationalBreak the barriers: girls' experiences of periods in the UK. Plan International, London2018Google Scholar In addition to the stigma surrounding menstruation and deficiencies in education and support, a prominent issue is the struggle to afford sufficient menstrual materials.2Hennegan J Shannon AK Rubli J Schwab KJ Melendez-Torres GJ Women's and girls' experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.PLoS Med. 2019; 16e1002803Crossref PubMed Scopus (115) Google Scholar, 4Hennegan J Sol L Confidence to manage menstruation at home and at school: findings from a cross-sectional survey of schoolgirls in rural Bangladesh.Cult Health Sex. 2019; : 1-20Crossref PubMed Scopus (18) Google Scholar Women and adolescent girls have described discomfort, irritation, odour, and fears of leaking that contribute to avoidance of school and social settings.2Hennegan J Shannon AK Rubli J Schwab KJ Melendez-Torres GJ Women's and girls' experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.PLoS Med. 2019; 16e1002803Crossref PubMed Scopus (115) Google Scholar Growing advocacy to address menstrual needs has urged governments and non-governmental organisations to act. Many responses have focused on providing free products.5Bobel C Making menstruation matter in the global south: mapping a critical history.in: Bobel C The managed body. Springer Nature, Cham2019: 69-109Crossref Google Scholar In 2018, the Scottish Government committed £5·2 million to provide free menstrual products in schools,6Khomani N Scotland to offer free sanitary products to all students in world first.The Guardian (London). Aug 24, 2018; Google Scholar and similar policies have been implemented across the globe (eg, New York, NY, USA; South Africa; Kenya; and India7Garg R Goyal S Gupta S India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls—issues and challenges.Matern Child Health J. 2012; 16: 767-774Crossref PubMed Scopus (62) Google Scholar). Disposable pads have been the main product distributed; however, product alternatives include tampons, reusable pads, reusable menstrual underwear, and menstrual cups. In The Lancet Public Health, Anne Maria van Eijk and colleagues8van Eijk AM Zulaika G Lenchner M et al.Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.Lancet Public Health. 2019; (published online July 16.)http://dx.doi.org/10.1016/S2468-2667(19)30111-2Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar provide the first systematic review and meta-analysis of acceptability, safety, and experiences of using menstrual cups; a lesser known alternative product. The authors found that menstrual cups are effective at collecting menses, with similar or lower leakage compared with disposable pads or tampons. They listed the low frequency of adverse events associated with cup use, compiling possible harms for future monitoring. The report also highlighted the likely lower cost of menstrual cups over their lifespan and lower plastic and non-plastic waste generated compared with use of disposable pads or tampons, although the authors did not include production waste in their assessments. For consumers purchasing menstrual products, the results highlight that menstrual cups are a safe and cost-effective option. Crucially, their findings indicate that menstrual education resources are not providing a comprehensive overview of products to support informed choices. The authors found that awareness of menstrual cups was low, and that only 30% of websites with educational materials on menarche included information about menstrual cups.8van Eijk AM Zulaika G Lenchner M et al.Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.Lancet Public Health. 2019; (published online July 16.)http://dx.doi.org/10.1016/S2468-2667(19)30111-2Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar The findings of van Eijk and colleagues8van Eijk AM Zulaika G Lenchner M et al.Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.Lancet Public Health. 2019; (published online July 16.)http://dx.doi.org/10.1016/S2468-2667(19)30111-2Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar raises more complex questions for free or subsidised menstrual product distribution policies and programmes, including what is the best product to provide? How do providers balance cost and sustainability with informed choices and maximise benefits for recipients? The authors found a pooled estimate of 73% (95% CI 59–84) of women and girls reported willingness to continue menstrual cup use after familiarisation. With many brands of cups lasting up to 10 years, the product is a cost-effective option and could reduce distribution challenges inherent in providing monthly supplies of disposable products and waste management issues from single-use products.9Elledge M Muralidharan A Parker A et al.Menstrual hygiene management and waste disposal in low and middle income countries—a review of the literature.Int J Environ Res Public Health. 2018; 15E2562Crossref PubMed Scopus (38) Google Scholar However, the pooled estimate of 27% of users who might not find cups acceptable would not be aided by their provision and might feel pressured to continue use despite insertion difficulties and pain. In development and humanitarian response, 2019 UNICEF guidance on menstrual hygiene materials provides information on the range of menstrual material options and emphasises community engagement to identify preferred products for distribution.10UNICEFGuide to menstrual hygiene materials. United Nations International Children's Emergency Fund, New York, NYMay, 2019Google Scholar Positively, this strategy places community preferences at the centre of distribution. Findings from van Eijk and colleagues8van Eijk AM Zulaika G Lenchner M et al.Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.Lancet Public Health. 2019; (published online July 16.)http://dx.doi.org/10.1016/S2468-2667(19)30111-2Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar complicate this strategy, highlighting that menstrual cup uptake might be slower than other products and require a learning curve of 2–5 months, assisted by education. In the absence of exposure or opportunities to learn to use menstrual cups, these products are less likely to be selected by communities than alternative products despite their potential long-term benefits. How to truly support informed choice in the community in settings where many people have not been exposed to the full range of products and when commercial interests might provide unbalanced marketing infor-mation about particular products is unclear.11Mahajan T Imperfect information in menstrual health and the role of informed choice.Indian J Gend Stud. 2019; 26: 59-78Crossref Scopus (11) Google Scholar The answers to these questions might not be simple and more high-quality studies are needed to support community decision making. van Eijk and colleagues found the overall quality of existing studies to be low.8van Eijk AM Zulaika G Lenchner M et al.Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.Lancet Public Health. 2019; (published online July 16.)http://dx.doi.org/10.1016/S2468-2667(19)30111-2Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar They showed the value of integrating evidence from both high-income countries and low-income and middle-income countries to accelerate learning. The authors noted the rich information described by users, which could be explored in further rigorous studies. All those who menstruate need access to their choice of menstrual materials that are safe, comfortable, and support sustainable production and use. To achieve this end, researchers and policy makers need to tackle the complexity of what informed choice means for product distribution and how menstrual experiences can be improved considering the range of factors involved, beyond products,2Hennegan J Shannon AK Rubli J Schwab KJ Melendez-Torres GJ Women's and girls' experiences of menstruation in low- and middle-income countries: a systematic review and qualitative metasynthesis.PLoS Med. 2019; 16e1002803Crossref PubMed Scopus (115) Google Scholar and van Eijk and colleagues' Article offers an important step in this process. I declare no competing interests. Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysisOur review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products. Full-Text PDF Open Access