By Meera Tiwari

This essay provides an overview of the key challenges in menstrual health faced by women and adolescent girls in rural Bihar and Uttar Pradesh (UP), India, during 2018–19, within the framework of the literature on dignity. The purpose of the inquiry was to explore whether there was any link between social dimensions anchored in dignity and better menstrual health outcomes.

The literature on dignity, discussions with civil society organisations working on period poverty and menstrual health awareness both in the UK and India have been instrumental in shaping this inquiry with menstrual health and not menstrual hygiene at its centre, as has been previously done.

By situating menstruation under the 'health' umbrella, attention is drawn to the normal functions of the female body, the well-being of women and their families, as well as the social dimensions that affect them. The reference to hygiene, on the other hand, has connotations of cleanliness and disease prevention. While hygiene may well be one of the dimensions of menstrual health, it certainly should not be the key focus when addressing poor menstrual health outcomes. Further, referring to it as menstrual hygiene may also suggest that menstruation is an unclean process thus reinforcing the "taboo and stigma" discourse and highlighted by the Bollywood biopic "Padman" and the Oscar winning documentary "Period. End of Sentence", among others.

Another outcome of this research has been the conceptualisation of menstrual health as a societal concern, an issue that affects both men and women and not only women. This insight stems from grounding menstruation within women's health as an essential bodily function for childbearing because under the patrilineal norm and the preference for a male child in South Asia, childbearing acquires a higher function.

On the other hand, the mother's wellbeing affects the health and nutrition of the children as well as the overall welfare of the family as per the comprehensive literature on mother and child well-being. The family in this situation comprises children, teenage boys and girls, adult male and female members and the elderly. Hence, including women, adolescent girls and boys and men in this study has been central to capturing the perceptions surrounding menstrual health.

The Context

Improving menstrual health outcomes is crucial for tackling the global challenges of inequalities of opportunities experienced by girls and women in education, health and well-being. The fundamental right of women to manage menstruation with safety and dignity is yet to be accepted globally.

The UN's 2015 Sustainable Development Goals (SDGs) are a blueprint for ending poverty through a global partnership. The seventeen SDGs focus on improving health, education, reducing inequalities and spurring economic growth while addressing climate change and sustainability in all domains. According to the SDG Index India Report 2018, India's performance against SDGs 3 (good health and well-being), 5 (gender equality) and 6 (clean water and sanitation) were inadequate with a score of 52, 38 and 63 out of 100, respectively. Moreover, the states of Bihar and UP where this research was conducted, had the lowest scores in the country. The SDG 3, SDG 5 and SDG 5 scores were 40, 24 and 31 for Bihar and 25, 27 and 55 for UP. Especially notable was the negligible progress India and its lowest performers Bihar and UP had made against SDG 5 for gender equality.

However, it must be mentioned that at the global level there is no target or indicator for menstrual health within the SDGs nor under Indian national or state-level plans for achieving SDG 6 relating to sanitation.

Research has established links between menstrual health practices and the rates of reproductive infections but there is a lack of general public awareness about the same, though civil society activism and Bollywood have made some progress in this respect. Recent data shows that 28 per cent of girls in rural India quit school soon after their first period, and a large proportion of them regularly miss school because of poor menstrual health. Overall, 39 per cent of girls aged between 15 and 18 years in India drop out of school, far higher than the percentage for boys.

Period shaming is common. For instance, at a women's college in the state of Gujarat, a complaint was lodged with the school authorities about female students breaking rules for menstruating women. The social and cultural rules usually applicable to menstruating women were being extended to the school and classroom. Regularly observed restraints, including barring menstruating women from entering temples and kitchens, not touching other students during their periods, maintaining social distance while eating and washing their dishes separately were imposed by the school. Segregation was enforced in the classrooms where menstruating girls were expected to sit separately on the last bench. The female students were even forced to strip to prove whether they were menstruating or not. Such period-shaming incidents make this study even more relevant.

The Dignity Discourse

According to UNICEF's 2019 report, 1.8 billion people menstruate globally and millions of those are unable to exercise their right to good menstrual health and dignity due to discriminatory norms, cultural taboos, poverty and lack of access to basic amenities. Adolescent girls often face stigma and social exclusion during menstruation, resulting in school absenteeism and frequent dropouts. Women with lower literacy levels face additional chronic nutritional deficiencies and health problems. Cumulatively, these practices have far-reaching negative consequences on the lives of girls and women as they restrict their mobility, freedom, choices, affect attendance and participation in school and community life, compromise their safety and cause stress and anxiety.

These in turn lead to unequal opportunities and chances of success in education and life.

To understand what UNICEF meant by 'menstrual health with dignity', the word dignity needs to be examined more closely. The literature on dignity can be traced back to the Aristotelian discourse on human flourishing. The Latin root of the word "dignity" is dignus which means "worthy of esteem and honour", and its meaning has been expanded to include the significance people have of themselves in their own eyes – self-respect and self-worth – as well as in the eyes of society. Further insights into understanding the notion of dignity are offered by the capability approach discussed in (other works), where human dignity is associated with being valued and having freedom from discrimination, shame and humiliation.

Although closely linked to respect, the core focus of dignity is on self respect, self-esteem and self-worth, implying one's perception of oneself. Respect, on the other hand, is measured in terms of value and honour received by an individual from the society and/or community based on another's perception and judgement. These notions of dignity and respect have helped shape this research.

Methodology and Findings

The densely populated states of Bihar and UP are the worst performing states in terms of female well-being indicators such as maternal mortality (149 and 197 deaths per 100,000 live births compared to the country average of 113), female literacy (51.5 and 57 per cent versus 65.5 per cent for the country), female work participation (4 and 13 per cent as compared with the 23 per cent all-India average) and declining child sex ratio (0–6 years), which has fallen from 927 females per 1,000 males in 1991 to 908 as per the 2021 census in UP and from 953 to 916 in Bihar.

For this research, a sample of six villages was selected (three each from UP and Bihar) where there was an active presence of self-help groups (such as Jeevika and RGMVP). The self-help network comprises formal membership-based groups of poor and socially excluded rural women who function as a collective. The network platform enables the empowerment and financial inclusion of these women so that they are equipped to access better opportunities and public service provisions to improve their livelihood and well-being.

The data set comprised 600 women and 300 men over the age of eighteen. The selected cohorts were representative of the rural socio-economic contexts in the two states in terms of low literacy, poor incomes and dependence on low-paying jobs in agriculture. In the female sample, 45 per cent had no schooling, while the remaining 55 per cent were split almost equally between having completed primary and secondary education. The male sample had 21 per cent with no schooling, 46 per cent with completed primary education and 33 per cent with secondary education. Almost 50 per cent of the women reported engaging in seasonal agricultural labour while 60 per cent of men identified themselves as being self-employed. A significant 81 per cent of women aged between 18 and 25 were married.

A mixed-methods approach was deployed to capture the perceptions, practices and challenges of menstrual health. While conducting the research, it was found that there was strong reluctance from men to participate in the research, because they believed menstruation was a women's issue. To overcome this and encourage active male engagement, it was decided to share the key findings of an earlier pilot study via street theatre in the village squares.

After conducting 900 interviews, two interactive performances at each research site were used as data-capture tools. During the performances, researchers collected observational data in terms of the number of villagers present – male versus female, their reactions and responses, how many left or stayed, etc. While the literature on theatre as a data-display strategy to engage new audiences in research is not novel, using it to both nudge the respondents to react and record their interactions is the innovation in this research.

The performances while facilitating the study also educated the audience about the connection between menstruation and societal aspirations. Information on taboos and ill-conceived perceptions of menstruation, as well as the necessity of a regular menstrual cycle for a waris (heir/child /grandchild) to ensure the continuity of one's bloodline were discussed. The data collected from the audience at the performances revealed that 83 per cent of the men were aware that menstruation is linked with having children but did not think it was important for the men to be involved. However, connecting healthy menstruation directly with their aspirations for an heir made it evident to the men its critical role in the survival of the family lineage, thereby underlining the importance of and supporting dignified menstruation.

The responses gathered offer interesting insights into perceptions of menstrual health within the dignity discourse.

Taboo

Generally speaking, the word menstruation was not mentioned in the presence of young children, or men and elders. About 87 per cent of the women had no knowledge of menstruation until their first period, and the majority of the men learnt about menstruation only after getting married. The most common restrictions for menstruating women included not touching pickles or grains, avoiding cooking, not serving food, not going to school or work, and hiding the menstrual cloths from male members of the family. The religious prohibitions included constraints on praying at home, entering a place of worship, and participating in any religious ceremony or touching the offerings.

Shame/Worthlessness

About 62 per cent of the women admitted to feeling worthless, embarrassed or like a burden during menstruation. The remaining 38 per cent emphasised the pain and mental stress they experienced during menstruation.

Menstrual Health Awareness

The women's understanding of menstruation was almost 100 per cent. This was captured in a focus group discussion where the women used the analogy of the relationship between fruits and flowers – the fruits being their children and the flowers being their menstruating bodies. Eighty-three per cent of the men were aware of the biological connection between menstruation and conception. Both men and women commonly held perceptions of menstrual blood being dirty, having a foul smell and being caused by heat in women's bodies.

Further, unfounded claims and myths were also reported by the women. These included the idea that irregular or no menstruation led to blindness, gas, bodily swelling, filth accumulation in the stomach, infertility and other illnesses. The men believed menstruation was a way for women's bodies to expel poisonous, dirty blood and black filth.

Access

Three-quarters of the interviewed women used rags while the rest used menstrual pads to manage their menstruation. Rags made from old clothes were easily available but reusing them required washing which was a challenge because clean water sources were usually in open courtyards or public spaces. While pads were easier to use, they were expensive, even though the local brands were much cheaper, priced at Rs 2 or Rs 3 per pad.

Over a third of the women used a room inside the house to change, while 50 per cent out of the remaining two-thirds used the toilet and the other 50 per cent changed outside due to the absence of clean running water and toilets. The disposal of either the pad or the rag was difficult, and women either buried the used product or discarded it in the open on a rubbish heap.

Dignity and Respect

An important difference in the way men and women understood dignity and respect emerged from their responses. While the men's focus was on pride derived from work and what society thought of them, for the women self-esteem and self-respect were based on their ability to care for the family, happiness in the family, offering hospitality to guests and being valued by their husbands.

Conclusion

An analysis of the data collated during this study reveals that the lack of appropriate menstrual health practices in rural Bihar and UP result in the women feeling dirty, worthless, ashamed and like a burden on their families. These sentiments were reinforced by their exclusion from social practices and religious traditions. The link between menstruation and childbearing is masked by myths that menstruation is a mechanism to expel dirt, poison, black blood, body heat and filth which accumulates in a woman's body, and irregular menstruation is linked to blindness and internal diseases.

While over two-thirds of the women reported feelings of shame and worthlessness during menstruation, their understanding of dignity did not directly mention menstrual challenges, even though they identified self-esteem and self-respect as part of their understanding of what constituted dignity. This suggests that the women perceived menstrual health to be a women's concern only. They associated dignity with the ability to care for their families but did not relate it to the idea that a woman who considers herself to be a burden, was unwell and felt worthless was unlikely to be able to take care of the family properly.

Moreover, the idea of the 'self' was found to be absent from the women's conception of dignity. This suggests that the women did not prioritize their health and the misconceptions about menstruation added to them disregarding menstruation as a healthy bodily function. The study concluded that the idea of the 'self', including the menstruating self, is critical for women's understanding of dignity.

There have been efforts globally to improve the 'dignity' of menstruating women, and one solution has been to facilitate access to affordable sanitary pads. For example, since 2018, the UNFPA has been distributing 'dignity kits' to refugees in Angola. The dignity kit includes sanitary napkins, soap, laundry detergent and other essential hygiene supplies. This undoubtedly helps girls and women achieve better menstrual hygiene and respect for their bodies. However, the dignity kit does not help tackle the stigma and lack of information surrounding menstruation. Much more needs to be done to restore the essential dignity of menstruating women.

It is only with the eradication of misinformation and thereby the inclusion of the 'self' in women's conception of dignity that improved menstrual health will become possible.